Simultaneous Cardiac Surgery and Micronet-covered Stent Carotid Revascularization in High Perioperative Stroke Risk Patients

John Paul II Hospital, Krakow50 enrolled

Overview

Prospective, single-center, clinical registry of patients with symptomatic/critical carotid artery stenosis at risk of stroke coexisting with unstable or multivessel severe coronary artery disease and/or severe valvular heart disease undergoing endovascular treatment of carotid atherosclerosis using a mesh stent in combination with cardiac surgery (coronary artery bypass grafting (CABG) and/or valve surgery). A study involving clinical data evaluation of truly simultaneous treatment outcomes in patients deemed to require carotid revascularization at the time of surgical cardiac intervention (single-stage, simultaneous treatment). An open-label study, without randomization - a single arm study. Academic Registry - scientific activity of the Faculty of Medicine, Collegium Medicum, Jagiellonian University and John Paul II Hospital.

The coexistence of symptomatic or unstable stroke-threatening carotid atherosclerotic stenosis with cardiac disease requiring urgent / fast-track cardiac surgery (such as advanced unstable or multivessel coronary artery disease, recent myocardial infarction or pulmonary edema, severely impaired myocardial contractility, and/or severe valvular disease requiring surgical treatment) represents a major medical and therapeutic/logistics challenge. According to current guidelines, in absence of prospective randomized evidence, the most appropriate management strategy for a given patient should be determined by a multispecialty team. In hemodynamically compromised patients sequential treatment (i.e., first carotid stenosis repair followed by surgery or first cardiac surgery followed by carotid stenosis treatment, either surgical or endovascular) is associated with a high risk of cardiac complications in case of first-stage carotid stenosis treatment and a high risk of neurological complications in case of the first-stage cardiac surgery. In this challenging patient group, we have introduced single-stage, truly simultaneous procedure. The fundament of the strategy is to establish extracorporeal circulation back-up ("CEC standby") prior to the minimally invasive (endovascular) treatment of stroke-threatening carotid artery stenosis in the hybrid room under single anesthesia. For CAS (proximal or distal protected), in case of suboptimal femoral access (or lack of femoral access), a direct access via carotid artery is used (transcervical or transcarotid revascularization), this is immediately followed by cardiac surgery. The procedure, each time, follows recommendation of the Multispecialty Team (Heart Team + NeuroVascular Team) as the lowest-deemed risk management in patients with indications for both urgent both carotid revascularization and cardiac surgery. Both carotid and cardiac treatment are performed under single anesthesia with the feasibility of immediate extracorporeal circulation support during carotid revascularization in case of hemodynamic collapse. Eligibility for treatment is based on the decision (recommendation) of a multidisciplinary Heart Team along with a NeuroVascular Team consisting of a cardiac surgeon, cardiologist, anesthesiologist, angiologist, neurologist, and vascular surgeon, with the concomitant use of routine pharmacotherapy and non-pharmacological prevention - according to current guidelines.

Interventions

Simutaneous (single anaesthesia) carotid artery stenting with MicroNet covered stent (CGuard) and cardiac surgery (CABG or surgical valve replacement / repair procedure)PROCEDURE

The registry enrolls patients qualified for treatment with the methods evaluated in the registry, using routinely applicable procedures and devices. In cardiac surgery - surgical treatment systems for advanced ischemic heart disease and/or valvular disease (including - mechanical/biologic heart valves - regulatory approved for routine use and typically used at the Facility. In the simultaneous treatment of stroke-threatening carotid artery atherosclerosis - temporary neuroprotection systems (proximal, distal, according to medical indications and local experience) - regulatory approved for routine use and typically used at the center (for over 20 years). CGuard anti-embolic mesh stent system - a self-expanding nitinol carotid stent wrapped in MicroNet, which prevents fragments of atherosclerotic plaque from entering the lumen of the carotid artery - approved for routine use and typically used at the Center (over 5 years).

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

Inclusion Criteria: * Patients eligible for concomitant carotid artery stenting in conjunction with cardiac surgery based on Heart Team and NeuroVascular Team reccomendation and according to local standards of practice. * Signed informed consent form * Consent to (routinely performed in this group of patients) follow-up visits and tests performed (routinely) during long-term follow-up * De novo atherosclerotic lesions or neo-atherosclerosis. * Symptomatic patients (with a history of ipsilateral transient cerebral ischemia, stroke or amaurosis fugax within the past 6 months) with carotid artery stenosis ≥50% as assessed by NASCET angiography or * Asymptomatic patients with carotid artery stenosis ≥70-80% as assessed by angiography (NASCET method). * Coronary angiography-confirmed multivessel disease or left main stem stenosis with the symptoms of unstable angina or non-ST-segment elevation myocardial infarction. * Severe symptomatic valvular disease detected by echocardiography. Exclusion Criteria: * Expected survival time \<1 year (e.g., cancer). * Renal failure with GFR \< 20 ml/min/1.73 m2 as calculated by the CKD-EPI formula * Women who are pregnant (pregnancy test). * Coagulopathies. * History of hypersensitivity to a contrast agent that does not respond to pharmacotherapy. * Total carotid artery occlusion. * Stent in the carotid artery that protrudes into the aortic arch. * Anatomic variants that preclude stent implantation. * Significant stenosis of the common carotid artery proximal to the target lesion. * Mobile atherosclerotic plaques in the aortic arch. * Anatomy of the coronary arteries unsuitable for bypass grafting. * Lack of available vascular material for grafting. * Porcelain aorta.

Outcomes

Primary Outcomes

Freedom from major clinical complications comprising MACNE (major adverse cardiovascular or neurologic event) at 30 days

Freedom from any death, any stroke, and myocardial infarction at 30-day follow-up

Time frame: 30 days from index procedure

Secondary Outcomes

Freedom from major clinical complications comprising MACNE at 6 months

Freedom from any death, any stroke, and myocardial infarction at 6 months follow-up

Time frame: At 6 months from index procedure

Freedom from major clinical complications comprising MACNE at 12 months

Freedom from any death, any stroke, and myocardial infarction at 12 months follow-up

Time frame: At 12 months from index procedure

Procedural success rate for carotid stenting

Success of endovascular treatment of carotid artery stenosis i.e. technical success (stent delivery and implantation, withdrawal of stent delivery system, residual stenosis ≤30% of vessel lumen diameter) plus clinical success (procedure without complications).

Time frame: Periprocedural

Technical success

Number of procedures (both carotid and coronary) completed in relation to the number of attempted procedures

Time frame: At the procedure completion

Clinical success

Number of procedures (both carotid and coronary) completed in relation to the number of attempted procedures in absence of stroke

Time frame: Day 2 after procedure

Rate of arterial access complications

Peri-procedural vascular access complications of carotid artery stenting (pseudoaneurysm of the femoral artery, acute ischemia of the lower limb, massive bleeding from the puncture site) occurring within 24 hours.

Time frame: Up to 24 hours post-procedure

Rate of cardiac surgery related complications

Peri-procedural complications associated with cardiac surgery - bleeding requiring re-thoracotomy, cardiac tamponade

Time frame: Up to 24 hours post-procedure

Rate of other major peri-procedural complications

Other major peri-procedural complications: acute renal failure, systemic infection, respiratory failure requiring prolonged ventilation (\>24 hours).

Time frame: Up to 7 days post-procedure

Rate of ipsilateral stroke in the first year

Occurence of any ipsilateral stroke

Time frame: From 31 days till 365 days post-procedure

Rate of ipsilateral stroke up to 5 years

Occurence of any ipsilateral stroke

Time frame: From 1 year till 5 years post-procedure

Rate of any stroke up to 5 years

Occurence of any stroke during registry follow up

Time frame: Untill 5 years post-procedure

Stroke free survival rate up to 1 year

Survival without any stroke up to 1 year follow up

Time frame: Untill 1 year post-procedure

Ipsilateral stroke free survival rate up to 1 year

Survival without ipsilateral stroke up to 1 year follow up

Time frame: Untill 1 year post-procedure

Stroke free survival rate up to 5 years

Survival without any stroke up to 5 year follow up

Time frame: Untill 5 year post-procedure

Ipsilateral stroke free survival rate up to 5 years

Survival without ipsilateral stroke up to 5 year follow up

Time frame: Untill 5 year post-procedure

Rate of coronary or carotid restenosis

Clinical coronary or carotid restenosis requiring treatment

Time frame: Untill 5 year post-procedure

Rate of cardiac or carotid reintervention

Clinically indicated carotid or cardiac reintervention during folow up period

Time frame: Untill 5 year post-procedure

Ultrasound Evaluated Carotid Artery Velocities

Peak Systolic Velocity (PSV) and End Diastolic Velocity (EDV) in the internal carotid/common carotid artery assessed by ultrasound - after the procedure, then at 12 months after the procedure.

Time frame: After procedure and at 12 months follow up

Recurrence of angina or valvular heart disease at 30 days and 12 months

Recurrence of angina or symptomatic valvular heart disease

Time frame: At 30 days and 12 months after surgery

Recurrence of angina or valvular heart disease up to 5 years

Recurrence of angina or symptomatic valvular heart disease

Time frame: Up to 5 years thereafter after surgery

Feasibility of combined treatment

Number of patients actually treated with combined treatment to the number of patients qualified for treatment (excluding deaths in-between)

Time frame: At the procedure completion

Simultaneous Cardiac Surgery and Micronet-covered Stent Carotid Revascularization in High Perioperative Stroke Risk Patients

Overview

Conditions

Interventions

Eligibility

Locations (1)

Outcomes

Primary Outcomes

Secondary Outcomes

Central Contacts