Recent Results for Carotid Artery Stenosis Complicated with Severe Aortic Valve Stenosis: TAVI and CEA, from the Examination of Our Institution

Abstract

Purpose: Carotid artery stenosis (CS) is occasionally observed during preoperative examinations for cardiovascular disease. In 2016, our institution introduced transcatheter aortic valve implantation (TAVI) as a treatment for severe aortic valve stenosis (severe AS). Here, we report a retrospective examination of patients treated with carotid endarterectomy (CEA) for CS found during preoperative examinations for TAVI.

Materials and Methods: Between April 2016 and August 2018, 37 CEA procedures were performed at our institution. Within this group, a retrospective examination compared patients with CS who were diagnosed during preoperative examination for TAVI (Group A) to all patients who received CEA treatment (Group B).

Results: Five patients (five lesions; mean age 79 years, 20% female) were classified into group A, and 30 patients (32 lesions; mean age 71 years; 9% female) were classified into Group B. The median North American Symptomatic Carotid Endarterectomy (NASCET) for Group A was 79% compared to 66.5% in Group B (p = 0.033). Overall, group A tended to experience a relatively better outcome, despite older mean age and a higher percentage of severe stenosis. Preoperatively, most patients reported a modified Rankin Scale (mRS) score of 0 (Group A=40%, Group B=44%) or 1 (Group A=40%, group B=25%), with 20% of patients in Group A and 19% of patients in Group B reporting an mRS score of 2. None of the patients in Group A and 12% of the patients in group B reported an mRS score of 3. At discharge, a greater proportion of patients reported an mRS score of 0 (Group A = 60%, Group B= 53%) or 1 (Group A=20%, Group B=25%). While 20% of patients in group A and 16% of patients in Group B reported an mRS score of 2 at discharge, 6% of patients in Group B reported a worsened mRS score of 4 (0% Group B, no reported mRS score of 3).

Discussion and Conclusion: Among patients with severe AS, the CAS procedure as treatment for CS is typically not recommended, as it may result in a rapid decrease in blood pressure, causing myocardial ischemia. In contrast, CS may be a risk factor for cerebral infarction during surgical treatment of severe AS. There is no current agreement on whether treating cases of CS with severe AS is safe and on which stenosis should be treated first. Our cases suggest that CEA treatment for CS in patients who also present with severe AS can be safely combined with TAVI after careful discussion with the patient.