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Ischemia-targeted coronary revascularization improves 5-year survival following carotid endarterectomy
Dainis Krievins, Gustavs Latkovskis, Sanda Jegere, Aigars Lacis, Edgars Zellans, Indulis Kumsars, Davis Putrins, Janis Vetra, Andrejs Erglis, Christopher K Zarins
Pauls Stradins clinical university hospital, Riga, Latvia
Background: Long-term survival following carotid endarterectomy (CEA) is limited by adverse cardiac events with 5% annual mortality. Short term studies have shown no improvement in survival with selective coronary revascularization. We sought to determine whether ischemia-targeted coronary revascularization of asymptomatic ischemia-producing coronary lesions can reduce adverse cardiac events and improve long-term survival of patients following CEA.
Methods: Observational cohort study of patients with no cardiac history or coronary symptoms undergoing elective CEA during 2017-2019. Patients enrolled in a prospective IRB-approved study of pre-operative cardiac evaluation using coronary CT-derived fractional flow reserve (
FFRCT) to identify patients with asymptomatic ischemia-producing coronary stenoses with ischemia-targeted coronary revascularization following CEA were compared to matched
Controls with standard pre-op cardiac evaluation and no elective coronary revascularization. In the FFRCT cohort lesion-specific ischemia was defined as FFR
CT ≤0.80 distal to >30% stenosis; severe ischemia defined as FFRCT ≤0.75. Endpoints included all-cause death, cardiac death, myocardial infarction (MI), stroke and MACE (major adverse cardiovascular events = CVdeath, MI or stroke) during 5-year follow-up.
Results: FFRCT (n=100) and Control (N=100) cohorts were well matched with no significant differences in age, gender, comorbidities or indications for CEA (symptomatic stenosis: 53% in FFRCT, 48% in Control). In FFRCT, coronary CT revealed ≥50% stenosis in 48 patients. Lesion-specific coronary ischemia was present in 57 FFRCT patients, with severe ischemia in 44, multivessel ischemia in 28 and left main ischemia in 7 patients; 43 patients had no coronary ischemia (FFRCT >0.80). The status of coronary ischemia was unknown in Controls. CEA was performed successfully in both groups with no deaths or neurologic events and all patients received optimal post-op medical therapy. In FFRCT, 42 patients
were evaluated with coronary angiography 1-3 months following CEA and elective coronary revascularization was performed in 33 patients (27 PCI; 6 CABG). Controls had no elective coronary revascularization. Results during 5-year follow up are shown in the
Table. Compared to Control, FFRCT had a two-fold reduction in all-cause death (11% vs 24%, p=.016) primarily due to a fourfold reduction in cardiac death (3% vs 13%, p=.009) and a sevenfold reduction in MI (3% vs 21%, p=.001). There was a threefold reduction in MACE (10% vs 33%, p<.001)) with no difference in stroke. There were no cardiac deaths or MIs among patients with no coronary ischemia (FFRCT >0.80). The
Figure shows Kaplan-Meier curves for cardiac death with flattening of the FFRCT curve
. Five-year survival in FFRCT was 89% compared to 76% in Control (p<.001).
Conclusions: FFRCT diagnosis of coronary ischemia together with ischemia-targeted coronary revascularization reduced the 5-year risk of cardiac death and myocardial infarction following CEA by more than 50% and improved long-term survival compared to current standard of care. Prospective randomized trials are indicated.
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