Simultaneous Cardiac Surgery and Micronet-covered Stent Carotid Revascularization in High Perioperative Stroke Risk Patients
- Conditions
- Valvular Heart DiseaseCarotid StenosisMyocardial InfarctionCoronary Artery DiseasePulmonary Edema With Heart Failure
- Interventions
- Procedure: Simutaneous (single anaesthesia) carotid artery stenting with MicroNet covered stent (CGuard) and cardiac surgery (CABG or surgical valve replacement / repair procedure)
- Registration Number
- NCT04973579
- Lead Sponsor
- John Paul II Hospital, Krakow
- Brief Summary
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.
- Detailed Description
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.
Recruitment & Eligibility
- Status
- RECRUITING
- Sex
- All
- Target Recruitment
- 50
- 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.
- 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.
Study & Design
- Study Type
- OBSERVATIONAL
- Study Design
- Not specified
- Arm && Interventions
Group Intervention Description Simultaneous cardiac surgery and carotid stenting Simutaneous (single anaesthesia) carotid artery stenting with MicroNet covered stent (CGuard) and cardiac surgery (CABG or surgical valve replacement / repair procedure) Patients with Heart Team and NeuroVascular Team recommendation to perform simutaneous (single anaesthesia) carotid artery stenting with MicroNet covered stent (CGuard) including proximal or distal neuroembolic protection and cardiac surgery (CABG or surgical valve replacement / repair procedure)
- Primary Outcome Measures
Name Time Method Freedom from major clinical complications comprising MACNE (major adverse cardiovascular or neurologic event) at 30 days 30 days from index procedure Freedom from any death, any stroke, and myocardial infarction at 30-day follow-up
- Secondary Outcome Measures
Name Time Method Rate of ipsilateral stroke in the first year From 31 days till 365 days post-procedure Occurence of any ipsilateral stroke
Freedom from major clinical complications comprising MACNE at 6 months At 6 months from index procedure Freedom from any death, any stroke, and myocardial infarction at 6 months follow-up
Freedom from major clinical complications comprising MACNE at 12 months At 12 months from index procedure Freedom from any death, any stroke, and myocardial infarction at 12 months follow-up
Procedural success rate for carotid stenting Periprocedural 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).
Technical success At the procedure completion Number of procedures (both carotid and coronary) completed in relation to the number of attempted procedures
Clinical success Day 2 after procedure Number of procedures (both carotid and coronary) completed in relation to the number of attempted procedures in absence of stroke
Rate of ipsilateral stroke up to 5 years From 1 year till 5 years post-procedure Occurence of any ipsilateral stroke
Rate of arterial access complications Up to 24 hours post-procedure 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.
Rate of cardiac surgery related complications Up to 24 hours post-procedure Peri-procedural complications associated with cardiac surgery - bleeding requiring re-thoracotomy, cardiac tamponade
Rate of other major peri-procedural complications Up to 7 days post-procedure Other major peri-procedural complications: acute renal failure, systemic infection, respiratory failure requiring prolonged ventilation (\>24 hours).
Rate of any stroke up to 5 years Untill 5 years post-procedure Occurence of any stroke during registry follow up
Stroke free survival rate up to 1 year Untill 1 year post-procedure Survival without any stroke up to 1 year follow up
Ipsilateral stroke free survival rate up to 1 year Untill 1 year post-procedure Survival without ipsilateral stroke up to 1 year follow up
Stroke free survival rate up to 5 years Untill 5 year post-procedure Survival without any stroke up to 5 year follow up
Ipsilateral stroke free survival rate up to 5 years Untill 5 year post-procedure Survival without ipsilateral stroke up to 5 year follow up
Rate of coronary or carotid restenosis Untill 5 year post-procedure Clinical coronary or carotid restenosis requiring treatment
Rate of cardiac or carotid reintervention Untill 5 year post-procedure Clinically indicated carotid or cardiac reintervention during folow up period
Ultrasound Evaluated Carotid Artery Velocities After procedure and at 12 months follow up 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.
Recurrence of angina or valvular heart disease at 30 days and 12 months At 30 days and 12 months after surgery Recurrence of angina or symptomatic valvular heart disease
Recurrence of angina or valvular heart disease up to 5 years Up to 5 years thereafter after surgery Recurrence of angina or symptomatic valvular heart disease
Feasibility of combined treatment At the procedure completion Number of patients actually treated with combined treatment to the number of patients qualified for treatment (excluding deaths in-between)
Trial Locations
- Locations (1)
Department of Cardiac and Vascular Diseases, John Paul II Hospital
🇵🇱Krakow, Poland