Compatibility of carotid stenting and cardiac surgery

We read with great interest the study by Randall et al1 describing their experience on carotid artery stenting before cardiac surgery. They present 19.2% combined minor stroke, major stroke and death rate, which appears to be higher than previously documented in the literature, as they admit. The only published trial (investigation performed by the same authors)2 comparing dual antiplatelet regime versus aspirin alone for carotid artery stenting was prematurely interrupted for excess of benefit on the dual antiplatelet arm of the study, confirming the necessity of dual antiplatelet regime before, during and after carotid artery stenting. Stent endothelialization takes between 28 and 96 days.3 During this time the exposed metallic stent continuous to act as a source of platelet activation2 so the dual antiplatelet regime benefits may be explained on the basis of the limitation of this phenomenon. It is also well known that antiplatelet drugs increase bleeding complications during cardiac surgery, and dual antiplatelet regimes could increase furthermore the risk of bleeding in the perioperative period. Consequently, in our opinion the 2 procedures are not compatible in their optimal version and compromise is inevitable. That is, the cardiac surgeon must decide to interrupt dual antiplatelet regime for the intervention to minimize bleeding complications, but increasing the risk of neurological adverse events, or perform the operation under dual antiplatelet regime reducing the risk of perioperative stroke, but increasing perioperative bleeding complications. The third solution, the delay of the cardiac procedure to permit stent endothelialization and a less risky suspension of antiplatelet drugs was shown hazardous in their study, as they observed 3 deaths for cardiac causes (2 documented and 1 presumed) over a total of 52 patients pending for the operation. In their study they state that the timing of cardiac surgery after stenting was at the discretion of the cardiac surgeon, but it would be very interesting to specify the mean time between the 2 procedures. We also believe that is of great importance to clarify if cardiac surgery was performed under dual antiplatelet therapy or they suspended 1 or both antiplatelet drugs in the perioperative period. This could explain the high rates of combined postoperative neurological adverse events.