Catheterization and Cardiovascular Interventions 60:314 –319 (2003)

Simultaneous Stenting of the Carotid Artery and Other

Coronary or Extracoronary Arteries: Does a Combined
Procedure Increase the Risk of Interventional Therapy?
Robert Hofmann,1* MD, Klaus Kerschner,1 MD, Alexander Kypta,1 MD,
Clemens Steinwender,1 MD, Dietmar Bibl,2 1
MD, and Franz Leisch, MD

Simultaneous interventions in carotid and other extracarotid arteries are not performed
on a routine basis up to now. In 67 out of 295 consecutive patients (23%) undergoing
elective stenting of the internal carotid artery, additional interventions in the coronary
arteries (n ⴝ 65), the iliac artery (n ⴝ 3), renal artery (n ⴝ 1), left subclavian artery (n ⴝ 3),
vertebral artery (n ⴝ 4), or a combination thereof were performed. Primary stenting was
done in 51 (74%) out of 69 carotid arteries, in 48 (74%) of 65 coronary arteries, and in 10
(91%) of 11 other targeted vessels. Neurological complications consisted of two (2.9%)
transient ischemic attacks and one (1.5%) minor stroke. In addition, one (1.5%) myocar-
dial infarction occurred during coronary artery intervention. In comparison, 16 (6.6%)
transient ischemic attacks, 1 minor stroke (0.4%), 5 (2.2%) major strokes, and 3 (1.2%)
deaths were observed in 228 patients without combined procedures. Simultaneous
percutaneous interventions including carotid arteries and other extracarotid arteries are
feasible, relatively safe, and cost-effective. Catheter Cardiovasc Interv 2003;60:314 –319.
© 2003 Wiley-Liss, Inc.

Key words: carotid artery stenting; combined intervention

INTRODUCTION stricted to symptomatic patients with clear evidence of

stenoses confirmed by Doppler echo.
Many times, clinical manifestations of atherosclerosis
Renal failure defined as a serum creatinine of ⱖ 2.0
in different vessels occur simultaneously [1–3]. In par-
mg/dl was present in 10 patients and was considered as a
ticular, the coincidence of stroke in coronary artery pa-
contraindication for simultaneous intervention in 2 pa-
tients and, conversely, myocardial infarction in neuro-
tients. In two patients, the hazards for coronary interven-
logical patients is well known. Corresponding clinical
tions were considered to exceed the potential benefit of a
events count for many fatal complications of interven-
single procedure and the intervention was delayed, to be
tional therapy. The aim of our study was to test the
carried out in a second session. Finally, bypass surgery
feasibility and safety of simultaneous coronary and other
was performed electively in three patients with multives-
extracoronary interventions in patients undergoing elec-
sel disease after carotid artery stenting.
tive carotid artery stenting.
Carotid Artery Stenting

MATERIALS AND METHODS The indication for the procedure was ⱖ 80% stenosis
of the extracranial carotid artery in asymptomatic pa-
From December 1997 to June 2002, 295 patients un- tients or ⱖ 60% stenosis in symptomatic patients. Base-
derwent elective stenting of the internal carotid artery in
our institution. In all patients without recent coronary 1
angiography (⬍ 3 months), a coronary angiography was Cardiovascular Division, City-Hospital Linz, Linz, Austria
2
Neurological Department, City–Hospital Linz, Linz, Austria
performed in a single session before envisaged carotid
artery intervention. The intention was to treat coronary *Correspondence to: Dr. Robert Hofmann, Cardiovascular Division,
stenoses in all symptomatic patients or in asymptomatic City Hospital Linz, Krankenhausstrasse 9, A-4020 Linz, Austria.
patients with high-degree stenosis (ⱖ 90%) in the same E-mail: robert.hofmann@akh.linz.at
session.
Received 4 December 2002; Revision accepted 10 June 2003
Renal angiography was performed as a routine proce-
dure in hypertensive patients. Angiography with subse- DOI 10.1002/ccd.10652
quent intervention in other peripheral vessels was re- Published online in Wiley InterScience (www.interscience.wiley.com).

© 2003 Wiley-Liss, Inc.

 Simultaneous Stenting 315

TABLE I. Baseline Clinical Characteristics of All Patients TABLE II. Neurologic Symptoms and Carotid Artery
Undergoing Stenting of the Carotid Artery Angiography
With Without With Without
simultaneous intervention simultaneous intervention
Number of patients, n 67 228 Number of patients, n 67 228
Age, years 70 ⫾ 9 71 ⫾ 9 Clinical presentation
Male, n (%) 43 (64) 149 (65) Asymptomatic, n (%) 32 (48) 92 (40)
NASCET ineligible n (%) 36 (54) 128 (56) Unspecific symptoms 8 (12) 31 (13)
Previously angiographically documented History of transient ischemic attack, n
coronary artery disease, n 31 (46) 91 (40) (%) 18 (27) 78 (34)
Congestive heart failure, n (%) 13 (19) 26 (11) History of stroke, n (%) 9 (13) 27 (12)
Hypertension, n (%) 45 (67) 169 (74) Number of carotid arteries stented,a n 69 243
Current smoking, n (%) 6 (9) 27 (12) Left carotid artery, n (%) 32 (46) 125 (51)
Diabetes, n (%) 19 (28) 73 (32) Right carotid artery, n (%) 37 (54) 118 (49)
Hypercholesterolemia, n (%) 45 (67) 159 (70) Location of stenosis
Atrial fibrillation, n (%) 8 (12) 34 (15) Within internal carotid artery, not
Chronic renal failure, n (%) 2 (3) 8 (3) involving the ostium, n (%) 33 (48) 129 (53)
Within internal carotid artery,
affecting the ostium, n (%) 9 (13) 29 (12)
Bifurcational lesion, n (%) 27 (39) 85 (35)
line demographic characteristics are listed in Table I. An Morphology
independent neurological assessment of all patients was No or minor irregularities, n (%) 21 (30) 86 (35)
made the day before and after the procedure. Major irregularities, n (%) 48 (70) 157 (65)
Benefits and risks of a surgical intervention as opposed Calcification, n (%) 31 (45) 104 (43)
Stenosis before intervention, % 85 ⫾ 10 84 ⫾ 9
to a percutaneous intervention were discussed in detail
Length of lesion, mm 11 ⫾ 3 11 ⫾ 8
with each patient; informed consent was obtained. A total Contralateral occlusion, n (%) 6 (11) 29 (12)
of 164 patients had exclusion criteria according to the a
Two patients in the combined intervention group and 15 patients in the
NASCET study [4]. Of these, 35 patients presented with control group had interventions in both carotid arteries.
contralateral occlusion of the internal carotid artery, 59
patients had previous carotid endarterectomy, 42 had
atrial fibrillation, and, most importantly, 11 had unstable
angina pectoris (Tables I and II). tion was performed using a 6 Fr guiding catheter and
At least two projections of the carotid artery stenosis premounted stents (Herculink and ACS Ultra, Guidant).
were obtained for the calculation of the vessel diameter The stent balloon/artery diameter ratio was sized at about
and the degree of the stenosis. The diameter of the 1.1:1. Distal neuroprotection devices were not used.
stenosis was determined according to the NASCET cri-
teria with the distal internal carotid artery serving as the Coronary Artery Interventions
reference segment. The calculation was performed using Fifty-four patients were symptomatic; eight patients
a semiautomatic device (Hicor, Siemens). Two experi- presented with unstable angina (Table III). Coronary
enced cardiologists using commercially available bal- artery interventions were carried out according to stan-
loons and stents performed carotid artery stenting. A dard techniques. Guiding catheter, guidewire, and bal-
description of the principles of our technique has been loon were chosen based on the operator’s personal ex-
published earlier [5]. In summary, stenting was per- perience. Elective stenting was attempted in all coronary
formed using a percutaneous transfemoral access. A 6 or arteries with a diameter of 3 mm or more. In smaller
8 Fr modified cerebral guiding catheter (Cordis) was vessels, stenting was performed depending on the degree
placed in the common carotid artery just proximal to the of residual stenosis and the presence of a visible dissec-
segment to be treated. In suitable cases, the right coro- tion. If the target lesion seemed to be suitable, primary
nary artery guiding catheter used for intervention in the stenting was performed.
right coronary artery was also used for subsequent ca-
rotid artery stenting and, if necessary, for further inter- Extracoronary Artery Interventions
vention in other extracardiac vessels. An extrasupport The technique of interventions in supra-aortic arteries
coronary guidewire (Stabilizer, Cordis) was chosen to as well as in renal and iliac arteries was similar to the
pass the stenosis. After predilation with a 4 or 5 mm technique applied to gain access to the carotid artery.
balloon with a length of 20 mm, a self-mounted slotted- Various guiding catheters were used according to the
tube stent (Palmatz-Schatz, Jo-stent) was deployed with location and anatomy of the target vessel; in all cases, a
high-pressure inflations (12–16 atm). In the last 176 relatively stiff guidewire (Stabilizer, Cordis) was used.
consecutive patients, primary stenting without predila- Elective stenting was performed in all cases. Depending
316 Hofmann et al.

TABLE III. Cardiac History and Symptoms in Patients TABLE IV. Procedural Data of Simultaneous Intervention in
Undergoing Carotid Artery Stenting Coronary and Extracoronary Arteriesa
With Without Number of patients, n 67
simultaneous intervention Coronary artery intervention
Number of patients, n 67 228 Left anterior descendens artery, n (%) 23 (34)
Coronary angiography already Circumflex branch of left coronary artery, n (%) 11 (16)
performed, n (%) 31 (46) 68 (30) Right coronary artery, n (%) 26 (39)
History of coronary bypass Saphenous vein graft, n (%) 3 (4)
grafting, n (%) 8 (12) 43 (19) Main stem of left coronary artery, n (%) 2 (3)
History of percutaneous coronary Stentless interventions, n (%) 7 (11)
intervention, n (%) 18 (27) 30 (13) Predilatation plus stenting, n (%) 10 (15)
Prior documented myocardial Primary stenting, n (%) 48 (74)
infarction, n (%) 4 (6) 22 (10) Stenting of extracoronary arteries
Clinical symptoms (CCS) Iliac artery, n (%) 3 (4)
Asymptomatic or atypical chest Renal artery, n (%) 1 (1)
pain, n (%) 13 (19) 192 (84) Left subclavian artery, n (%) 3 (4)
II, n (%) 23 (34) 28 (12) Vertebral artery, n (%) 4 (6)
III, n (%) 23 (34) 6 (3) a
In addition to carotid artery stenting, 17 patients had interventions in more
IV, n (%) 8 (12) 3 (1) than one vessel.

on the operator’s decision, either self-mounted or pre- development of new Q-waves on the ECG or as elevated
mounted stents were used. In all cardiac and extracardiac CK-MB levels to more than twice the normal value,
interventions, a residual stenosis of ⱕ 30% was required functional class defined according to the Canadian Car-
for a procedure to be defined as successful. diovascular Society (CCS) classification for angina pec-
toris symptoms before and after the procedure, and, fi-
Sequence of Interventions nally, the occurrence of clinical events and repeat
The sequence of interventions was based on clinical intervention during follow-up. Angiographic endpoints
symptoms of the patients. Usually, routine coronary an- were angiographic success rate, defined as a residual
giography and, if necessary, subsequent coronary inter- stenosis of ⱕ 30% in all targeted vessels, and the occur-
vention were performed prior to carotid artery stenting. rence of restenosis of ⱖ 50% determined by Doppler
Patients with transient ischemic events and chronically ultrasound (carotid artery) or angiography (carotid artery
stable angina first underwent carotid artery stenting fol- and coronary arteries) during follow-up. The study was
lowed by coronary angiography with subsequent inter- approved by our institutional review board.
vention. Intervention in peripheral arteries was always
carried out last. Statistics
All values are expressed as mean ⫾ standard devia-
Concomitant Medical Therapy tion. Differences between the coronary intervention
Premedication consisted of aspirin (100 mg/day) and group and the control group were compared with the
clopidogrel (75 mg/day) or ticlopidine (500 mg/day) unpaired Student’s t-test and the chi-square test. P values
starting 2 days before intervention. After vascular access of ⱕ 0.05 were considered significant. Data were ana-
was obtained, a bolus of 5,000 units of heparin-sodium lyzed on an intention-to-treat basis.
was given intravenously. In 41 patients, GP IIb/IIIa in-
hibitor abciximab was given as a single bolus following
RESULTS
the protocol of a clinical study [6]. As the study showed
no benefit but possible harm in the setting of carotid Combined procedures were carried out in 67 patients,
artery stenting, the drug was no longer used on a routine meaning that nearly a quarter (23%) of the total patient’s
basis. CK-MB, cardiac troponin T, and an ECG were cohort of 295 underwent combined interventions. Stent-
obtained immediately after the procedure, 6 hr later, and ing of the carotid artery plus one coronary artery was
the following day. In cases of suspected cerebral isch- done in 50 patients; intervention in the carotid artery plus
emic events, a computer tomography of the brain was two coronary arteries was performed in 6 patients; three
performed within 24 hr. patients had interventions in both coronary arteries and
All clinical, angiographic, and stenting data were re- peripheral arteries in addition to carotid artery stenting;
corded prospectively. Clinical endpoints were any tran- and in 8 patients carotid artery stenting was combined
sient ischemic event, minor or major stroke during hos- with intervention in other extracardiac arteries (Table
pital stay, myocardial infarction defined either as the IV).
 Simultaneous Stenting 317

TABLE V. Results and Complications of Carotid Artery increase), the mean fluoroscopy time increased from 9 ⫾
Stenting* 14 to 13 ⫾ 16 min (44% increase), and the mean amount
With Without of contrast medium used increased from 204 ⫾ 112 to
simultaneous intervention 256 ⫾ 167 ml (25% increase).
Number of carotid arteries, n 69 243
Successful intervention, n (%) 69 (100) 239 (98) Complications
Residual stenosis, % 3.4 ⫾ 5 3.5 ⫾ 7
Neurological complications are listed in Table V. All
Stent diameter, mm 5.0 ⫾ 3 5.1 ⫾ 2
Stent length, mm 17.2 ⫾ 5 18.2 ⫾ 4 ischemic events occurred intraprocedurally or immedi-
Number of patients, n 67 228 ately after the intervention. The number of neurological
Transient ischemic attack, n (%) 2 (2.9) 16 (6.6) complications was not statistically significantly different
Minor stroke, n (%) 1 (1.5) 1 (0.4) between the groups of patients with and those without
Major stroke, n (%) 0 5 (2.2)
concomitant interventions. Myocardial infarction (maxi-
Death, n (%) 0 3 (1.2)
Myocardial infarction, n (%) 1 (1.5) 0 mum rise of CK-MB 29 U/l) occurred in one patient
resulting from occlusion of a small side branch.
*P ⬎ 0.05 for all parameters.
No complications occurred in connection with stenting
of peripheral vessels. Nonischemic complications con-
sisted of three cases of inguinal hematoma, making blood
Results of Carotid Artery Stenting transfusions necessary in one patient in the group of
Of the 67 patients with concomitant interventions in patients with combined procedures compared to nine
other vessels, all 69 stenoses of the internal carotid artery hematoma and three cases of blood transfusions in the
could be stented successfully (Table V). Bilateral carotid group without concomitant interventions (P ⫽ NS).
artery stenting was performed in two patients (3%). Pri-
mary stenting was successful in all 51 attempted cases. In Functional Results
the group of patients without combined procedures, 15 Clinical status improved in all patients with concom-
patients had bilateral carotid artery stenting. Results of itant coronary artery intervention except for those who
carotid artery stenting were not statistically different had a positive stress test but were asymptomatic prior to
from patients with concomitant extracarotid artery inter- the intervention. Unstable angina was present in eight
vention (Table V). patients, six of whom could be dismissed from hospital
without any symptoms of coronary artery disease. Func-
Results of Coronary Artery Intervention tional class improved from CCS III to II in 7 patients,
Revascularization of the target lesion was possible in from CCS III to I in 16 patients, and from CCS II to I in
all 57 cases (Table IV). Revascularization was complete 23 patients.
in 47 patients. In 10 cases with occlusion or diffuse Patients with stenoses in the left subclavian artery
disease of a second major branch, only the ischemia- suffered from pain in the forearm during exertion or had
related vessel was dilated. Primary stenting was success- unspecific symptoms before intervention. All of them
ful in all attempted cases. could be dismissed asymptomatically. Likewise, three
patients with stenotic iliac arteries who had symptoms of
Results of Stenting of Extracoronary Arteries peripheral artery disease prior to the intervention were
All 11 attempted interventions were successful. In 10 dismissed asymptomatically.
patients, primary stenting was performed. No complica-
tions occurred in connection with the interventions. In 36
DISCUSSION
cases, carotid artery stenting was performed after coro-
nary artery intervention. In 21 patients, carotid artery The frequent coincidence of coronary artery disease in
stenting preceded coronary intervention. patients undergoing carotid artery procedures is a well-
known fact [7,8]. The population scheduled for vascular
Procedure Time interventional therapy becomes increasingly older, at the
Primary stenting technique was applied whenever it same time the percentage of patients with more diffuse
seemed feasible, thus keeping procedure time, fluoros- disease is continuously growing, resulting in ischemic
copy time, and amount of contrast medium in minimal symptoms in different regions. Adverse events arising
ranges (Table IV). Compared to single carotid artery from coronary artery disease count for clinically signif-
stenting and coronary angiography procedures, the mean icant complications in patients undergoing carotid artery
procedure time, defined as the time between access to the interventions. Consequently, severe coronary artery dis-
femoral artery and final angiogram after the last inter- ease as well as unstable angina was considered as con-
vention, increased from 26 ⫾ 14 to 38 ⫾ 21 min (46% traindications to elective carotid artery endarterectomy in
318 Hofmann et al.

the NASCET trial evaluating the benefit of carotid end- symptoms rather than neurological deficits prevailed,
arterectomy vs. conservative treatment [4]. Conversely, therefore the number of patients undergoing cardiac in-
stroke is an important and often fatal complication of tervention prior to carotid artery stenting was higher than
coronary artery bypass grafting [9,10]. In the past, com- the reverse.
bined interventional procedures dealing with cerebrovas- Carotid artery stenting is performed worldwide by
cular disease and coronary artery disease were only in- cardiologists as well as neurologists and radiointerven-
vestigated extensively in the setting of surgical tionalists. The advantages of combined procedures could
revascularization [11,12]. In addition, the question of become a strong argument that carotid artery stenting
combined surgical procedures vs. a stepwise approach is should be performed predominantly by cardiologists, es-
still a matter of debate [13–16]. pecially when accompanying coronary artery disease is
A systematic percutaneous approach has not been per- suspected.
formed up to now. As percutaneous techniques replace
surgery more and more often for various reasons, there is Study Limitations
an increasing number of case reports or small nonsys- The primary limitation of this study is the fact that it is
tematic series of combined procedures [17–22]. Shawl et not a randomized trial. Interventions were carried out in
al. [23] reported on 73 patients out of 170 who underwent a single center by only two highly experienced operators
both carotid artery stenting and coronary intervention. with extensive practical knowledge of interventions in
However, only 10 of these patients had a single proce- both carotid arteries as well as coronary arteries. It is not
dure, the remaining 63 patients underwent staged proce- clear whether the results could be extrapolated to less
dures. A consecutive series of patients undergoing com- experienced centers. For this reason, it is too early to
bined interventions has not been published up to now. draw significant clinical implications from this study.
The rationale for our study was to investigate the
feasibility and safety of a systematic approach with the
REFERENCES
intention of treating coronary artery stenoses together
with carotid artery stenting in a single session. The 1. O’Leary DH, Polak JF, Kronmal RA, Manolio TA, Burke GL,
estimated advantages for this single combined approach Wolfson SK, for the Cardiovascular Health Study Collaborative
Research Group. Carotid-artery intima and media thickness as a
are, first, that it is a matter of comfort for the patient who risk factor for myocardial infarction and stroke in older adults.
has to undergo a femoral puncture only once. As com- N Engl J Med 1999;340:14 –22.
plications resulting from vascular access still play a role, 2. Rothwell PM. The interrelation between carotid, femoral and
these risks can be minimized by complex interventions coronary artery disease. Eur Heart J 2001;22:11–14.
instead of staged procedures. Second, although a detailed 3. Held C, Hjemdahl P, Eirksson SV, Björkander I, Forslund L,
Rehnqvist N. Prognostic implications of intima-media thickness
cost analysis was not done, the economic impact of and plaques in the carotid and femoral arteries in patients with
combined procedures is obvious. In many procedures, stable angina pectoris. Eur Heart J 2001;22:62–72.
the same guiding catheter could be used for cannulation 4. North American Symptomatic Carotid Endarterectomy Trial col-
of the right coronary artery as well as the carotid artery laborators. Beneficial effect of carotid endarterectomy in symp-
and most other vessels treated in the same session. In tomatic patients with high-grade carotid stenosis. N Engl J Med
1991;325:445– 453.
virtually all cases, the same guidewire was used for 5. Leisch F, Kerschner K, Hofmann R, Bibl D, Engleder C, Berg-
interventions in all different vessels. In addition, the mann H. Carotid stenting: acute results and complications. Z
costs for introducer sheath, vascular suture device, and Kardiol 1999;88:661– 668.
the sum of all other nonsterilizable products necessary 6. Hofmann R, Kerschner K, Steinwender C, Kypta A, Bibl D,
for percutaneous interventions are considerable. The ma- Leisch F. Abciximab bolus injection does not reduce cerebral
ischemic complications of elective carotid artery stenting: a ran-
jor source of cost reduction in patients undergoing com- domized study. Stroke 2002;33:725–727.
bined procedures as opposed to staged interventions is a 7. Birincioglu L, Arda K, Bardakci H, Ozberk K, Bayazit M, Cum-
shorter hospital stay or the avoidance of a second hospital hur T, Tasdemir O, Bayazit K. Carotid disease in patients sched-
admission, whichever applies. uled for coronary artery bypass: analysis of 678 patients. Angiol-
To answer the question of safety, results and compli- ogy 1999;50:9 –19.
8. Steinwender C, Kerschner K, Hofmann R, Grund M, Leisch F.
cations observed in patients who have undergone simul- Simultaneous coronary angiography in patients undergoing ca-
taneous combined procedures were compared with re- rotid artery stenting: importance of combined interventions in the
sults of other patients of our institution who had elective coronary arteries. Eur Heart J 2001;22:634.
stenting of the carotid artery without simultaneous cor- 9. Hirotani T, Kameda T, Kumamoto T, Shirota S, Yamano M.
onary artery intervention (Table V). The sequence of Stroke after coronary bypass grafting in patients with cerebrovas-
cular disease. Ann Thorac Surg 2000;70:1571–1576.
interventions was based on the clinical presentation. Ac- 10. Furlan AJ, Craciun AR. Risk of stroke during coronary artery
cording to the patient population admitted to our institu- bypass graft surgery in patients with internal carotid artery disease
tion, the number of patients presenting with cardiac documented by angiography. Stroke 1985;16:797–799.
 Simultaneous Stenting 319

11. Darling RC III, Dylewski M, Chang BB, Paty PS, Kreienberg PB, gioplasty a safe procedure? J Am Coll Cardiol 1998;31(Suppl
Lloyd WE, Shah DM. Combined carotid endarterectomy and A):454A.
coronary artery bypass grafting does not increase the risk of 18. Yadav JS, Roubin GS, Iyer S, Vitek J, King P, Jordan WD, Fisher
perioperative stroke. Cardiovasc Surg 1998;6:448 – 452. WS. Elective stenting of the extracranial carotid arteries. Circu-
12. Kau TK, Fields BL, Riggins LS, Wyatt DA, Jones CR. Coexistent lation 1997;95:376 –381.
coronary and cerebrovascular disease: results of simultaneous 19. Leisch F, Kerschner K, Hofmann R. Percutaneous carotid artery
surgical management in specific patient groups. Cardiovasc Surg stenting combined with stenting/angioplasty of other central ar-
2000;8:355–365. teries. Dtsch Med Wschr 2000;125:273–279.
13. Johnson RG. Carotid endarterectomy and coronary artery bypass: 20. Hofmann R, Steinwender C, Kerschner K, Leisch F. Simultaneous
the staged approach. Ann Thorac Surg 1998;66:1480 –1482.
intervention of five coronary and extra-coronary vessels. Int J Car-
14. Trachiotis GD, Pfister AJ. Management strategy for simultaneous
diol 2001;80:99 –100.
carotid endarterectomy and coronary revascularisation. Ann Tho-
21. Al-Mubarak N, Roubin GS, Liu MW, Dean LS, Gomez, CR, Iyer
rac Surg 1997;64:1013–1018.
SS, Vitek JJ. Early results of percutaneous intervention for severe
15. Takach T, Reul GJ Jr, Cooley DA, Duncan JM, Ott DA, Livesay
JJ, Hallman GL, Frazier OH. Is an integrated approach warranted coexisting carotid and coronary artery disease. Am J Cardiol
for concomitant carotid and coronary artery disease? Ann Thorac 1999;84:600 – 602.
Surg 1997;64:16 –22. 22. Kiesz RS, Rozek MM, Bouknight D. Bilateral carotid stenting
16. Borger MA, Fremes SE, Weise RD l, Cohen G, Rao V, Lindsay combined with three-vessel percutaneous coronary intervention in
TF, Naylor CD. Coronary bypass and carotid endarterectomy: single setting. Catheter Cardiovasc Interv 2001;52:100 –104.
does a combined approach increase risk? a metaanalysis. Ann 23. Shawl F, Kadro W, Domanski MJ, Lapetina FL, Iqbal AA, Doug-
Thorac Surg 1999;68:14 –20. erty KG, Weisher DD, Marquez JF, Shahab ST. Safety and effi-
17. Laborde JC, Fajadet J, Cassagneau B. Is combined percutaneous cacy of elective carotid artery stenting in high-risk patients. J Am
carotid artery stenting and coronary or extra-coronary artery an- Coll Cardiol 2000;35:1721–1728.