Carotid Disease for the Cardiologist: New Evidence, New Insights

Join our guest, Dr. Mehdi Shishehbor from University Hospitals of Cleveland, for a discussion reviewing the latest evidence for management of both asymptomatic and symptomatic carotid disease. We review the presenting symptoms of carotid disease, diagnostic testing, as well as medical, endovascular, and surgical management strategies. Dr Shishehbor also addresses strategies for patients with concomitant coronary and carotid disease. 

For more information, see:

Medical Management and revascularization for Asymptomatic Carotid Disease (CREST-2 Study)

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Transcript

Speaker 2 0:09

welcome back to Cardio Ohio Podcast. This is Ellen Sabak, your host, coming to you from Cleveland. And today we actually have a special guest host, Dr. Anne Albers from OhioHealth down in Columbus. And Anne is the Ohio chapter of the ACC's newest president-elect, and as such, she's going to be taking the reins in about one year. So Anne, first, congratulations, and welcome to the podcast.

Ellen 0:35

would you be to tell our audience a little bit about yourself and your professional life at OhioHealth?

Anne 0:41

Yes. I have been with OhioHealth, but in practice at Riverside Methodist Hospital, and also have had the opportunity to serve on the Ohio ACC board. and then that evolved into, serving as the co-liaison or co-chair for the advocacy work that the Ohio ACC chapter does, both at a Ohio level and then at the federal level. So I don't know that I ever would've imagined myself being as involved with advocacy, but being in Columbus, we're right here. the Ohio ACC board and then our members are active with different advocacy issues that have come along or that we have generated. But, I've been involved with the American Heart Association. my practice launched at right when the Go Red For Women was launching, so this awareness that heart disease is indeed a leading killer, the leading killer for women, and so much of it is preventable. I, definitely have a preventive cardiology, flavor to my practice but also interested in sports cardiology, imaging, and vascular medicine.

Ellen 1:51

Wonderful. now we get to turn to our guest for today, Dr. Mehdi Shishabhour, who is a world-renowned interventional cardiologist. He is the president of the Harrington Heart and Vascular Institute at University Hospitals Cleveland Medical Center. And he not only, does coronary work, he is very active, both published and, creating new, interventions in the world of PAD as well as pulmonary embolism, interventions, and what's most pertinent for today, carotid artery interventions. So Dr. Shishabhour is going to be talking to us today about, asymptomatic carotid disease. But first, Mehdi, could you please tell us a little bit about your professional journey and how as a cardiologist you got so interested in the fields of PAD, PE, as well as carotid disease?

Mehdi 2:44

thank you so much, Ellen and Ann, for having me, and congratulations again, Ann, for this new role. I-- like many cardiologists, in training, we had, not a lot of exposure to vascular. once I became interventional cardiologist, I had the fortune as I was, finishing my training, my two years of training in interventional cardiology at Cleveland Clinic, the clinic had an interest of, retaining me to become a vascular interventional cardiologist. And they gave me an opportunity to take a sabbatical, which was a very impactful and pivotal moment in my career, to be honest with you. that sabbatical took me to Greenville, South Carolina, and Sioux Falls, South Dakota, and gave me the exposure and the, and the connection, with Dr. Bruce Gray and Dr. Mike Mackrack, which then got me exposed and involved, with, vascular disease, vascular medicine. And after my-- that sabbatical, I came back, and I actually, joined as an interventional cardiologist the section of vascular medicine at Cleveland Clinic. And, then I started kind of collaboration and work with Dr. Heather Gornick and, Jerry Bartholomew and my other colleagues in vascular medicine at Cleveland Clinic. So I be-began to really love and build a passion for vascular care, and I realized that, there were a lot of opportunities as a cardiologist because we obviously had the medical background, but also now I had the kind of procedural background. And the two of them together could significantly impact the care of these patients because There's obviously a significant role for prevention and the medical aspect of care for these patients, but also there's obviously the procedural aspect and the revascularization aspect. And, now, over time, after all those years, my focus has become, mainly vascular, which it, to me encompasses venous disease, carotid disease, aortic disease, and PAD.

Ellen 4:47

Mehdi, I always find people's professional journeys so interesting and really quite inspiring, so thank you for sharing that with us. So our topic today is the treatment of asymptomatic carotid disease. But before we get started with that, could you please remind our audience and also me, for a person who comes in with severe carotid disease, what symptoms typically would they present with if they are symptomatic?

Mehdi 5:14

Yeah, that's a great question, Ellen, because that's a very common mistake that even some of my colleagues that are experts in vascular make. because, patients may come with syncope, confusion, dizziness, and all kinds of symptoms that are honestly not related to carotid disease. symptoms of carotid disease are very specific, and there are really, three symptoms that folks can have. One is obviously stroke, which will have motor deficit associated with it, so I cannot move my arm, I cannot move one side of my body. We call it MCA territory kind of a stroke, which, is I think most people, obviously are familiar with. So having a stroke, a real stroke. The second thing is a TIA, which is a, as we all know, is a transient stroke, is a stroke that happens where you may have slurred speech or have a motor deficit, but it goes away. And then the third one is amaurosis fugax, which is not, double vision, is not, hazy vis- vision. It's basically the patients usually say that I felt like a curtain covering my eyes. So those are the three main symptoms related to carotid disease. There are frequently I have patients referred to me because they have dizziness or syncope or balance issues. Those may be related to posterior circulation. They may also be related to aortic stenosis and other diseases, but they are not carotid disease related, and, that's the major differentiator. So stroke, meaning, slurred speech, dysphagia, or motor deficit. TIA, which is s- those symptoms, but transient, they go away, and they resolve. Or amaurosis fugax. Those three.

Anne 7:13

Mehdi, again, we're all boarded in cardiovascular disease, and you certainly have moved this field ahead. But since we see patients with coronary artery disease and risk factors for coronary artery disease routinely, these same risk factors, they can develop atherosclerosis of the carotid arteries. So any cardiologist is going to have a lot of patients with these risk factors, but who should we be screening for carotid disease, and what test would you say is best for the screening purposes?

Mehdi 7:45

Yeah. Thank you, Anne. That's another great question. in general, the guidelines have, recommended against routine, screening. But that being said, as cardiologists, we hopefully examine our patients. I would say that there are some, patients that deserve, further screening and evaluation. to me, in my practice and what the data supports are the following. If you hear a bruit on physical examination, that's a patient that I would say you should consider for a screening, because, the loudness of a bruit does not have a good correlation with severity. So you may hear a soft bruit, and that patient may have a 90% asymptomatic carotid disease, or you may hear a very loud bruit, and that patient may have a 40%, stenosis of their carotid disease. So any bruit will be a indication for me to send that patient for evaluation. So that's on physical exam. That's the easy one. When it comes to, clinical risk factors that, I think highlight a higher risk, I think any patient that has significant coronary disease, especially three-vessel disease- They have a prevalence of about 10 to 15% of having severe carotid disease. So if you have a patient that has... that gets a cardiac catheterization, has three vessel disease, left main disease, those are patients that I would say that I would agree that we should send them for a screening for a carotid ultrasound, carotid, testing. the next cohort of patients would be those with multiple risk factors. So if you have diabetes, you are a h- you have history of smoking, those would be the other two that I would say probably are high risk for carotid disease. So that would be a cohort of... that I would say that, I would consider high risk, and I would want to screen them. The gold standard screening test for these patients is a duplex carotid ultrasound, and the nice thing about that is that test does not require radiation, and is relatively cost-effective test, and is pretty standard, across United States and worldwide. So I would typically order for these patients a carotid duplex ultrasound.

Anne 10:04

if the duplex comes back abnormal or high risk, where do you go from there? What would you recommend after the carotid duplex?

Mehdi 10:13

Yeah. So the, the cut points, again, de- depends on your comfort level, meaning that if you're comfortable with kind of carotid duplex and the velocities and the degree of stenosis, you can manage this yourself. Historically, we consider, um, severe carotid disease, anything that has a end-diastolic velocity of greater than 100 or a internal carotid artery to a common carotid artery ratio of greater than four is considered significant. So if I had a patient, let's say I was a cardiologist or an internist, and I order the... I heard a bruit, and I send the patient for a carotid duplex, and the result came back and said that the end-diastolic velocity was 60 or 70. I think if there is moderate carotid stenosis, that means 50 to 69%, I would wanna monitor that patient, start intensive medical therapy and risk factor modification, and we can talk about that, and then, repeat the ultrasound in one year if the patient is asymptomatic. And then once the velocities get to be in the ranges that I mentioned earlier, meaning end-diastolic velocity of greater than 100 or a internal carotid to common carotid artery ratio of greater than four, then I would wanna refer that patient to a vascular expert. And me, that could be in your hospital, a vascular surgeon, it could be an interventional cardiologist, it could be a vascular medicine expert, could be any of those. And then they can then have a kind of a shared decision-making with the patient and discuss the pros and the cons of revascularization for severe carotid disease with the patient as to whether medical therapy alone would be optimal, or the patient may consider revascularization because now they have severe carotid disease.

Anne 12:13

would you consider, MRA or CTA or do you move from the duplex?

Mehdi 12:21

Yeah. So what happens is that, MRA and CTA, they usually over-call the degree of stenosis. I think if you have a asymptomatic patient, I would want at least the ultrasound to indicate that it is severe disease. Once you have severe disease, you're exactly right. The next step would be to then, if you were to send that patient to me, I probably would get a CTA or a MRA, and then to then reconfirm that, but also help me decide what would be the best approach for the patient. Because obviously, the decision to consider surgery versus stenting, and as stenting has two categories, you can do transfemoral or transcervical, depends a lot on anatomy and what the anatomy looks like. And for that, it would be useful to have additional information from a CTA rather than ultrasound alone. Ultrasound gives you a lot of information, but the CTA gives you some additional information. So I think rather than exposing a lot of patients to radiation, potentially with CTA, I wouldn't be ordering routine CTA unless the ultrasound said that it was severe, I think up to that point, I think duplex ultrasound alone is enough, especially if we're talking about asymptomatic carotid disease.

Ellen 13:41

Wonderful. So Mehdi, we're gonna go back a little bit. You were talking about medical management for patients. So clearly, the people with severe disease need medical management plus, but for someone who either has moderate disease, and oftentimes we'll get back these reports that say heterogeneous plaque and maybe, 30 to 40%. first of all, I'm assuming it's aspirin and statins. First of all, what would be your LDL target, for these patients? And also, is there ever a role for dual antiplatelet therapy, and is that mixed heterogeneous plaque enough to warrant this medical therapy?

Mehdi 14:20

Yes. Yeah, great. Another wonderful question. my recommendation, I think this is the evidence-based, I... and I t- I'm trying to... everything that I'm saying here is hopefully evidence-based and based on the, the guidelines and, a combination of obviously vascular guidelines, but also carotid guidelines and the, other guidelines, like the lipid guidelines and others. in, in, in correlation or in alignment with the kind of the coronary guidelines, to me, if you have carotid plaque and carotid disease, it's like calcium score. Think of it like a calcium score, right? so I think of it in that way. if you have a normal carotid arteries, it's like you have zero calcium score, right? You have normal... You don't have any evidence of disease. Once you are in the mild to moderate carotid disease or more severe carotid disease, now we're talking about folks that have s- calcium score that is significant, maybe in the 100 to, 399 or 400 range. So I think of them in that way, meaning that they have vascular disease, And we-- And the guideline is pretty aggressive, I in those population, especially if they have diabetes and other comorbidities. So my recommendation, the guideline recommendation, is monotherapy with antiplatelet therapy, so either aspirin or clopidogrel monotherapy. There is no evidence for dual antiplatelet therapy for these patients. Even for stroke patients, there is very little evidence for dual antiplatelet therapy, so we rarely do dual antiplatelet therapy for this population. Monotherapy with aspirin or Plavix is adequate. the second item is LDL cholesterol. if the patient has moderate heterogeneous plaque and, and/or severe carotid disease, I believe that the LDL should be 55 milligram per deciliter or less. And then we'll try to follow the same guidelines, for blood pressure, which is a systolic blood pressure of less than one hundred and thirty millimeters of mercury. So we tend to be pretty aggressive with blood pressure reduction in these patients. And then we have the routine, obviously discussion around exercise and diet for these patients in my practice, so that, that aligns with, thirty minutes of exercise, five, six days a week, and then a diet that is rich in Mediterranean style of food intake and stay away from red meat as much as you can and focus more on vegetables and herbs and greens similar to a Mediterranean diet. And then lastly, obviously, all of these patients should be, advised on smoking cessation and be referred to a smoking cessation clinics, which is what we do in our clinic if a patient is a smoker.

Ellen 17:00

So Mehdi, you just made my job for my coronary disease patients much easier. If you've counseled them for that, you've also counseled them for my coronary disease as well. if we now move at least towards the severe disease. historically, the teaching has been that asymptomatic cr-- patients with carotid disease have an overall reasonable prognosis with a relatively low stroke risk. However, the prior studies did lump the moderate disease in with the severe disease, which might affect the prognosis overall. And the more recent studies, including things like the CRESST II trial published in the New England Journal of Medicine in twenty twenty-five, show that maybe these outcomes for severe carotid disease, if we isolate those patients, is really much worse than previously thought, and maybe that will obviously have implications of whether or not, in addition to all this wonderful medical management, we should be intervening on these patients. Can you comment on the more recent studies and also what the implications are for how we should manage these patients with truly severe carotid disease?

Mehdi 18:05

Absolutely. I think there has been the publication of CRESST II in the New England Journal of Medicine. As this was NIH sponsored, very large, over, two thousand five hundred patients, in two separate arms. An arm that compared stenting to intense medical therapy, and another arm that compared carotid endarterectomy surgery to intense medical therapy was-- is a really a paradigm shift and a very impactful and, uh, let's put it this way, invested. a lot of times we see trials and we're like,"Oh my God, did we spend all this money doing this trial?" But I think this one was really impactful. And it comes down to shared decision-making and how we speak to our patients, and goes back To your important point. Unfortunately, until CREST-2, we did not have prospective randomized data that gave us a sense of what the risk of a stroke was with intense medical therapy and, and obviously contemporary medical therapy in this population. We didn't know. So we were relying on retrospective small studies, and as you highlighted very nicely, many of these studies were, they had lesions that were moderate. They were-- They didn't have good ultrasound, data, and they were, single center, not core lab adjudicated. Many patients had crossed over to revascularization. So the data was very bothersome, to be honest with you. And we were making some tough decisions with our patients in regards to deferring revascularization based on this data. What CREST two, two did was that gave us contemporary core lab adjudicated prospective in a randomized setting data contemporary as to what the risk of a stroke is per year with very advanced medical therapy. And what it showed that the risk of a stroke was about one point three to one point seven percent per year. So let's say one point five, if you average it. And that is cumulative. So that means that if your patient is going to live for three years, that's one point five percent times three, so it's about four point five percent, if my math is correct. Four point five percent risk of a stroke at three years. And that's important. So when you talk to your patients and you're trying to discuss, and we're talking about severe carotid disease, not moderate disease, people that have an end-diastolic velocity of greater than a hundred or a ratio of greater than four. if you're talking to your patient, those are the kind of numbers you need to discuss, that, your risk of a stroke is about four point five percent in three years. Or if you're talking about five years, multiply it by five, one point five by five. If it's ten years, obviously, that would be fifteen percent risk of a stroke, at, at ten years. And, so that the patients have a sense of what kind of risk they're taking if they decide to go the medical approach and take medical therapy. And then obviously, the medical therapy has to be intense, like we just discussed, because that's what they did in CREST-2. So if you just say medical therapy and your blood pressure is one sixty and your LDL is ninety and you are not eating a healthy Mediterranean diet and your weight is not being controlled, that's not really CREST-2. So then your risk may not be one point five percent, it may be two percent, three percent. So that's another thing that we need to take into consideration because in CREST-2, it was intense medical therapy, not just any medical therapy.

Anne 21:36

So the main power of CREST-2 is the power of the intense medical therapy, which I guess you could argue, I, I don't know that I achieve that with all my patients. We definitely work toward it,

Mehdi 21:47

yeah. Anne, you know what CREST-2 showed was that when you, randomize patients to intense medical therapy, uh, including... By the way, they gave free medication to patients. If a patient had a difficult time getting PCSK9 or statins or other medication for blood pressure, it was offered for free. Patients had frequent phone calls for dietary guidelines and exercise and smoking cessation. uh, despite all of that, what they showed after four years of follow-up, four years of follow-up, that there was about a 1.3% absolute risk reduction, when you compare patients that underwent stenting versus those that had intense medical therapy alone. Both group, by the way, had intense medical therapy, both groups. Stent versus intense medical therapy, and CEA was the same. Intense medical therapy versus, CEA plus intense medical therapy. But in the stent arm, which was statistically significant, it showed that stenting had a 1.3%, absolute risk reduction, which translates to about, you need to treat 70 patients, 75 patients or so with, carotid stenting to get one benefit of preventing a stroke. So when you look at it that way, it doesn't seem like a lot, but the reality is that we don't know. That's the challenge in our field. As many of the things that we do to our patients, we need to treat many patients to get one benefit. Statins are like the most powerful medication that we have, and even with the statins, you need to treat about five to six patients to get one benefit over five years. so the bottom line, it comes down to the fact that there was a statistically significant absolute 1.3% in risk, in patients that underwent stenting against medical therapy, and, and that was the advantage of offering patients revascularization versus not doing so. In the CEA arm, there was a also a significant reduc- there was a reduction in absolute risk, but it did not reach statistical significant. It was about 1%. But that was not statistically significant. So the bottom line from the trial was that, revascularization overall, especially with the stenting, was statistically significantly better than intense medical therapy alone. However, again, I think that the more important thing was that, there needs to be a good discussion with the patient. We know what the, the risk is if you do intense medical therapy alone, which is about 1.5%. And it all comes down to, at least in my practice, to the life expectancy of the patient.. So for a patient that's going to live 10 years, 15 years, you can imagine if you multiply 15 by 1.5, that adds up to be a lot, about 25, 30% risk over 15 years. So in that patient, you may want to consider revascularization. If your patient's life expectancy is two years, maybe that patient, the risk, is not, worth pursuing revascularization if, given the risk. The risk, by the way, of doing the revascularization is around 1%. There is about a 1% periprocedural risk for the revascularization of having a stroke or death, from revascularization.

Ellen 25:10

Mehdi, one thing I think we really have to point out here is that this study, as you pointed out, was so well and precisely done, and it was done at specific institutions who are high-volume centers and who have excellent revascularization outcomes. So I think in some respects, yes, it is very generalizable in that it is very important to consider that revascularization may be a better option in these people, but should probably be done at these very specialized, high-volume centers in addition to that very rigorous medical management, right?

Mehdi 25:48

Ellen, I think you hit the nail on the head. The reality of it is that, there is very little room, with carotid disease and revascularization for errors. And, and, trying to prevent a stroke, but unfortunately giving a patient a stroke or death while you revascularize the carotid disease is not something that anyone wants. And we have learned, and we published ourselves around this, that experience is a key factor when it comes to carotid revascularization. And as you highlighted very nicely, in CREST-2 one of the things that makes that trial so important and so powerful is that they had a very robust and a stringent certification for physicians to be able to be part of the study, either as stentors or as surgeons, for that study. I can tell you that in my institution at University Hospitals, I was the only physician that was certified to be a CREST-2, operator. but in my institution, there are many people that offer carotid revascularization. So just to give you a sense is that it was very vigorous. So it goes back to your point, for our patients and for our referring physicians, it is important to make sure that, that the surgeon or the interventionalist that's gonna be performing this has extensive knowledge and experience with performing these procedures. Because if we just refer this to anyone and they don't have the expertise and the experience, I don't think this data applies to them, to your point.

Anne 27:25

Who should we be referring these patients to? And I know you've touched on this, but, vascular surgery, interventional cardiology, do we have to have a, awareness of, obviously awareness of our institution, but are there places with multidisciplinary groups that look at carotid disease at institutions? Or I guess, how do we best replicate CREST-2?

Mehdi 27:48

That's one of the... And, the another very important point, and to be honest with you, that's one of the challenges in our field in medicine, is the heterogeneity of the care. And we have published on this too, showing that, for example, if you refer to a surgeon that does only open They are invariably they offer their patients open surgery. If you refer to someone like me that does only stenting, I obviously am biased towards stenting, and that's one of the challenges in medicine. I think that as primary care and as primary cardiologists, we need to demand and know our organizations and make sure that we are in a-- as a patient advocate, that we are referring these patients to someone that is presenting a balanced kind of a picture to the patients. That is, they are discussing the surgical options, the stenting options, and the medical options, and they are having an, a sh- a nice, a discussion with the patient that is based on the data, the CRESST II, evidence, and there's a shared decision-making that includes all the options with the patient. And one way to address that is to have teams, that a patient-centric team that sees these patients because these are not minor, diseases. carotid disease is a serious condition. We're talking about stroke. as myself included, when you look at surveys of patients that have been offered a stroke versus a heart attack, nine out of, ten patients take a heart attack over a stroke because nobody wants to deal with the implication of having a stroke, so for those reasons, I don't think it's unreasonable in, in this day and age to have a team that evaluate these patients that brings different expertise. So if you have severe carotid disease, for example, you are evaluated by a multidisciplinary group of experts that do surgery and stenting and medical, and that they give you a full recommendation after reviewing your case as to what the best approach should be for someone with your condition. I know I'm maybe talking way out there, and maybe this is a dream state, but to me, that's the ideal state.

Ellen 30:02

Well, Mehdi, thank you so much for that answer. I think, multidisciplinary, groups to evaluate, disease processes usually give us the best answer for our patients. with regards to deciding between, let's say, if we do decide that revascularization is the best, considering carotid endarterectomy versus stenting, what factors would you consider to decide who would be served best by one versus the other?

Mehdi 30:27

So when we look at these patients, once we have decided and, in agreement with the patient in regards to revascularization, the following are what we take into consideration as to whether we should offer surgery, or stenting. And a lot of times, to be honest with you, it's equipoise, meaning that the patient decides because, there may be, equipoise between the two. But some of the things that favors, stenting are things that we learned from the SAPPHIRE trial. for example, if you have had prior radiation to your neck, that would be a reasonable patient to consider for stenting because of the risk of surgery, if there is contralateral occlusion, that would be a high-risk surgical patient, so we offer a stenting. If the lesion is very high or very low in the neck, that may be difficult for clamping purposes for surgical revascularization, so maybe offering stenting in those population. If you have significant coronary artery disease, because a significant portion of these patients require general anesthesia for carotid endarterectomy, so for very high risk, coronary disease or those with low EF and coronary disease, we may offer stenting. so those are, some of the, high-risk features, for surgery that would favor stenting. Things that favor surgery over, stenting are heavy calcification, as you pointed out. obviously, that may make it challenging to get a good expansion with a stent. And for that reason, if you have significant amount of, calcification, we may consider surgical revascularization. The other thing that is, uh, co- We, the other, item that we consider for surgery is tortuosity. So if there's a lot of tortuosity, it makes stenting difficult, we may consider surgical approach. The third item is that if the lesion has a lot of thrombus and we think that it would be safer, to do it surgically because of a soft plaque and thrombus burden, we may consider a surgical approach. That would be the third item. And then the fourth, is that in some rare cases, the patients may have nitinol allergy or, or metal allergy, and in those patients we may consider a surgical approach in those patients. If those criterias favoring stenting or surgery are not there, then it's a equipoise, even though CREST two kind of favored stenting, to be honest with you, but I still think it's relatively equipoise. I think that then you can have a nice conversation with the patient. I think the elephant in the room is honestly the experience in the organization. So if the organization has a lot of experience in surgery, then obviously I think we should lean towards surgery. If the organization, has a significant experience in the stenting, then maybe you should offer stenting. If there is equal experience in both and there is equipoise, then, obviously patient preference comes into the picture

Anne 33:24

I think that's great. it definitely brings more to the cardiologist, managing the patient to know your institution and know, what you have available and how things are. But what about the patients who have severe coronary artery disease and severe carotid disease? So how would you manage that? And which do you tackle first? Could you just talk a little bit about how, you might manage that one versus the other or timing?

Mehdi 33:53

sure. This is an area that we have done some research. so I'm gonna take a little bit of a more of a intense kind of a, little bit more of a firmer kind of a approach to this one, if you don't mind. because I think this is an important question that you asked, and I think that there are mistakes that are happening that may not, be favorable for our patients. So based on the current evidence and everything that we have published and everything that others have published, if you have unilateral asymptomatic carotid disease and you have significant coronary disease requiring CABG, there is absolutely no indication to fix the carotid or do a combined approach. All those patients should be referred for CABG, get their coronary disease taken care of, and then once they have recovered from the coronary disease, they can be then, have a evaluation for what's the best approach for their carotid disease. That's for unilateral asymptomatic carotid disease in a setting of severe coronary disease requiring CABG. If you have symptomatic carotid disease, then I think the carotid disease needs to be addressed before CABG. If the coronary disease is so advanced and, that cannot be done percutaneously, I would say that, I would do both percutaneously. I think it's a very high risk to send a patient with symptomatic carotid disease to CABG. And most surgeons probably won't do it anyway because they would know that this is very high risk, and these patients don't do well with a combined approach. so I would take an endovascular approach for both, for the carotid and for the coronary- or if you can get away with doing the carotid and then do the coronary two to three to four weeks later because of dual antiplatelet therapy after carotid stenting, then I would take that approach. If you have bilateral carotid disease, and you have severe coronary disease, it's rare. Thankfully, we don't have a lot of patients like this. But if you do, that would be a very high-risk patients for cabbage. as during cabbage, especially if you're doing it on pump, that can be risky. I think that those have to be personalized. So you need to find a very talented surgeon, to consider doing it off pump and so on and so forth if you want to go with the cabbage route first. Alternatively, that may be a kind of patient that you may want to consider a percutaneous approach coronary and percutaneous approach for the carotid because, of the risk of hypoperfusion and stroke, in a setting of cabbage for those patients, especially if they are done on pump. That's the general, a overview and guidelines for these kind of patients with severe carotid disease that have also severe coronary disease.

Ellen 36:41

Mehdi, thank you so much for sharing all of your expertise with us today. We have learned so much from many of the trials actually that you were involved in. hopefully, we can all be better cardiologists and also better, with team-based approach for taking care of our patients who do have carotid disease. So thank you again from, Cardio Ohio Podcasts, And Anne, thank you for co-hosting with us.

Mehdi 37:11

Thank you so much. It was a pleasure, and, thank you for the great questions. I think you, both of you highlighted some of the most important decisions and aspects of, carotid disease. So thank you so much, Ellen and Anne.

37:24

Thank you for joining today's podcast. For more information about the speakers or the topics, please go to Ohio acc.org,