All Asymptomatic Patients with Carotid Stenosis of 70-80% Should Undergo Surgery or Stenting before Myocardial Revascularization Surgery

Abstract

Managing patients scheduled for cardiac surgery with significant carotid artery disease is a controversial issue that usually produces very polarized opinions, even in the literature. Discussion focuses on determining if carotid disease, concomitant with the need for coronary artery bypass, is an important etiologic factor for post-surgical stroke, or simply a marker of increased risk of vascular disease. There are different clinical situations and therapeutic alternatives for patients with carotidcoronary artery disease. Carotid artery stenosis can be symptomatic or asymptomatic, unilateral or bilateral, stenotic or occlusive. Furthermore, the treatment can be both conservative and endovascular or open, sequential or simultaneous, and the order can also be changed. In some cases, the evidence is fully established, but unfortunately, in other cases it has to be drawn up according to the patient and the experience of the treating group. Whether or not a consequence of carotid atherosclerosis, coronary artery bypass surgery in the presence of carotid artery disease faces a greater risk of stroke, even when most of the cerebrovascular events are not mechanically associated with carotid artery stenosis. The published reports indicate that cardiac surgery without carotid artery bypass surgery in patients with symptomatic carotid artery stenosis is associated with high rate of stroke (OR 3.6), and even higher if stenosis is > 50% (OR 4.3, CI 95%, 3.2-5.7). Internationally, morbidity and mortality of combined surgery is close to 10%. By contrast, separately, cardiac surgery in the presence of severe symptomatic carotid disease shows a 2-22% rate of stroke, while carotid surgery in the presence of severe or unstable coronary artery disease has a rate of acute myocardial infarction (AMI) that may reach 40%. For that reason, the AHA/ASA consensus recommends (Class IIa recommendation) carotid artery bypass (carotid endarterectomy [CE] or carotid angioplasty and stenting [CAS] and brain protection system) for those patients with stenosis > 80%, provided they