Hemodynamically Significant Carotid Disease and Prophylactic Carotid Endarterectomy in CABG Patients—Impact on Perioperative Neurologic Events

Abstract

Perioperative neurologic deficits occur in 2-5% of patients undergoing isolated coronary artery bypass grafting (CABG). The effect of preexisting high-grade carotid artery stenosis, as determined by (1) the presence of a cervical bruit, (2) ocular plethysmog raphy (OPG), and (3) duplex scan, and the value of prophylactic carotid endarterectomy in preventing stroke, are uncertain. The hospital courses of 427 patients who underwent pre-CABG carotid duplex scan and coronary artery bypass (CAB) as the only cardiac procedure between April 1992 and June 1994 were reviewed (1) to evaluate the rela tionship between carotid stenosis and perioperative neurologic events and (2) to determine whether endarterectomy for high-grade lesions (80-99%) decreases the risk of perioperative cerebrovascular accident (CVA). There were 11 strokes (2.58%) in 427 patients, 4 CVAs occurred in 389 patients without significant carotid disease; 12 patients had total occlusion of one carotid artery and 4 of them developed a CVA (33.3%); 26 patients had a high-grade stenosis (80-99%) of one carotid artery. Twelve of these patients underwent either a pre-CABG carotid endarterectomy (CE) (5 patients) or simul taneous CE + CABG (7 patients). There were no neurologic events in this group. The 14 other patients with 80-99% stenosis did not undergo a CE. There were 3 CVAs and 1 transient ischemic attack (TIA) in this group. Seven of 11 CVAs (64%) occurred in 34 patients with either total or high-grade carotid disease (P < .0001 by Fisher Exact Test and Wilcoxin Rank Sum). Conclusions: (1) high-grade or total occlusion of a carotid artery is associated with significantly increased risk or perioperative neurologic events. (2) Carotid endarterec tomy appears to be protective. (3) A significant number (4 of 11) of neurologic events are due to causes other than carotid stenosis.