Regarding “Trends and outcomes of concurrent carotid revascularization and coronary bypass”

Abstract

The optimal management of patients with concomitant carotid and coronary artery disease remains an enduring controversy.1Timaran C.H. Rosero E.B. Smith S.T. Valentine R.J. Modrall J.G. Clagett G.P. Trends and outcomes of concurrent carotid revascularization and coronary bypass.J Vasc Surg. 2008; 48: 355-361Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar, 2Naylor A.R. Mehta Z. Rothwell P.M. Bell P.R. Carotid artery disease and stroke during coronary artery bypass: a critical review of the literature.Eur J Vasc Endovasc Surg. 2002; 23: 283-294Abstract Full Text PDF PubMed Scopus (309) Google Scholar, 3Van der Heyden J. Lans H.W. van Werkum J.W. Schepens M. Ackerstaff R.G. Suttorp M.J. Will carotid angioplasty become the preferred alternative to staged or synchronous carotid endarterectomy in patients undergoing cardiac surgery?.Eur J Vasc Endovasc Surg. 2008; 36: 379-384Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Timaran et al1Timaran C.H. Rosero E.B. Smith S.T. Valentine R.J. Modrall J.G. Clagett G.P. Trends and outcomes of concurrent carotid revascularization and coronary bypass.J Vasc Surg. 2008; 48: 355-361Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar described trends and outcomes in 27,084 concurrent carotid and coronary artery bypass grafting (CABG) revascularization procedures during a 5-year period. More than 96% of these patients received their carotid revascularization procedure for an asymptomatic carotid stenosis. The real debate is not about being staged or synchronous, nor about treatment type (carotid artery stenting [CAS] vs carotid endarterectomy), but whether treatment of asymptomatic carotid stenosis will reduce perioperative morbidity and mortality when combined with CABG at any stage. In understanding the predominant cause of post-CABG stroke, hypoperfusion and microembolization remain important etiologic mechanisms. Patients with severe aortic disease have a 15% risk of perioperative stroke, paralleling the increased risk caused by severe carotid stenosis. It has to be realized that 50% of post-CABG stroke sufferers do not have carotid disease. Moreover, 60% of territorial infarctions cannot be attributed to carotid disease, confirming the multifactorial etiology of postcardiac surgery neurologic events. Even when prophylactic carotid revascularization would carry no additional risk at all, it can at most prevent 40% of procedural strokes.2Naylor A.R. Mehta Z. Rothwell P.M. Bell P.R. Carotid artery disease and stroke during coronary artery bypass: a critical review of the literature.Eur J Vasc Endovasc Surg. 2002; 23: 283-294Abstract Full Text PDF PubMed Scopus (309) Google Scholar Timaran concludes with suggesting that CAS may provide a safer carotid treatment option for patients who require CABG. Van der Heyden3Van der Heyden J. Lans H.W. van Werkum J.W. Schepens M. Ackerstaff R.G. Suttorp M.J. Will carotid angioplasty become the preferred alternative to staged or synchronous carotid endarterectomy in patients undergoing cardiac surgery?.Eur J Vasc Endovasc Surg. 2008; 36: 379-384Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar recently found a combined death/stroke rate of 1.7% in CAS for asymptomatic carotid stenosis before surgery; however, the overall death/stroke/myocardial infarction rate of combined CAS/CABG still was 8.7%. Showing that CAS can be performed with an acceptable complication rate is not the issue. First, it must be proven that the combination of CAS and CABG has a significant lower stroke/death rate than CABG alone when the asymptomatic carotid artery is left untreated. Until then, any revascularization before CABG is unwarranted because it exposes patients to the risks of perioperative stroke and myocardial infarction twice, without significantly reducing the risk of stroke. ReplyJournal of Vascular SurgeryVol. 49Issue 5PreviewWe appreciate the letter from de Borst et al and do agree that the optimal management of patients with concomitant carotid and coronary artery disease has not been established, particularly for patients with asymptomatic severe carotid stenosis. We also consider that there is an urgent need to establish the role of any carotid intervention in the management of patients with asymptomatic carotid disease who need open coronary revascularization. Unfortunately, only a well-designed and conducted randomized clinical trial could provide the answer to this important clinical problem. Full-Text PDF Open Archive