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Myocardial revascularization before carotid endarterectomy
1Division of Vascular Surgery, Department of Surgery, University of Colorado Health Sciences Center, Denver, CO 80262, USA. William.Krupski@uchsc.edu
The Journal of Cardiovascular Surgery
|July 2, 2003
Summary
For patients with carotid artery stenosis and coronary artery disease (CAD), routine heart revascularization before carotid endarterectomy (CEA) is not recommended. Best medical care for CAD is generally prudent due to low cardiac event rates after CEA.
Area of Science:
- Cardiovascular Surgery
- Vascular Surgery
- Interventional Cardiology
Background:
- Diffuse atherosclerosis affects multiple vascular beds, complicating treatment decisions.
- Carotid artery stenosis often coexists with coronary artery disease (CAD), necessitating careful management strategies.
- Optimal treatment for patients with both carotid stenosis and CAD remains controversial, with challenges in CAD screening and risk assessment.
Purpose of the Study:
- To evaluate the necessity and efficacy of routine myocardial revascularization prior to carotid endarterectomy (CEA) in patients with co-existent coronary artery disease (CAD).
- To assess the perioperative cardiac event rates in patients undergoing CEA.
- To determine the optimal management strategy for CAD in patients undergoing CEA.
Main Methods:
- Review of existing studies and clinical evidence regarding the management of combined carotid artery stenosis and CAD.
- Analysis of perioperative cardiac event rates, including myocardial infarction (MI), congestive heart failure (CHF), and arrhythmias, following CEA.
- Consideration of ongoing trials like the Coronary Artery Revascularization Prophylaxis (CARP) study, although CEA is excluded.
Main Results:
- The incidence of perioperative myocardial infarction (MI) after CEA is low, averaging approximately 1.0% for nonfatal and 0.4% for fatal events.
- Unlike peripheral arterial stenoses, significant coronary artery stenoses do not always correlate with the index lesions causing myocardial infarctions (MIs).
- Anecdotal evidence suggests improved outcomes with pre-CEA revascularization, but robust prospective randomized controlled trials are lacking.
Conclusions:
- Given the low incidence of adverse cardiac events, routine prophylactic myocardial revascularization before CEA is generally not prudent.
- Best medical care for co-existent coronary artery disease (CAD) is the recommended approach for most patients undergoing CEA.
- Further research may be needed, but current evidence supports prioritizing CEA and managing CAD medically unless specific high-risk indicators are present.