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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
Insights
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.
Abstract:
Diffuse atherosclerosis involving more than 1 vascular bed is a challenging problem. The natural histories of carotid and coronary atherosclerosis are clearly intertwined. The optimal strategies for treatment of patients who present with carotid artery stenoses and co-existent coronary artery disease (CAD) remain controversial. Minimally invasive screening tests for CAD are often unreliable, and patients presenting with significant extracranial carotid artery stenoses should usually be assumed to harbor some degree of CAD. Numerous studies have confirmed, however, that in contrast to peripheral artery stenoses, hemodynamically significant stenoses of the coronary arteries are not necessarily the index lesions that produce myocardial infarctions (MIs). Although there are some anecdotal reports that myocardial revascularization prior to carotid endarterectomy (CEA) improves the short- and long-term cardiac outcomes of patients after CEA, no prospective, randomized, controlled studies have proven this hypothesis. Numerous adverse cardiac events can occur in the perioperative period including congestive heart failure (CHF), arrhythmias, unstable angina pectoris and both nonfatal and fatal MIs. Of these, only MIs are truly "hard" endpoints. The incidence of MI after CEA is much lower than after other commonly performed peripheral arterial operations such as aortic or infrainguinal procedures. The perioperative nonfatal and fatal MI rates after CEA average about 1.0% and 0.4%, respectively. The Coronary Artery Revascularization Prophylaxis (CARP) study is currently ongoing in the United States as a multicentered randomized prospective controlled trial sponsored by the Department of Veterans Affairs. In this study, patients with significant CAD who are undergoing operations for peripheral arterial disease are randomized to myocardial revascularization versus best medical care; however, CEA procedures are excluded from this study because cardiac morbidity is low. Based on the low incidence of adverse cardiac events in CEA patients, it is generally prudent to treat their CAD with best medical care rather than routine prophylactic myocardial revascularization.
