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Carotid intervention prior to or during coronary artery bypass grafting. When is it necessary?
D F Bandyk1, M R Back, B L Johnson
1Division of Vascular and Endovascular Surgery, University of South Florida, College of Medicine, Tampa, FL, USA. dbandyk@hsc.usf.edu
Insights
Individualized management for advanced atherosclerosis is key. Identifying high-grade carotid stenosis before coronary revascularization can reduce stroke risk, especially with severe disease.
Area of Science:
- Vascular Surgery
- Cardiology
- Neurology
Background:
- Advanced atherosclerosis often affects both carotid and coronary arteries.
- Management requires balancing risks of stroke and cardiac events.
Purpose of the Study:
- To outline an individualized approach for managing patients with combined carotid and coronary artery disease.
- To recommend strategies for identifying and treating high-grade carotid stenosis prior to coronary revascularization.
Main Methods:
- Review of current guidelines and clinical evidence for managing synchronous carotid and coronary artery disease.
- Emphasis on duplex ultrasound for identifying significant carotid stenosis (>50% or >70% diameter reduction).
Main Results:
- Carotid intervention is effective in reducing stroke in severe (>70%) bilateral internal carotid artery disease, particularly with impaired cerebral perfusion.
- Combined carotid-coronary revascularization morbidity should be <5%, though urgent cases with recent symptoms carry higher risks.
- Symptomatic >50% internal carotid artery stenosis warrants consideration for carotid endarterectomy during coronary revascularization.
Conclusions:
- An individualized, symptom- and severity-based approach is crucial for managing advanced atherosclerosis.
- Screening for high-grade carotid stenosis before coronary revascularization is recommended.
- Carotid endarterectomy or angioplasty with cerebral protection are viable options for selected patients.
Abstract:
Management of patients with advanced atherosclerosis involving the extra-cranial carotid and coronary arteries should be individualized based on symptoms and disease severity. A liberal policy to identify high-grade carotid stenosis using duplex ultrasound testing prior to coronary revascularization is recommended. Carotid intervention is efficacious for stroke reduction in patients with severe (>70% diameter reduction), bilateral internal carotid artery disease, especially if testing indicates abnormal cerebral perfusion via the circle of Willis. The morbidity of a combined carotid-coronary revascularization procedure should be less than 5%, but higher stroke and death rates can be expected in urgent cases with recent hemispheric symptoms. Patients with symptomatic >50% internal carotid artery stenosis should be considered for carotid endarterectomy at the time of coronary revascularization. Carotid angioplasty with cerebral protection is also an appropriate option in "high-risk" cardiac patients, especially in vascular centers with expertise and experience in performing this procedure. A policy of carotid endarterectomy prior to coronary bypass grafting is justified only in patients with stable coronary disease, good ejection fraction, and is best-performed using regional anesthesia.
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