[Treatment of combined carotid and cardiac disease]

The proper management strategy for patients with combined carotid and cardiac disease remains unsettled. It is controversial whether the operations should be synchronous, staged or reversed staged, and most publications also lack conservatively treated control groups. The role of endovascular treatment in this situation has not been documented. We present our current treatment strategy and results.

During the period January 2001 to December 2003, 95 procedures for internal carotid artery stenosis were performed in 81 patients. Median age was 70 years, range 44-83; 24 were women. In 37 patients invasive treatment of carotid stenosis and cardiac disease was performed (group A). In another 23 patients the carotid stenoses were treated invasively, while the cardiac disease was treated conservatively (group B). No heart disease was diagnosed in 21 patients treated for carotid stenoses (group C). Postoperative stroke/death was registered after all interventions.

Stroke/death: Group A: one ipsilateral non-disabling stroke after carotid endarterectomy and one cardiac death after coronary artery bypass surgery (5.4%). Group B: one ipsilateral fatal cerebral haemorrhage and 1 contralateral ischaemic stroke (8.7%). Group C: none.

Meta-analyses have calculated the risk of stroke/death after treatment for combined carotid and cardiac disease to be 7-9%, independently of whether the procedures are performed synchronously, staged or reversed staged. Our results are comparable. The aim of treatment for carotid and cardiac disease is to prevent death, stroke and heart failure. The benefit from treatment thus depends on a low complication rate, but patients with combined disease have an increased risk of complications. Counseling of these patients should be based on a multidisciplinary approach, taking into account all possible treatment options including conservative, endovascular and surgical, with an aim to reducing total cardiovascular risk.