Patients undergoing cardiac surgery with asymptomatic unilateral carotid stenoses have a low risk of peri-operative
D Baiou1, A Karageorge, T Spyt
1The Department of Vascular Surgery, Leicester Royal Infirmary, Leicester, UK.
Insights
Patients undergoing cardiac surgery with asymptomatic carotid stenosis did not experience strokes after a policy change. This study suggests routine prophylactic carotid revascularisation may not be necessary for these patients.
Area of Science:
- Vascular Surgery
- Cardiology
- Neurosurgery
Background:
- Controversy exists regarding optimal management of asymptomatic unilateral carotid artery stenosis in cardiac surgery patients.
- A policy change in 2004 shifted from synchronous cardiac and carotid revascularisation to cardiac procedures alone.
- This study audits stroke incidence following the practice change.
Purpose of the Study:
- To audit the incidence of peri-operative stroke in patients with asymptomatic carotid stenosis undergoing cardiac surgery after a policy change.
- To evaluate the necessity of routine prophylactic carotid revascularisation in this patient group.
Main Methods:
- A five-year audit of 61 consecutive open cardiac procedures.
- Focus on patients with asymptomatic unilateral 70-99% NASCET carotid stenoses who did not undergo prophylactic carotid endarterectomy.
- 30-day post-operative stroke risk was audited.
Main Results:
- 61 procedures included: 44 CABG, 6 valve replacements, 9 CABG+valve, 2 CABG+aneurysm repair.
- Three deaths (4.9%) occurred, all due to myocardial infarction.
- No strokes were observed within the 30-day post-operative period.
Conclusions:
- The findings challenge the assumption that asymptomatic unilateral carotid stenosis increases peri-operative stroke risk in cardiac surgery patients.
- Routine prophylactic carotid revascularisation may not be warranted.
- Further investigation into the management of this patient cohort is suggested.
Background:
There is considerable controversy regarding the optimal management of patients undergoing cardiac surgery who are found to have an asymptomatic, unilateral carotid artery stenosis. Prior to 2004, the policy of this Unit was to perform a synchronous cardiac and carotid revascularisation. After January 2004, the policy was changed and patients underwent their cardiac procedure without carotid revascularisation. The aim of this study was to audit the incidence of stroke in the peri-operative period following this change in practice.
Methods:
Five-year audit of the 30-day risk of stroke after 61 consecutive open cardiac procedures in patients with unilateral, asymptomatic 70-99% (NASCET) stenoses who did not undergo prophylactic carotid endarterectomy.
Results:
61 cardiac procedures; coronary artery bypass grafting (CABG)=44, valve replacement=6, CABG+valve replacement=9, CABG+repair of left ventricular aneurysm=2 were undertaken and the 30-day outcomes audited. There were three deaths (4.9%), all due to myocardial infarction. No strokes occurred in any patient in the 30-day post-operative period.
Conclusion:
These results challenge the opinion that the presence of a unilateral, asymptomatic carotid stenosis in patients undergoing open cardiac surgery is associated with an increased risk of peri-operative stroke, sufficient to warrant routine prophylactic carotid revascularisation.
