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Synchronous cardiac and carotid revascularisation: the devil is in the detail
1Vascular Surgery Group, Division of Cardiovascular Sciences, Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX, United Kingdom. ross.naylor@uhl-tr.nhs.uk
Insights
Synchronous carotid revascularization before heart surgery shows low stroke risk. Even with untreated contralateral stenosis, the risk of stroke from asymptomatic carotid disease during cardiac procedures is very low.
Area of Science:
- Vascular Surgery
- Cardiology
- Neurology
Background:
- Studies suggest reduced procedural strokes with staged/synchronous carotid revascularization before cardiac surgery.
- The risk of stroke in patients with bilateral carotid disease undergoing cardiac procedures with an unoperated contralateral stenosis is under-examined.
- Such patients should theoretically have a higher stroke risk if carotid disease is a major peri-operative factor.
Purpose of the Study:
- To evaluate the stroke risk in patients with bilateral carotid disease undergoing synchronous carotid endarterectomy and cardiac surgery.
- To assess the impact of an unoperated contralateral carotid stenosis on peri-operative stroke risk.
- To challenge the assumption that asymptomatic carotid disease significantly contributes to stroke during cardiac surgery.
Main Methods:
- Retrospective audit of prospectively acquired data.
- Analysis of 132 consecutive patients undergoing synchronous carotid endarterectomy and cardiac surgery.
- Assessment of 30-day outcomes including mortality and stroke rates.
Main Results:
- Overall 30-day mortality was 5.3%, ipsilateral stroke 1.5%, and any stroke 3%.
- The 30-day death/stroke rate was 6.8%, with similar rates in patients with and without prior stroke/TIA.
- Only one stroke occurred ipsilateral to a non-operated contralateral stenosis (90-99% stenosis).
Conclusions:
- Synchronous procedures demonstrate a low procedural stroke rate, potentially justifying the approach.
- The risk of procedural stroke in patients with significant asymptomatic contralateral carotid disease is extremely low.
- This finding challenges the established view of asymptomatic carotid disease as a major cause of stroke during cardiac surgery.
Background:
Studies reporting outcomes following staged/synchronous carotid revascularisation prior to cardiac surgery have generally concluded that procedural strokes are reduced. However, virtually none have commented specifically on the risk of stroke in patients with bilateral carotid disease who then undergo their cardiac procedure in the presence of an unoperated, contralateral stenosis. If carotid disease really was an important cause of peri-operative stroke, these patients should incur a much higher risk of stroke following their cardiac procedure.
Methods:
Retrospective audit of prospectively acquired data in 132 consecutive patients undergoing synchronous carotid endarterectomy and cardiac surgery.
Results:
Overall 30-day rates of mortality, ipsilateral stroke and any stroke were 5.3%, 1.5% and 3% respectively. The 30-day rate of death/stroke was 6.8%. In 51 patients with a prior history of stroke/TIA, the 30-day rate of death/stroke was 5.9%, compared with 7.4% in neurologically asymptomatic patients. The majority (57%) had significant bilateral disease and underwent their combined procedure in the presence of a significant, non-operated (asymptomatic) contralateral stenosis (50-99% = 75, 60-99% = 54, 70-99% = 32). Only one patient (90-99% stenosis) suffered a post-operative stroke in the hemisphere ipsilateral to the non-operated, contralateral stenosis.
Conclusions:
Patients undergoing synchronous procedures incurred a low rate of procedural stroke, perhaps justifying this management approach. However, an alternative and more critical analysis suggested that the risk of procedural stroke in patients with significant (non-operated) contralateral asymptomatic carotid disease was extremely low. This challenges the assumption that asymptomatic carotid disease is an important cause of stroke during cardiac surgery.
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