Stroke after cardiac surgery and its association with asymptomatic carotid disease: an updated systematic review and
1The Department of Vascular Surgery at Leicester Royal Infirmary, Leicester LE2 7LX, UK. ross.naylor@uhl-tr.nhs.uk
Insights
Prophylactic carotid endarterectomy or stenting is not recommended for most cardiac surgery patients with asymptomatic carotid disease. The procedure may benefit a small percentage with severe bilateral carotid disease.
Area of Science:
- Vascular Surgery
- Cardiology
- Neurology
Background:
- Carotid artery disease is a significant risk factor for stroke, particularly in patients undergoing cardiac surgery.
- The optimal management of asymptomatic carotid stenosis in this population remains controversial.
- Prophylactic intervention aims to reduce perioperative stroke risk but carries its own morbidity.
Purpose of the Study:
- To determine the prevalence of stroke in cardiac surgery patients with varying degrees of carotid artery disease.
- To evaluate the effectiveness of prophylactic carotid endarterectomy (CEA) or carotid stenting (CAS) in preventing stroke.
- To assess stroke risk in patients with bilateral carotid disease undergoing synchronous procedures.
Main Methods:
- Systematic review and meta-analysis of existing studies.
- Inclusion of patients undergoing cardiac surgery with unilateral or bilateral carotid disease (including stenosis and occlusion).
- Analysis of stroke prevalence based on stenosis severity, laterality, and presence of symptoms.
Main Results:
- Cardiac surgery patients with 50-99% stenosis or occlusion had a 7.4% stroke risk.
- For asymptomatic patients without prior stroke/TIA, stroke risk was 3.8% for 50-99% stenosis and 2.0% for 70-99% stenosis.
- The risk of ipsilateral stroke in unilateral asymptomatic stenosis was 2.0%; bilateral disease conferred a 6.5% stroke risk.
Conclusions:
- No strong evidence supports prophylactic CEA/CAS for unilateral asymptomatic carotid disease in cardiac surgery patients.
- Prophylactic intervention may be considered for severe bilateral asymptomatic carotid disease, benefiting only 1-2% of patients.
- Individualized risk-benefit assessment is crucial for managing carotid disease in cardiac surgery candidates.
Objectives:
(i) Prevalence of stroke in neurologically symptomatic/asymptomatic patients with unilateral/bilateral carotid disease (including occlusion) undergoing cardiac surgery without prophylactic carotid endarterectomy (CEA) or carotid stenting (CAS). (ii) Prevalence of stroke in asymptomatic patients with unilateral/bilateral carotid disease (excluding occlusion) who underwent isolated cardiac surgery. (iii) Prevalence of stroke in the hemisphere ipsilateral to a non-operated asymptomatic stenosis in patients with severe bilateral carotid disease undergoing a synchronous unilateral CEA + cardiac procedure.
Methods:
Systematic Review and meta-analysis.
Results:
Cardiac surgery patients with a symptomatic/asymptomatic 50-99% stenosis or occlusion incurred a 7.4% stroke risk (95%CI 4.8-9.9), increasing to 9.1% (95%CI 4.8-16) in those with 80-99% stenoses or occlusion. After excluding patients with a history of stroke/TIA and those with isolated/bilateral occlusions, the stroke risk fell to 3.8% (95%CI 2.0-4.8) in patients with asymptomatic 50-99% stenoses and 2.0% in those with 70-99% stenoses (95%CI 1.0-5.7). The prevalence of ipsilateral stroke in patients with a unilateral, asymptomatic 50-99% stenosis was 2.0% (1.0-3.8), while the risk of any stroke was only 2.9% (2%-5.7%). These risks did not increase with stenosis severity (70-99%, 80-99%). Patients with bilateral, asymptomatic 50-99% stenoses or a 50-99% stenosis + contralateral occlusion incurred a 6.5% stroke risk following cardiac surgery, while the risk of death/stroke was 9.1% (3.8%-20.6%). Patients with bilateral 80-99% stenoses undergoing a unilateral synchronous cardiac/carotid revascularisation incurred a 5.7% risk of stroke in the hemisphere ipsilateral to the non-operated, contralateral stenosis.
Conclusions:
There is no compelling evidence supporting a role for prophylactic CEA/CAS in cardiac surgery patients with unilateral asymptomatic carotid disease. Prophylactic CEA/CAS might still be considered in patients with severe, bilateral asymptomatic carotid disease, but such a strategy would only benefit 1-2% of all cardiac surgery patients.
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