Carotid Stenosis in Cardiac Surgery Patients

Ischemic stroke is a potential perioperative complication after an open heart surgery (OHS). Whether a carotid stenosis or occlusion is associated with an increased risk of perioperative stroke in patients or just a risk factor has been a concern of intense debate in the literature.

We retrospectively analyzed patients submitted to OHS between January and December2016 with known asymptomatic carotid disease. The data from 85 consecutive patients undergoing coronary artery bypass grafting, valve replacement, or both was collected. The final events registered were stroke, acute myocardial infarct or death. Our aim was to assess whether the presence of carotid stenosis precluded a higher rate of stroke after cardiac surgery.

70 male and 15 female patients, with a medium age of 74(min 45,max84) years were analyzed. 45(53%) patients were submitted to bypass grafting, 21(25%) to valve replacement and 19(22%) to both. Of these patients,42(49%) had unilateral significant carotid stenosis equal or greater than 50%, 12(14%) had bilateral significant stenosis and 20(24%) had a stenosis equal or greater than70%. 2(2%) patients had a previous history of neurologic event. In the peri-operative period, 3 patients (3,5%) developed transient ischemic attack (TIA) or stroke, 3(3,5%) a cardiac event and 6(7%) patients died (3 due to a cardiac event and 2 due to a neurologic event). Two (67%) of the neurologic events occurred in the corresponding side of an hemodynamic carotid stenosis although both this patients had also significant aortic arch calcification and atrial fibrillation. None of the patients that developed post-operative TIA or stroke had previously a neurologic event.

Some studies reported an average stroke incidence around 1.9%following OHS. Despite carotid stenosis, other risk factors should be taken into consideration before considering OHS such as advanced age, prior stroke/TIA, unstable angina, predicted prolonged time for cardiopulmonary bypass, severe aortic arch disease and atrial fibrillation. In our studied population two of the post-operative neurologic events occurred in patients with significant bilateral stenosis, one side between50-69% and the other side 70-99%. According to the new guidelines "Management of Atherosclerotic Carotid and Vertebral Artery Disease:2017 Clinical Practice Guidelines of the European Society for Vascular Surgery" staged or synchronous carotid intervention may be considered for OHS patients with bilateral asymptomatic 70-99% carotid stenosis, or a 70-99% stenosis with contralateral occlusion. Our results may suggest that a sub-group of patients with bilateral significant (>50%) carotid stenosis may benefit from staged or synchronous carotid intervention.