Impact of a carotid stenosis on cardiac surgery: marker more than risk factor

A concurrent carotid and cardiac disease is the paradigmatic expression of a multidistrictal vasculopathy related to an atherosclerotic burden, that shares the same risk factors and onset pathophysiological mechanisms. The absolute incidence of a stroke after open heart surgery (OHS) is about 2%, higher in case of combined cardiac procedures, with a negative prognostic impact in terms of in-hospital mortality and neurological morbidity. Heterogenous and interlinked risk factors contribute to the genesis of cerebral injuries after OHS outlining patient general features, vascular risk parameters and severity indeces of cardiac disease; a model stroke for patients undergoing cardiac surgery may be helpful so as to identify subsets of patients at high risk and select the most appropriate strategy. A critical carotid stenosis should be contextualized not as the Romadirect cause of stroke, but as a risk marker of high grade atherosclerotic systemic disease, predicting a potential severe aortic or intracerebral vessel disease and leading to recognize and study carefully these multivascular patients before operation. The idea of carotid plaque as active embolic source is valid only in case of vulnerable plaques in relation to the potential detachment of particulate material. Until now the neurological status, in accordance with symptomatic or asymptomatic carotid stenosis, has markedly influenced the operation timing and the choice of the surgical strategy. Except for special circumstances, we generally suggest a 'reverse staged' surgical strategy with cardiac surgery before carotid timing in elective patients recommending strongly a pharmacological neuroprotection relied on the administration of Sodium Thiopentone. Most of carotid stenosis in patients undergoing OHS is asymptomatic and doesn't represent a proven independent risk factor for postoperative stroke; indeed, we advocate that synchronous surgical treatment of both carotid and cardiac lesions is burdened from higher perioperative mortality and stroke rates rightfully unjustifiable according to potential benefits.