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Is carotid screening redundant for patients undergoing coronary artery bypass grafting?
1Department of Cardiothoracic Surgery, Royal Papworth Hospital, Cambridge Biomedical Campus, Cambridge, United Kingdom.
Insights
Preoperative carotid ultrasound screening before coronary artery bypass grafting (CABG) is not recommended. While severe carotid stenosis (CS) increases stroke risk after CABG, its low prevalence and low intervention rates do not justify widespread screening.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Vascular Surgery
Background:
- Stroke is a serious complication after coronary artery bypass grafting (CABG).
- The utility of preoperative carotid ultrasound for identifying carotid stenosis (CS) before CABG is uncertain.
- Current guidelines do not clearly define management strategies based on preoperative CS detection.
Purpose of the Study:
- To systematically review the literature on the role of preoperative carotid ultrasound in patients undergoing CABG.
- To evaluate the impact of identifying carotid stenosis on perioperative stroke risk and management.
- To determine if routine screening for CS is justified in asymptomatic patients prior to CABG.
Main Methods:
- A systematic literature review adhering to PRISMA guidelines was conducted.
- MEDLINE database search from 1950 to May 2020.
- Fifteen studies were included from 5931 initially identified papers.
Main Results:
- Evidence indicates a higher incidence of postoperative stroke in patients with severe CS.
- However, the prevalence of severe CS is low, and the absolute stroke risk even in this subgroup remains not particularly high.
- International practice shows limited carotid intervention before or during CABG, even in patients with severe CS.
Conclusions:
- Widespread screening for asymptomatic carotid stenosis before CABG is not supported by current evidence.
- The low prevalence of severe CS and the low rates of intervention suggest that routine screening is not cost-effective or clinically beneficial.
- Further research may be needed to refine risk stratification and identify specific patient subgroups who might benefit from intervention.
Objectives:
Stroke is a devastating complication following coronary artery bypass grafting, which thankfully occurs with low incidence. The role of preoperative carotid ultrasound remains unclear. Whilst it is a cheap and reliable way of diagnosing carotid stenosis (CS), it is unclear if and how this knowledge should impact on subsequent patient management.
Methods:
A systematic review of the literature was performed using the PRISMA guideline. A literature search was conducted on the MEDLINE database from 1950 to May 2020 using the OVID interface. Fifteen papers out of a total of 5931 were identified for inclusion.
Results:
The evidence overall suggests that patients with severe CS are likely to have an increased incidence of postoperative stroke-however, the prevalence of severe CS is low, and even in this cohort of patients, the incidence is not particularly high.
Conclusion:
In screened patients identified to have severe CS, there appears to be a generally low appetite for undertaking carotid intervention internationally either before or concurrently with the coronary artery bypass grafting. Putting this all together, the widespread screening of asymptomatic patients would appear to not be justified.
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