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Asymptomatic carotid disease in patients undergoing major cardiovascular operations: can prophylactic endarterectomy
Insights
Routine prophylactic carotid endarterectomy before major cardiovascular operations is not supported by evidence for asymptomatic carotid disease. Careful postoperative follow-up is recommended for patients not undergoing endarterectomy due to potential late transient ischemic attacks.
Area of Science:
- Cardiovascular Surgery
- Neurology
- Vascular Surgery
Background:
- Asymptomatic carotid disease poses a risk for stroke in patients undergoing major cardiovascular operations.
- Prophylactic carotid endarterectomy is considered to mitigate this risk, but its routine use is debated.
Purpose of the Study:
- To review existing literature and present new data on the efficacy of prophylactic carotid endarterectomy in patients with asymptomatic carotid disease undergoing major cardiovascular surgery.
- To evaluate the perioperative stroke and mortality rates associated with prophylactic carotid endarterectomy versus no intervention.
Main Methods:
- Systematic review of published studies involving staged or concomitant carotid endarterectomy and coronary artery bypass grafting.
- Analysis of perioperative stroke rates in patients undergoing prophylactic carotid endarterectomy versus those undergoing major cardiovascular operations without it.
- Inclusion of a prospective study evaluating late postoperative neurologic deficits.
Main Results:
- A pooled perioperative stroke rate of 2.9% was observed in 1,483 patients undergoing carotid endarterectomy and coronary artery bypass grafting.
- No significant difference in perioperative stroke rate (2.7%) was found between patients undergoing major cardiovascular operations with or without prophylactic carotid endarterectomy.
- Staged procedures were linked to higher rates of perioperative myocardial infarction and death; late transient ischemic attacks were noted in patients not undergoing endarterectomy.
Conclusions:
- There is insufficient evidence to support the routine prophylactic use of carotid endarterectomy for asymptomatic carotid disease prior to major cardiovascular operations.
- Patients not undergoing prophylactic endarterectomy require vigilant postoperative monitoring for potential transient ischemic attacks that may necessitate surgical intervention.
Abstract:
This article reviews the published experience supporting or refuting the value of prophylactic endarterectomy in patients with asymptomatic carotid disease who are candidates for major cardiovascular operations. Reports of 1,483 patients subjected to staged or concomitant carotid endarterectomy and coronary artery bypass grafting reveal a perioperative stroke rate of 2.9%. Timing of carotid endarterectomy did not influence stroke rate, but staged procedures were associated with a significantly greater incidence of perioperative myocardial infarction and death. Studies of patients undergoing major cardiovascular surgical operations without prophylactic carotid endarterectomy reported a perioperative stroke rate of 2.7%, which is not significantly different from that of patients undergoing prophylactic carotid endarterectomy. However, the author's prospective study of such patients showed a significant incidence of late postoperative neurologic deficits, which are usually transient ischemic attacks. There is no evidence to justify routine prophylactic carotid endarterectomy of asymptomatic carotid disease before major cardiovascular operations. Patients not undergoing endarterectomy, however, should be given careful postoperative follow-up, because transient ischemic attacks may occur that require surgical intervention.