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Asymptomatic carotid disease in the cardiovascular surgical patient: is prophylactic endarterectomy necessary?
Insights
Asymptomatic carotid artery disease is common in patients undergoing vascular surgery but rarely causes perioperative stroke. Prophylactic carotid endarterectomy is not typically necessary before coronary or peripheral arterial reconstruction.
Area of Science:
- Vascular Surgery
- Cardiology
- Neurology
Background:
- Patients with peripheral vascular disease often have co-existing asymptomatic carotid occlusive disease.
- The clinical significance of asymptomatic carotid stenosis in patients undergoing major arterial reconstruction remains debated.
Purpose of the Study:
- To evaluate the prevalence of hemodynamically significant carotid obstruction in patients scheduled for coronary or peripheral arterial reconstruction.
- To assess the association between carotid obstruction, cervical bruits, and perioperative stroke.
- To determine the necessity of prophylactic carotid endarterectomy in this patient population.
Main Methods:
- Prospective screening of 314 patients using non-invasive techniques for carotid artery stenosis.
- Correlation of non-invasive findings with clinical examination (cervical bruit).
- Analysis of perioperative outcomes, including stroke, transient ischemic attack (TIA), and mortality.
Main Results:
- Significant carotid obstruction (≥50% stenosis or occlusion) was found in 13.1% of patients.
- Cervical bruits were present in only one-third of patients with significant obstruction.
- Only 37.5% of audible bruits correlated with significant carotid obstruction.
- No prophylactic carotid endarterectomies were performed.
- One perioperative TIA and one non-fatal stroke occurred, unrelated to detected carotid obstruction.
- Perioperative mortality was higher in patients with carotid obstruction or bruit, primarily due to myocardial infarction.
Conclusions:
- Asymptomatic carotid occlusive disease is common in patients with peripheral vascular disease but does not significantly increase perioperative stroke risk.
- Routine prophylactic carotid endarterectomy is not indicated prior to coronary or peripheral vascular reconstruction.
- Cervical bruits are unreliable indicators of significant carotid obstruction in this setting.
Abstract:
This prospective study used non-invasive techniques to screen for asymptomatic carotid occlusive disease in 314 patients who were to have coronary or peripheral arterial reconstruction. Hemodynamically significant carotid obstruction (greater than or equal to 50% stenosis or occlusion) was present in 54 arteries of 41 patients (13.1%), but only one-third of these lesions were accompanied by a cervical bruit. Among 48 carotid arteries where a bruit was heard, only 18 (37.5%) were associated with significant obstruction demonstrated by non-invasive screening. No prophylactic carotid endarterectomies were performed. There was only one perioperative TIA and one non-fatal stroke, neither of which was related to detectable carotid obstruction. In patients with peripheral vascular disease and detectable carotid obstruction or bruit, the perioperative mortality was higher than in patients without carotid obstruction or bruit (15.0% and 18.2 vs 3.1% and 2.1%, respectively). The deaths were primarily due to myocardial infarction. This study suggests that asymptomatic carotid occlusive disease, while common in patients with other cardiovascular disease, does not necessarily predispose to perioperative stroke and thus does not necessitate prophylactic carotid endarterectomy prior to indicated coronary or peripheral vascular reconstruction.