Preoperative screening and management of carotid artery disease in patients undergoing cardiac surgery

Abstract

Careful clinical examination together with detailed previous history taking can identify the majority of patients with CAS. Further data are required for the construction of a scientifically valid policy as a guideline.

Does preoperative carotid stenosis screening reduce perioperative stroke in patients undergoing coronary artery bypass grafting?

“…However, low specificity would seem to dictate ultrasound screening, and possibly additional confirmatory testing 4 of a large proportion of these patients, to alleviate a false-positive diagnosis. On the other hand, carotid duplex ultrasound screening, whether selective or nonselective, identifies only a minority of patients who will develop perioperative stroke, and intervening for those with carotid disease might not decrease the risk of these neurologic events.…”

“…Peripheral artery disease, cerebrovascular disease (prior stroke or transient ischemic attack), and old age were the risk factors most consistently identified in these studies. 2–4,6,37,76–81 Applying carotid disease–screening algorithms to cohorts of ultrasound-screened patients undergoing CABG showed that most who had significant carotid artery stenosis could be detected. 5,77,82 Thus, Durand and colleagues 5 found that a risk-profiling algorithm based on a prior stroke or transient ischemic attack, carotid bruit on exam, or age >65 years would have missed significant carotid disease in only 2.3%of patients undergoing CABG (26 of 1138), although this represented 17% of 152 patients with significant carotid disease, and 582 had a false-positive result.…”

“…However, if carotid artery stenosis is not a direct etiologic risk factor for perioperative stroke, routine nonselective screening may not be cost effective. 4,10 In addition, the benefit of prophylactic carotid revascularization in patients with asymptomatic unilateral carotid disease is controversial. 11–15 Therefore, we have reviewed the literature for evidence that preoperative carotid artery screening, by identifying patients with substantial carotid stenosis and altering their management, decreases perioperative neurologic events in patients undergoing CABG.…”

Surgical coronary revascularization on-pump versus offpump in patients with stenosis of the main tree of the

“…Numerous studies have shown that the risk of occurrence of ICV during CABG is in direct correlation with the degree of carotid stenosis (14). As a consequence a common strategy for the treatment of such patients was "carotid before coronary" that is, first, an operation on the carotid arteries (CEA) and only then CABG in two parts, or as a simultaneous operation (15). However, in patients with significant stenosis of the main tree of the left coronary artery, "left main stenosis" (LMS) and carotid stenosis, priority is given to CABG, primarily because of the seriousness of the location of the stenosis, the symptoms, the possibility of hemodynamic instability, which is rather frequent in those patients, as well as because of the operation itself.…”

Management of Carotid Artery Disease in the Setting of Coronary Artery Disease in Need of Coronary Artery Bypass Surgery

“…Anastasiasdis et al evaluated carotid arteries in 307 patients undergoing CABG and reported that while 3 out of 4 patients undergoing CABG had carotid atherosclerosis, the majority of these (63%) had < 50% ECAS. (Anastasiadis, Karamitsos et al 2009). Various studies have reported the incidence of ECAS with varies degree of stenosis among the patient populations undergoing CABG which are summarized in table 1.…”