Should patients with asymptomatic significant carotid stenosis undergo simultaneous carotid and cardiac surgery?

Abstract

A best evidence topic in cardiovascular surgery was written according to a structured protocol. The question addressed was whether patients with severe asymptomatic carotid and coronary artery diseases should undergo simultaneous carotid endarterectomy (CEA) and coronary artery bypass grafting (CABG). A total of 624 papers were found using the reported search, of which 20 represent the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study results of these papers are tabulated. Previous cohort studies showed mixed results, while advocating for the necessity of a randomized controlled trial (RCT). A recent RCT showed that patients undergoing prophylactic or simultaneous CEA + CABG had lower rates of stroke (0%) compared with delayed CEA 1-3 months after CABG (7.7%), without significant perioperative mortality difference. This study included patients with unilateral severe (>70%) asymptomatic carotid stenosis requiring CABG. An earlier partly randomized trial also showed better outcomes for patients undergoing simultaneous procedures (P = 0.045). Interestingly, systematic reviews previously failed to show compelling evidence supporting prophylactic CEA. This could be partly due to the fact that these reviews collectively analyse different cohort qualities. Neurological studies have, however, shown reduced cognitive and phonetic quality and function in patients with unilateral and bilateral asymptomatic carotid artery stenosis. Twenty-one RCTs comparing lone carotid artery stenting (CAS) and CEA informed the American Heart Association guidelines, which declared CAS comparable with CEA for symptomatic and asymptomatic carotid stenosis (CS). However, the risk of death/stroke for CAS alone is double that for CEA alone in the acute phase following onset of symptoms, while CEA alone is associated with a doubled risk of myocardial infarction. There is, however, no significant difference for combined 30-day risk of death/stroke/myocardial infarction. Outcomes of hybrid or simultaneous CAS/CABG procedures show comparable results, albeit from rather small cohorts. While current evidence leans towards simultaneous CEA/CABG, the emergence of hybrid operating theatres in various institutions may allow larger cohorts with subsequent significant data on simultaneous CAS/CABG. A randomized controlled trial comparing both approaches would be crucial in informing future updates of existing guidelines.

A New Rat Model of Chronic Cerebral Hypoperfusion Resulting in Early-Stage Vascular Cognitive Impairment

“…In recent, an increasing number of elderly patients are presenting with asymptomatic carotid stenosis accompanied by varying degrees of cognitive dysfunction (Elhfnawy et al, 2019;Gray et al, 2019;Nickel et al, 2019;Seo et al, 2019). Pharmacological treatments such as propofol and sevoflurane (Shmelev and Neimark, 2013), as well as non-pharmacological therapy options (Ogutu et al, 2014;Lal et al, 2017;Gray et al, 2019) such as surgical treatment, should be used with caution to reduce the incidence of concurrent cognitive impairment. Therefore, it is essential to establish novel VCI models characterized by simplicity, stability, and low mortality to enable drug tests that evaluate their potential efficacy before clinical trials.…”

Predictors of intracranial cerebral artery stenosis in patients before cardiac surgery and its impact on perioperative and long-term stroke risk

“…However, there is lack of high quality evidence to guidedecision making about revascularization in patients undergoing CABG, and available guidelines are based on limited data in this area of clinical practice [19]. Carotid revascularization is recommended in patients scheduled for CABG when carotid stenosis is symptomatic or bilateral [20,21].…”

“…Carotid revascularization is recommended in patients scheduled for CABG when carotid stenosis is symptomatic or bilateral [20,21]. Unilateral asymptomatic carotid stenosis management before CABG is still unsolved [19].…”

How Can We Treat Asymptomatic Carotid Disease in Patients with a Planned CABG?

“…Optimal surgical intervention and timing for patients having concomitant severe carotid and coronary artery stenosis remains uncertain. A hypothesis for the higher death and stroke rates is that combined procedures reveal higher operative stress, prolonged operative time and instability in hemodynamics on cardiac and cerebrovascular system (29) . There are different surgical techniques which can be chosen depending on patient status and characteristics of carotid disease.…”