Faramarz Amiri MD IUMS

 Severe carotid disease (defined as >80%) 8–12%  Severe carotid disease (>70%) in those with three vessel or left main coronary disease 7–11%  Occlusions in general 1–1.5%  The prevalence as well as severity of carotid stenosis shows a stepwise correlation with the extent of coronary disease  Approximately 28% of patients who are candidates for carotid endarterectomy (CEA) have significant coronary artery disease; 12% of patients undergoing myocardial revascularization are noted to have significant carotid artery stenosis

 Class IIa indication for screening in those with Left main disease Smoking Age greater than 65 years Peripheral vascular disease Carotid bruit Stroke DM

ESC/EACTS Guidelines

 Incidence of postoperative stroke 1.3%  Risk factors : older age, female sex, aortic calcification, CHF,HX of stroke, preop AF, AAA ( cross-clamping and release), on-pump, combined valve-CABG, bypass time

 peri-CABG stroke risks Unilateral 50–99% % 3 Bilateral 50–99% % 5 Carotid occlusion % 7-11  60–80% of strokes in patients with significant carotid stenosis occur in the territory not perfused by the affected carotid

 peri-CABG stroke risks  Unil 50–99% % 3 Bil 50–99% %5 occlusion % 7-11  An incomplete circle of Willis may play a role in cerebral ischemia during carotid cross clamping, the importance of other collateral pathways was demonstrated in a recent study  60–80% of strokes in patients with significant carotid stenosis occur in the territory not perfused by the affected carotid  50–75% of periop strokes occur in the absence of significant carotid stenosis

 Primary carotid thromboembolic disease alone was not responsible for up to 59% of post CABG strokes  A significant proportion of post-operative strokes was in the vertebro-basilar territory or located contralateral to the severely stenosed carotid or ipsilateral to an insignificant stenosis.  Aortic arch atherosclerosis embolization may be an important cause of stroke in the majority of cases

ESC/EACTS Guidelines

 A combined approach might especially be beneficial in patients undergoing CABG who are symptomatic from a neurologic standpoint or the morphology of the carotid lesions suggests high risk of embolization; ie, ulcerated plaque, which will require intervention for both.  The available evidence suggests that staged CAS plus CABG exhibits similar safety profiles to the more conventional staged and synchronous surgical procedures.  Commonly, CAS is “staged” several weeks prior to CABG to permit treatment with dual antiplatelet therapy (aspirin and thienopyridine).

 Advocates of a staged procedure perform CEA several days prior to CABG or several weeks following cardiac surgery. The rationale of the staged procedure is to decrease the risk of stroke in the cardiac procedure and eliminate the need for longer and more stressful combined procedure.  Men with asymptomatic bilateral severe carotid stenoses (50% to 99%) or a unilateral severe stenosis in conjunction with a contralateral carotid artery occlusion may be considered for carotid revascularization in conjunction with CABG. Little evidence exists to suggest that women with asymptomatic carotid artery disease benefit from carotid revascularization in conjunction with CABG

 performing CEA and CABG in the same setting: If the combined approach can be done safely, a second surgical procedure and hospital stay may be eliminated, with significant cost reduction. Long-term stroke free survival may also be significantly improved.The problem with this approach is that the stroke rate is exceedingly high.

 Ignoring the carotid disease initially and addressing it weeks to months later after the CABG procedure may be another approach. This idea is supported by a retrospective review of 94 patients with asymptomatic high-grade carotid stenosis undergoing CABG. There was one perioperative stroke and no deaths in this group of patients. These data prophylactic CEA could barely prevent < 40% of post-CABG strokes

In the absence of clear guidelines, the decision is better individualized dealing with the more symptomatic vascular bed first. The simultaneous performance of CABG and CEA carries a high risk but is warranted in patients with recent symptoms of both severe coronary disease (unstable angina) and severe carotid stenosis.

(1) Neurological symptoms (stroke/TIA) (2) Bilateral carotid stenosis 80–99%. (3) Unilateral or bilateral carotid occlusions. (4) Unilateral 50–99% carotid stenosis with contralateral occlusion. (5) Asymptomatic 80–99% carotid stenosis with impaired cerebral perfusion reserve.