Is Canadian cardiac surgeons' management of asymptomatic carotid artery stenosis at coronary artery bypass supported by the literature? A survey and a critical appraisal of the literature.
OBJECTIVE
To document and compare the management of asymptomatic carotid stenosis (ACS) by Canadian cardiac surgeons at coronary artery bypass grafting (CABG) against a critical literature analysis.


METHODS
A multiple choice survey and a structured literature review.


METHODS
Seventy-seven surgeons and 272 publications selected from the English literature between 1980 and 1997. Search terms used were "carotid," "coronary bypass," and "cardiac surgery."


METHODS
Five natural history studies were identified, and 58 studies were found that had objective documentation of ACS of 50% or more before cardiac surgery, and both operative stroke and mortality data reported for CABG with and without carotid endarterectomy (CEA).


METHODS
Natural history and outcome studies were independently rated against published guidelines. Outcome data were independently pooled and compared. Data discrepancy was resolved by consensus. Survey results were tabulated for simple descriptive statistics.


RESULTS
No methodologically sound natural history studies were found to document an increased risk of stroke from ACS after CABG. There were no randomized controlled studies to guide treatment recommendations. Pooled data for stroke or death did not support CEA for risk reduction from ACS at CABG (relative risk 0.9, p = 0.5). Ninety-four percent of surgeons believed that the literature is insufficient to support the routine use of CEA to reduce the risk of stroke from ACS after CABG. Despite this, 20% of surgeons advocated CEA for this purpose.


CONCLUSIONS
The management of ACS at CABG by the majority of Canadian cardiac surgeons is consistent with the results of the literature review; however, significant management variation exists.
Palerme
L P
LP
Division of Vascular Surgery, Faculty of Medicine, McGill University, Montreal, Que.
Hill
A B
AB
Obrand
D
D
Steinmetz
O K
OK
D002170:Canada / Q000453:epidemiology; D016893:Carotid Stenosis / Q000150:complications* / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D003131:Combined Modality Therapy; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality / Q000592:standards* / Q000706:statistics & numerical data*; D003327:Coronary Disease / Q000150:complications* / Q000601:surgery*; D016894:Endarterectomy, Carotid / Q000592:standards* / Q000706:statistics & numerical data*; D019317:Evidence-Based Medicine; D006801:Humans; D015999:Multivariate Analysis; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards* / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012107:Research Design; D012307:Risk Factors; D020521:Stroke / Q000209:etiology; D011795:Surveys and Questionnaires; D016896:Treatment Outcome