Carotid intervention prior to or during coronary artery bypass grafting. When is it necessary?
Management of patients with advanced atherosclerosis involving the extra-cranial carotid and coronary arteries should be individualized based on symptoms and disease severity. A liberal policy to identify high-grade carotid stenosis using duplex ultrasound testing prior to coronary revascularization is recommended. Carotid intervention is efficacious for stroke reduction in patients with severe (>70% diameter reduction), bilateral internal carotid artery disease, especially if testing indicates abnormal cerebral perfusion via the circle of Willis. The morbidity of a combined carotid-coronary revascularization procedure should be less than 5%, but higher stroke and death rates can be expected in urgent cases with recent hemispheric symptoms. Patients with symptomatic >50% internal carotid artery stenosis should be considered for carotid endarterectomy at the time of coronary revascularization. Carotid angioplasty with cerebral protection is also an appropriate option in "high-risk" cardiac patients, especially in vascular centers with expertise and experience in performing this procedure. A policy of carotid endarterectomy prior to coronary bypass grafting is justified only in patients with stable coronary disease, good ejection fraction, and is best-performed using regional anesthesia.
Bandyk
D F
DF
Division of Vascular and Endovascular Surgery, University of South Florida, College of Medicine, Tampa, FL, USA. dbandyk@hsc.usf.edu
Back
M R
MR
Johnson
B L
BL
Shames
M L
ML
D000800:Angioplasty, Balloon; D016893:Carotid Stenosis / Q000150:complications / Q000401:mortality / Q000601:surgery*; D003131:Combined Modality Therapy / Q000401:mortality; D015897:Comorbidity; D001026:Coronary Artery Bypass; D003324:Coronary Artery Disease / Q000150:complications / Q000401:mortality / Q000601:surgery*; D016894:Endarterectomy, Carotid; D006801:Humans; D018570:Risk Assessment; D015996:Survival Rate