Does the risk of post-CABG stroke merit staged or synchronous reconstruction in patients with symptomatic or asymptomatic carotid disease?

Abstract

The management of patients undergoing coronary artery bypass grafting (CABG) who are found to have co-existent carotid artery disease remains controversial. Management options include performing an isolated CABG, synchronous carotid endarterectomy (CEA) plus CABG, staged CEA-CABG, reverse staged CABG-CEA, synchronous CEA+CABG off bypass (OFFCAB) and staged carotid angioplasty with stenting (CAS) followed by CABG. For any of these combined or staged interventions to be clinically effective, the following conditions must be met; (1) CABG must be a proven intervention for ischaemic heart disease, (2) stroke must be an important cause of peri-operative morbidity and mortality, (3) the incidence of post-CABG stroke must be high enough to justify a programme of prevention, (4) carotid disease must be an important cause of post-CABG stroke, (5) CEA (CAS) must be a proven intervention in carotid artery disease and (6) prophylactic CEA (CAS) should reduce the risk of post-CABG stroke. This paper reviews the literature and concludes that conditions 1, 2 and 5 are met and that condition 3 can be achieved provided high risk' subgroups are targeted. However, there is limited evidence to support the contention that carotid disease is a major cause of post-CABG stroke and any potential benefit conferred by prophylactic intervention (whether by CAS or CEA) may be offset by the relatively high procedural risks observed in systematic reviews. Prophylactic carotid intervention is justified in CABG patients with a prior history of stroke or TIA. Debate continues about the role of CEA (CAS) in patients with asymptomatic bilateral carotid disease, but there seems to be little evidence to justify prophylactic CEA or CAS in CABG patients with unilateral asymptomatic carotid disease.