| Carotid stenosis & coronary
artery disease |
| Incidence of coronary artery
disease in patients needing CEA |
 | Patients with carotid stenosis frequently have coronary disease. |
| O'Donnell et al: 66% of patients undergoing Carotid Endarterectomy (CEA)
had clinical evidence of coronary disease. |
| Hertzer et al: coronary artery bypass grafting (CABG) warranted in 37% of
CEA patients. |
| Coronary disease was the cause of death in 24% of deaths occurring within
5 years of CEA. |
| CEA in patients with unstable coronary disease manifested by angina
pectoris: 15% risk of myocardial infarction & 18% risk of death. |
| Brener et al: meta-analysis of 15 studies, 407 patients treated with CEA
followed by CABG: risk of stroke 5.3%, myocardial infarction 11.3%, and death 9.4%. |
|
| Stroke risk of patients in CABG |
| Hertzer et al: 9714 patients being prepared for CABG: 2.8% has
symptomatic or high-grade carotid lesions. |
| Stroke risk for patients undergoing CABG is usually reported to be <
2%. |
| Stroke risk of CABG patients with hemodynamically significant carotid
stenosis: 6% to 16% |
|
| CEA & CABG: combined vs staged
operations |
Hertzer et al: prospectively randomized patients to
| Staged Surgery: CABG followed by CEA:
 | Unilateral asymptomatic patient: overall stroke risk of 14%
 | 58 patients underwent CABG with a 6.9% incidence of stroke. |
| Another 4 strokes occurred at the time of delayed CEA. |
|
| Symptomatic patients with unilateral stenosis: overall 13% had stroke
| 8.8% stroke risk at CABG |
| 1 stroke at delayed CEA |
|
|
| Combined surgery: CABG & CEA
| 71 patients with unilateral asymptomatic stenosis: 2.8% stroke rate |
| 60 symptomatic patients: 8.3% stroke rate. |
| Combined procedures have higher stroke and death rates than isolated
CABG. |
|
|
| Rizzo et al: combined operations on 127 patients with severe coronary
disease and carotid stenosis, with two thirds of the patients having carotid symptoms. The
stroke rate was 6.3%, and 5.5% myocardial-related deaths. |
| The presence of bilateral hemodynamically significant carotid disease
worsens the stroke risk of patients undergoing combined CABG and CEA and a delayed second
carotid endarterectomy. |
| Meta-analysis of 11 series:
| 6.9% stroke risk for combined procedures in patients with unilateral
carotid stenosis |
| 12.7% risk for patients with bilateral disease. |
|
| Highest-risk group: an occluded carotid and contralateral stenosis: 29%
stroke incidence with a combined procedure. |
| Patients with combined disease at low risk for cardiac events appear to
be best served with carotid endarterectomy before CABG. |
| Patients with unstable angina or left main or three-vessel coronary
disease may require CABG prior to CEA or need a combined approach. These patients appear
to be at greater risk for cerebral events if the carotid lesion is symptomatic or
bilateral. |
|
| Further reading |
| Riggs, PN, DeWeese JA. Carotid Endarterectomy.
Surgical Clin of N America. Vol 78, Num 5, Oct 1998 |
