Is carotid angioplasty followed by cardiac surgery a safe and effective treatment for carotid artery stenosis?
Peter RF Bell
Correspondence Department of Surgery, Robert Kilpatrick Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX, UK
Email peterrfbell@ntlworld.com
This article has no abstract so we have provided the first paragraph of the full text.
How best to treat patients with asymptomatic carotid stenosis who are scheduled to undergo cardiac surgery is an ongoing dilemma. A systematic review indicated that postoperative stroke occurs in about 2% of patients undergoing CABG surgery, but this figure varies from center to center and most strokes occur more than 24 h after the operation has been completed.1 Some clinical features can be used to predict stroke, but more than half of sufferers do not have any evidence of serious carotid disease, and autopsy evidence has shown that in many cases of fatal stroke the patient did not have territorial infarctions that correlated with patterns of existing carotid disease. The combined rate of death and ipsilateral stroke is undoubtedly highest among patients undergoing synchronous carotid endarterectomy (CEA) and CABG surgery, while CABG surgery performed before CEA in such patients carries the highest risk of stroke.2 Perioperative MI is lowest in patients undergoing CABG surgery before CEA and highest in patients undergoing CEA before CABG surgery. Overall, about 10% of patients undergoing staged or synchronous coronary and carotid procedures die or experience a nonfatal stroke or MI.1 Studies have shown that the best results, in terms of reducing the combined end point of death and stroke are observed when CEA is performed before off-bypass CABG surgery without aortic cross clamping.3 This finding indicates that the best way to treat patients with carotid stenosis who require cardiac surgery is to deal with the carotid lesion first and, where possible, to perform the procedures off-bypass.
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