Synchronous Cardiac and Carotid Revascularisation: The Devil is in the Detail

Abstract 

Background

Studies reporting outcomes following staged/synchronous carotid revascularisation prior to cardiac surgery have generally concluded that procedural strokes are reduced. However, virtually none have commented specifically on the risk of stroke in patients with bilateral carotid disease who then undergo their cardiac procedure in the presence of an unoperated, contralateral stenosis. If carotid disease really was an important cause of peri-operative stroke, these patients should incur a much higher risk of stroke following their cardiac procedure.

Methods

Retrospective audit of prospectively acquired data in 132 consecutive patients undergoing synchronous carotid endarterectomy and cardiac surgery.

Results

Overall 30-day rates of mortality, ipsilateral stroke and any stroke were 5.3%, 1.5% and 3% respectively. The 30-day rate of death/stroke was 6.8%. In 51 patients with a prior history of stroke/TIA, the 30-day rate of death/stroke was 5.9%, compared with 7.4% in neurologically asymptomatic patients. The majority (57%) had significant bilateral disease and underwent their combined procedure in the presence of a significant, non-operated (asymptomatic) contralateral stenosis (50–99% = 75, 60–99% = 54, 70–99% = 32). Only one patient (90–99% stenosis) suffered a post-operative stroke in the hemisphere ipsilateral to the non-operated, contralateral stenosis.

Conclusions

Patients undergoing synchronous procedures incurred a low rate of procedural stroke, perhaps justifying this management approach. However, an alternative and more critical analysis suggested that the risk of procedural stroke in patients with significant (non-operated) contralateral asymptomatic carotid disease was extremely low. This challenges the assumption that asymptomatic carotid disease is an important cause of stroke during cardiac surgery.

Keywords: Carotid endarterectomy, Cardiac surgery, Stroke, Carotid stenosis