|Carotid stenosis & coronary
|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
- 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 <
- Stroke risk of CABG patients with hemodynamically significant carotid
stenosis: 6% to 16%
|CEA & CABG: combined vs staged
|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
- 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
- Meta-analysis of 11 series:
- 6.9% stroke risk for combined procedures in patients with unilateral
- 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
|Riggs, PN, DeWeese JA. Carotid Endarterectomy.
Surgical Clin of N America. Vol 78, Num 5, Oct 1998