Andrew J. Gorton MD, Jeffrey A. Hutchens MD, Michael E. Sekela MD
University of Kentucky
September 3, 2024
Abbreviations & Definitions
CABG – coronary artery bypass graft
CAS – carotid artery stenting
CEA – carotid endarterectomy
CTA – computerized tomography angiography
MRA – magnetic resonance angiography
Indications & Guidelines for Management by Grade/Stage of Disease
The 2021 ACC/AHA guidelines on coronary artery revascularization do not address combined carotid and coronary artery disease.1 However, the 2011 ACC/AHA guidelines for CABG and extracranial carotid and vertebral artery disease provide Grade 2A recommendations for preoperative carotid stenosis screening of CABG candidates with any of the following: greater than 65 years of age, left main coronary artery stenosis, peripheral arterial disease, cerebrovascular disease, hypertension, smoking, or diabetes mellitus.2,3 More recently, the 2022 Society for Vascular Surgery clinical practice guidelines for the management of extracranial cerebrovascular disease provided a Grade 2B recommendation for all patients undergoing CABG to be screened for occult carotid stenosis.4 While the ACC/AHA guidelines do not discuss a preferred screening modality, the Society for Vascular Surgery recommends the use of duplex ultrasound and states that CTA or MRA may be used if results are equivocal.2-4
Figure 1: Indications for Carotid Artery Stenosis Screening
Management of carotid artery stenosis in pre-CABG patients is dependent on the presence or absence of symptoms, the degree of stenosis, and whether one or both internal carotid arteries are affected. Carotid stenosis is stratified as either mild (<50%), moderate (50-69%), severe (70-99%), or complete total occlusion (100%). The 2022 Society for Vascular Surgery Guidelines recommends CEA before or concomitant with CABG in symptomatic patients with carotid stenosis of 50-99%, asymptomatic patients with severe bilateral disease, and those with severe unilateral disease with contralateral total occlusion (Grade 2C). A staged approach is preferred except in those with severe symptomatic carotid disease and an urgent need for CABG. The choice of carotid revascularization therapy is to be determined by timing, need for anticoagulation or antiplatelet therapy, anatomy, and patient characteristics. In low-surgical risk patients, the SVS recommends CEA over CAS for the treatment of both symptomatic and asymptomatic carotid stenosis.4 CAS may require a longer delay to CABG compared to CEA due to the general need for dual antiplatelet therapy following stent placement.
Figure 2: Treatment Algorithm
Table 1. Summary table of guidelines
| Recommendations | Class of Recommendation | Level of Evidence |
|---|---|---|
| Preoperative Evaluation and Screening | ||
| Multidisciplinary team approach for patients with clinically significant carotid artery disease to undergo CABG to include vascular surgery and neurologist | Class I | C |
| Carotid artery duplex scanning is reasonable in high-risk patients | Class IIa | C |
| Concomitant Treatment | ||
| In patients with previous TIA or stroke and significant carotid artery disease (50-99%), it is reasonable to consider carotid revascularization in conjunction with CABG. Sequence and staging to be determined by relative magnitude of carotid and coronary disease. | Class IIa | C |
| Patients with no history of TIA or stroke that have bilateral severe carotid stenosis (70-99%) or unilateral severe stenosis with contralateral occlusion may be considered for carotid revascularization. | Class IIb | C |
Supporting Evidence for Current Indications & Guidelines
Perioperative stroke risk after CABG is <2% in asymptomatic patients with mild bilateral carotid artery stenosis. Risk increases to 3% in individuals with asymptomatic unilateral moderate to severe stenosis (50-99%), 5% in asymptomatic bilateral moderate to severe stenosis (50-99%), and 7-11% with contralateral complete total occlusion.5 Stroke risk for unilateral and bilateral symptomatic disease has been reported as 18% and 26%, respectively.6
Duplex ultrasound is the most cost-effective method to screen for carotid artery stenosis. In addition to a reported sensitivity of 85-92% and specificity of 84%, it can evaluate plaque morphology which may aid in the evaluation of stroke risk.4
The perioperative risk of stroke or death from isolated CEA is approximately 3%. The procedure has been shown to reduce the relative risk of ipsilateral stroke by approximately 30% over 3 years, which corresponds with an absolute risk reduction of approximately 1% per year. Therefore, the benefits of prophylactic carotid angioplasty in asymptomatic unilateral stenosis, regardless of severity, are not believed to outweigh the perioperative risk, while asymptomatic severe bilateral disease or severe unilateral disease with contralateral total occlusion and symptomatic disease are recommended.7,8
Ongoing Trials/Recent Publications
There are no ongoing large-scale randomized controlled trials relating to patients with combined carotid artery and coronary artery disease. Nardi et al. found no difference in freedom from major adverse cardiac and cerebrovascular events at 5 years in a cohort of 1046 CABG patients, 3% of whom underwent synchronous CAS.9 Nawrozi et al. reported a 13% incidence for the composite endpoint of mortality, stroke, and myocardial infarction at 30 days in subjects who underwent synchronous CEA and CABG.10 Haywood et al. reported no difference in the rate of stroke or mortality between synchronous and staged CEA and CABG at 30 days.11
Expert Commentary
It is our institutional policy to obtain carotid duplex screening on all patients undergoing elective CABG. In patients with asymptomatic carotid disease undergoing CABG, we often set higher mean arterial pressure goals while on cardiopulmonary bypass. Only in patients with symptomatic carotid and coronary disease do we consider concomitant operations. For patients with one symptomatic pathology and the other severe, we will arrange for staged interventions, addressing the symptomatic pathology first.
Sources
- Writing Committee Members; Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER, Beckie TM, Bischoff JM, Bittl JA, Cohen MG, DiMaio JM, Don CW, Fremes SE, Gaudino MF, Goldberger ZD, Grant MC, Jaswal JB, Kurlansky PA, Mehran R, Metkus TS Jr, Nnacheta LC, Rao SV, Sellke FW, Sharma G, Yong CM, Zwischenberger BA. 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2022 Jan 18;79(2):e21-e129. doi: 10.1016/j.jacc.2021.09.006. Epub 2021 Dec 9. Erratum in: J Am Coll Cardiol. 2022 Apr 19;79(15):1547.
- Hillis LD, Smith PK, Anderson JL, Bittl JA, Bridges CR, Byrne JG, Cigarroa JE, Disesa VJ, Hiratzka LF, Hutter AM Jr, Jessen ME, Keeley EC, Lahey SJ, Lange RA, London MJ, Mack MJ, Patel MR, Puskas JD, Sabik JF, Selnes O, Shahian DM, Trost JC, Winniford MD. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011 Dec 6;124(23):2610-42.
- Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, Cates CU, Creager MA, Fowler SB, Friday G, Hertzberg VS, McIff EB, Moore WS, Panagos PD, Riles TS, Rosenwasser RH, Taylor AJ; American College of Cardiology; American Stroke Association; American Association of Neurological Surgeons; American College of Radiology; American American College of Radiology; Society of NeuroInterventional Surgery; Society for Vascular Medicine; Society for Vascular Surgery. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation. 2011 Jul 26;124(4):e54-130.
- AbuRahma AF, Avgerinos ED, Chang RW, Darling RC 3rd, Duncan AA, Forbes TL, Malas MB, Murad MH, Perler BA, Powell RJ, Rockman CB, Zhou W. Society for Vascular Surgery clinical practice guidelines for management of extracranial cerebrovascular disease. J Vasc Surg. 2022 Jan;75(1S):4S-22S.
- Naylor AR, Mehta Z, Rothwell PM, Bell PR. Carotid artery disease and stroke during coronary artery bypass: a critical review of the literature. Eur J Vasc Endovasc Surg. 2002 Apr;23(4):283-94.
- D’Agostino RS, Svensson LG, Neumann DJ, Balkhy HH, Williamson WA, Shahian DM. Screening carotid ultrasonography and risk factors for stroke in coronary artery surgery patients. Ann Thorac Surg. 1996 Dec;62(6):1714-23.
- Chambers BR, Donnan GA. Carotid endarterectomy for asymptomatic carotid stenosis. Cochrane Database Syst Rev. 2005 Oct 19;2005(4):CD001923.
- Naylor AR, Bown MJ. Stroke after cardiac surgery and its association with asymptomatic carotid disease: an updated systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2011 May;41(5):607-24.
- Nardi P, Altieri C, Pisano C, Oddi FM, Ranucci A, Fresilli M, Salvati AC, Buioni D, Scognamiglio M, Ajello V, Bassano C, Ascoli Marchetti A, Ippoliti A, Ruvolo G. Early-Staged Carotid Artery Stenting Prior to Coronary Artery Bypass Grafting: Analysis of the Early and Mid-Term Results in Comparison with a Consecutive Cohort of Isolated Coronary Artery Surgery Patients. J Clin Med. 2024 Jan 15;13(2):480.
- Nawrozi P, Ratschiller T, Schimetta W, Gierlinger G, Pirklbauer M, Müller H, Zierer A. Perioperative and Long-Term Outcomes in Patients Undergoing Synchronous Carotid Endarterectomy and Coronary Artery Bypass Grafting: A Single-Center Experience. Adv Ther. 2024 May;41(5):1911-1922.
- Haywood NS, Ratcliffe SJ, Zheng X, Mao J, Farivar BS, Tracci MC, Malas MB, Goodney PP, Clouse WD. Operative and long-term outcomes of combined and staged carotid endarterectomy and coronary bypass. J Vasc Surg. 2023 May;77(5):1424-1433.e1. doi: 10.1016/j.jvs.2023.01.015. Epub 2023 Jan 18.
- Rokui S, Winicki NM, Pousatis S, Taylor B, Gammie J. Concomitant Coronary Artery and Carotid Disease. In: Baumgartner WA, Jacobs JP, Meyerson S, eds. Adult and Pediatric Cardiac Surgery. STS Cardiothoracic Surgery E-Book. Chicago: Society of Thoracic Surgeons; 2024. ebook.sts.org.
