Eur J Cardiothorac Surg 2002;22:327
© 2002 Elsevier Science NL
Staged carotid and coronary surgery for concomitant carotid and coronary artery disease
Idris M. Ali
Cardiovascular Surgery, QEII Health Science Center, Room 2265, Halifax Nova Scotia, Canada B3H 3A7
Received 28 April 2002;
accepted 15 May 2002.
We read with interest the article by Antunes et al. [1]. As stated, combined carotid and coronary artery disease is a very interesting clinical entity in cardiovascular surgery. The strategy of its management continues to be one of the Surgeon's dilemmas. The non-randomized data of the article revealed that the majority of the patients who required carotid endarterectomy (CEA) were asymptomatic (57 patients out of 77 patients).
Generally postoperative stroke in patients with asymptomatic carotid artery stenosis is a real risk. However, the author's conclusion that recommends their staged approach including the patients with the asymptomatic carotid stenosis is not well supported by their data or even by the data from the related literature. The North American Symptomatic Carotid Endarterectomy (NASCET) [2] and the asymptomatic Carotid Disease Study (ACAS) [3] showed that the risk of stroke in asymptomatic carotid artery patients is 2% per year and prophylactic CEA did not show any significant benefits, therefore the CEA was not recommended in this group of patients. In addition, the lack of information from other large randomized related clinical trials led to the same recommended management i.e. conservative (non-surgical) for the patients with asymptomatic carotid artery stenosis. This recommendation was also based on the fact that most of the strokes (45%) in the asymptomatic carotid stenosis are not from the large-artery disease [2]. In our center we adopted the strategy of performing CEA only for the symptomatic carotid stenosis, the results have been acceptable and comparable to the reported data from the literature [4]. Therefore we still believe that CEA should only be recommended, either staged or combined with coronary surgery, in patients with symptomatic carotid artery disease and not in those with asymptomatic carotid artery disease.
References
- Antunes P.E., Anacleto G., Ferrao de Oliverira J.M., Eugenio L., Antunes M.J. Staged carotid and coronary surgery for concomitant carotid and coronary artery disease. Eur J Cardiothorac Surg 2002;21:181-186.[Abstract/Free Full Text]
- Inzitari D., Eliasziw M., Gates P., Sharp B., Chan R., Meldrum H., Barnett H. The cause and risk of strke in patients with asymptomatic internal carotid artery stenosis. N Engl J Med 2000;342:1693-1700.[Abstract/Free Full Text]
- Executive committee for asymptomatic carotid atherosclerosis study. Endarterectomy for asymptomatic carotid artery stenosis stenosis. J Am Med Assoc 1995;273:1421-1428.[Abstract]
- Idris M.Ali, Cummings B., Sullivan J., Francis S. The risk of cerebrovascular accident in patients with asymptomatic critical carotid artery stenosis who undergo open-heart surgery. Can J Surg 1998;4:374-378.
