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Eur J Cardiothorac Surg 2002;22:327-328
© 2002 Elsevier Science NL

Letter to the Editor

Reply to Ali

Pedro E. Antunes, Manuel J. Antunes*

Coimbra University Hospital, Coimbra, P-3000, Portugal

Received 15 May 2002; accepted 23 May 2002.

* Corresponding author. Tel.: +351-239-400418, fax: +351-239-829674
e-mail: antunes.cct.huc{at}mail.telepac.pt

We would like to thank Ali et al. for their comments to our paper [1].

The optimal treatment of severe unilateral asymptomatic carotid artery stenosis in patients undergoing surgical coronary revascularization is far to be established as no prospective randomised investigation has, to date, compared the results of medical versus surgical treatment of the carotid lesion in this subgroup of patients. Data obtained among non-cardiac surgery patients seems to suggest that the prophylactic treatment of asymptomatic carotid stenosis is able to confer a moderate although significant decrease of neurological protection in the years after surgery when compared with the medical therapy. The asymptomatic carotid atherosclerosis (ACAS) study [2] demonstrated that if the perioperative mortality and the incidence of complications is low, endarterectomy of asymptomatic carotid lesions is superior to medical treatment in terms of stroke prevention and a recent meta-analysis which examined all published trials on this issue further supported this conclusion [3].

Although the role of carotid disease in the genesis of perioperative stroke in patients undergoing isolated myocardial revascularisation remains incompletely defined, because of its multifactorial etiology, several reports indicate that significant carotid artery stenosis is an important, and for some the strongest incremental risk factor. In this context, a recent study by Hirotani T et al. [4] not only identified the severity of carotid artery stenosis as an independent predictor of postoperative stroke, but also reported a postoperative stroke rate in asymptomatic patients with carotid stenosis greater than 75% fivefold higher than in patients with lesions of less than 50%. In their conclusion, they advocate that in order to reduce the incidence of stroke, the indications for prophylactic carotid endarterectomy may be extend to asymptomatic patients with carotid artery stenosis greater than 75%. Additionally, another recent work [5] concludes that the treatment, either staged or simultaneous, of unilateral asymptomatic carotid artery stenosis, at the time of CABG, confers significant neurological protection during the years after the operation.

Although this issue remains controversial, we do not have the same opinion expressed by Ali et al. and strongly believe that there are clinical perioperative and long term advantages in terms of neurologic protection in performing carotid endarterectomy before CABG.

References

  1. Antunes P.E., Anacleto G., Ferrão de Oliveira J.M., Eugénio 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]
  2. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. Endarterectomy for asymptomatic carotid artery stenosis. J Am Med Assoc 1995;273:1421-1428.[Abstract/Free Full Text]
  3. Benavent O., Mother D., Pham B. Carotid endarterectomy for asymptomatic carotid stenosis: a meta-analysis. Br Med J 1998;317:1477-1480.[Abstract/Free Full Text]
  4. Hirotani T., Kameda T., Kumamoto T., Shirota S., Yamano M. Stroke after coronary artery bypass grafting in patients with cerebrovascular disease. Ann Thorac Surg 2000;70:1571-1576.[Abstract/Free Full Text]
  5. Gaudino M., Glieca F., Luciani N., Celini C., Morelli M., Spatuzza P., Mauro M., Alessandrini F., Possati G. Should severe monolateral asymptomatic carotid artery stenosis be treated at the time of coronary artery bypass operation?. Eur J Cardiothorac Surg 2001;19:619-626.[Abstract/Free Full Text]




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