What is the best approach for patients requiring both Coronary Artery Bypass Grafting (CABG) and Carotid Endarterectomy (CE)?

Management of Patients Requiring Both CABG and Carotid Endarterectomy

For patients requiring both CABG and carotid revascularization, the approach must be determined by symptom status: symptomatic carotid stenosis (>70% with recent TIA/stroke <6 months) warrants carotid revascularization before or concurrent with CABG, while asymptomatic stenosis—even if severe—lacks evidence supporting prophylactic revascularization and should generally be managed with optimal medical therapy alone. 1

Symptomatic Carotid Disease (Recent TIA/Stroke <6 months)

Carotid revascularization is reasonable when:

• Stenosis is 70-99% with ipsilateral retinal or hemispheric symptoms within 6 months 1
• The indication applies to both CEA and CAS with embolic protection 1
• Timing (synchronous vs. staged) should target the most symptomatic territory first 1

Procedural considerations for symptomatic patients:

• CEA before CABG reduces stroke risk but increases myocardial infarction risk 1
• Combined CEA-CABG has not been tested in prospective trials but may reduce MI compared to staged approaches 1
• The sequence must be dictated by the relative severity of cerebral versus myocardial dysfunction 1

Asymptomatic Carotid Disease

Prophylactic carotid revascularization is NOT recommended because:

• Most strokes during CABG are mechanistically unrelated to carotid stenosis 1
• No convincing evidence shows that CEA or CAS reduces adverse events in asymptomatic patients undergoing CABG 1
• Contemporary medical therapy reduces stroke risk to ≤1% per year 2
• The 30-day combined death/stroke rate after combined procedures is >9% in most reports 1

Limited exceptions where revascularization may be considered (Class IIb):

• Bilateral 70-99% stenosis in men 1
• Unilateral 70-99% stenosis with contralateral occlusion in men 1
• NOT recommended in women or patients with life expectancy <5 years 1

Preoperative Screening Recommendations

Carotid duplex ultrasound screening is reasonable before elective CABG in patients with: 1

• Age >65 years
• Left main coronary stenosis
• Peripheral arterial disease
• History of stroke or TIA
• History of smoking
• Diabetes mellitus
• Hypertension
• Carotid bruit

Choice of Revascularization Method

CEA remains the procedure of choice over CAS: 1

• Meta-analyses show CAS results in significantly increased 30-day death or stroke (OR 1.60,95% CI 1.26-2.02) 1
• International Carotid Stenting Study showed 8.5% events with CAS vs. 5.2% with CEA (HR 1.69, P=0.006) 1
• New post-procedural brain lesions occur more frequently after CAS (OR 5.2, P<0.0001) 1

CAS may be considered only in specific circumstances: 1

• Post-radiation or post-surgical stenosis
• Hostile neck anatomy, tracheostomy, laryngeal palsy
• Severe comorbidities contraindicating CEA
• Should be performed only by experienced teams with demonstrated 30-day death-stroke rate <3% in asymptomatic patients 1

Timing Strategies and Outcomes

Combined (synchronous) CEA-CABG:

• Operative mortality 3.7%, perioperative stroke 2.5%, perioperative MI 3.7% in experienced centers 3
• Combined death/MI/stroke rate approximately 10% 3
• Meta-analysis shows increased risk of stroke or death (RR 1.49,95% CI 1.03-2.15) compared to staged procedures 4
• Recent series (2006-2018) show improved results: 2.2% mortality, 2.2% stroke rate 5

Staged CEA followed by CABG:

• Average interval 6.87 days between procedures 6
• Perioperative mortality 5.0%, stroke 5.0%, MI 5.0% after both operations 6
• Zero deaths, zero strokes, 2.5% MI immediately after CEA alone 6

Staged CAS followed by CABG:

• Lower postoperative stroke rate (2.4% vs. 3.9%) compared to CEA-CABG 1
• Combined stroke and death (6.9% vs. 8.6%) favors CAS-CABG 1
• However, requires aggressive antiplatelet therapy which increases CABG bleeding risk 1

Critical Pitfalls to Avoid

Do not perform prophylactic carotid revascularization in:

• Neurologically asymptomatic patients with unilateral carotid disease—the 9% procedural risk cannot be justified 1
• Acute coronary events—increased rates of unstable carotid plaques with high perioperative stroke risk 1
• Women with asymptomatic stenosis 1

Antiplatelet management challenges:

• Clopidogrel increases CABG bleeding risk but delaying therapy raises stent thrombosis risk 1
• Aspirin is mandatory immediately before and after carotid revascularization 1
• Dual antiplatelet therapy required for ≥1 month after CAS 1

Multidisciplinary Team Requirement

A multidisciplinary team including cardiologist, cardiac surgeon, vascular surgeon, and neurologist is mandatory for decision-making 1 to:

• Assess relative magnitudes of cerebral versus myocardial dysfunction
• Determine optimal timing and sequence of procedures
• Evaluate individual patient risk factors
• Consider off-pump CABG to avoid aortic cross-clamping in patients with severe carotid disease 1