What is the current consensus on managing a patient with carotid disease who is a candidate for Coronary Artery Bypass Grafting (CABG)?

Management of Carotid Disease in CABG Candidates

Patients with symptomatic carotid stenosis (prior stroke/TIA) and ≥50% stenosis should undergo carotid revascularization in conjunction with CABG, while routine carotid intervention is not recommended for asymptomatic unilateral stenosis regardless of severity. 1

Risk Stratification and Screening

The stroke risk during CABG varies dramatically based on carotid disease characteristics:

• Baseline CABG stroke risk: 1-2% in patients without carotid disease 1
• Unilateral severe carotid stenosis: 3% stroke risk 1
• Bilateral carotid stenosis: 5% stroke risk 1
• Symptomatic carotid stenosis left untreated: 8.5% stroke risk 1
• Carotid occlusion: 11% stroke risk 1

Selective carotid duplex screening is reasonable (Class IIa) for patients meeting any of these criteria: age >65 years, left main coronary stenosis, peripheral arterial disease, history of smoking, prior stroke/TIA, or carotid bruit. 1 This selective approach reduces unnecessary testing by 40% while maintaining detection of clinically significant disease. 1

Management Algorithm by Clinical Scenario

Symptomatic Carotid Stenosis (Prior Stroke/TIA)

For patients with prior stroke/TIA and 50-99% ipsilateral carotid stenosis, carotid revascularization in conjunction with CABG is reasonable (Class IIa, Level C). 1 The sequence and timing depend on the relative severity of cerebral versus cardiac dysfunction:

• Unstable cardiac disease with recent MI or ongoing ischemia: Consider simultaneous CEA and CABG, or endovascular carotid revascularization with embolic protection under cardiopulmonary bypass 1
• Stable cardiac disease: Staged carotid revascularization performed first, followed by CABG within 24 hours to 30 days minimizes both post-CEA MI and post-CABG stroke 2, 3
• Extreme-risk unstable patients: Single-stage CEA and cardiac surgery or endovascular intervention with micronet-covered stent may be considered 1

Asymptomatic Carotid Stenosis

Routine carotid revascularization is NOT recommended for unilateral asymptomatic stenosis prior to or concurrent with CABG, regardless of severity. 1 This represents the most recent consensus (2025) and supersedes older recommendations. 1

Consider carotid intervention (Class IIb) only in these specific asymptomatic scenarios:

• Bilateral severe (70-99%) carotid stenoses 1
• Unilateral severe stenosis with contralateral occlusion 1
• Evidence of ipsilateral cerebral infarction on imaging despite clinical silence 1
• High-risk plaque morphology with thrombotic features 1

When intervention is considered for asymptomatic disease, carotid revascularization is typically performed prior to cardiac surgery. 1

Multidisciplinary Decision-Making

A combined Heart Team and Neurovascular Team consultation is mandatory (Class I) when significant carotid stenosis is identified in CABG candidates. 1, 4 This team should include:

• Cardiologist
• Cardiac surgeon
• Vascular surgeon
• Neurologist

The team must consider patient-specific factors including symptom status, cerebral imaging findings (not just carotid imaging), lesion severity and morphology, urgency of cardiac revascularization, and local expertise. 1

Critical Pitfalls to Avoid

Do not assume all peri-CABG strokes are carotid-related. Other mechanisms including aortic clamping/de-clamping and aortic atheromatous disease contribute substantially to stroke risk. 1 Epiaortic ultrasound scanning (Class IIa) should be performed to identify ascending aortic atheroma and modify surgical technique. 4

Do not routinely revascularize asymptomatic unilateral carotid stenosis before CABG. The 2025 ESC consensus explicitly states this is not recommended, as proof is lacking that carotid intervention reduces adverse events in this population. 1 Most peri-CABG strokes are mechanistically unrelated to carotid stenosis. 1

Do not delay necessary CABG for carotid workup in unstable cardiac patients. The relative urgency of myocardial versus cerebral revascularization must guide timing decisions. 1

Recognize that carotid stenosis is a marker of systemic atherosclerotic burden. Even after carotid revascularization, these patients remain at elevated risk, with combined 30-day death and stroke rates of 12.3% in staged procedures. 5 Aggressive medical management with antiplatelet therapy, high-intensity statins, blood pressure control, and diabetes management is essential regardless of revascularization strategy. 1