From the Guidelines
A vascular opinion is generally not indicated for a patient with an asymptomatic carotid bruit who is scheduled for laparoscopic cholecystectomy. The presence of a carotid bruit alone, without symptoms of cerebrovascular disease (such as TIA or stroke), does not necessitate preoperative vascular consultation or intervention before non-carotid surgery 1. Laparoscopic cholecystectomy is considered intermediate-risk surgery, and the presence of an asymptomatic carotid bruit represents a potential risk factor but not an absolute contraindication. However, if the patient has had recent neurological symptoms (within 6 months), significant carotid stenosis (>70%), or a history of stroke, then vascular consultation would be appropriate.
Some key points to consider in the management of patients with carotid bruits include:
- The severity of stenosis is defined according to angiographic criteria, but it corresponds as well to assessment by sonography and other accepted methods of measurement such as CTA and MRA, although the latter may overestimate the severity of stenosis 2.
- Catheter-based angiography may be necessary in some cases for definitive diagnosis or to resolve discordance between noninvasive imaging findings 3.
- Indications for carotid duplex sonography include cervical bruit in an asymptomatic patient, follow-up of known stenosis (50%) in asymptomatic individuals, and vascular assessment in a patient with multiple risk factors for atherosclerosis 2, 3.
During the procedure, maintaining hemodynamic stability is important, with careful attention to blood pressure management to ensure adequate cerebral perfusion. Avoid significant hypotension or hypertension that could compromise cerebral blood flow. Postoperatively, resume any preexisting antiplatelet therapy as soon as hemostasis is assured. The rationale is that asymptomatic carotid bruits have a relatively low correlation with hemodynamically significant stenosis, and even with stenosis, the risk of perioperative stroke during non-carotid surgery is relatively low compared to the risks of delaying necessary surgery.
From the Research
Carotid Bruit and Vascular Opinion
- The presence of a carotid bruit may indicate an increased risk of cerebrovascular disease, as suggested by a meta-analysis of 28 prospective cohort studies 4.
- A carotid bruit is of moderate value for detecting clinically relevant carotid stenosis, with high specificity but low sensitivity, according to a meta-analysis of 26 studies 5.
- The likelihood of a carotid bruit does not increase at increasing degrees of stenosis, as shown by meta-regression analysis 5.
Clinical Utility of Carotid Bruit
- Carotid auscultation is a useful screening procedure in the detection of carotid stenosis or occlusion, but requires confirmation by carotid ultrasound, as found in a prospective study of 145 patients 6.
- The sensitivity of carotid auscultation for the detection of a 70%-99% stenosis of the common or extracranial internal carotid artery was 56% and specificity was 91% 6.
- Cervical bruits alone were not sufficiently predictive of high-grade symptomatic carotid stenosis to be useful in selecting patients for angiography, as shown by a cross-sectional comparison of clinical observations with contemporaneous angiography in the North American Symptomatic Carotid Endarterectomy Trial 7.
Vascular Opinion Indication
- Given the potential increased risk of cerebrovascular disease associated with a carotid bruit, a vascular opinion may be indicated for a patient with a carotid bruit scheduled for a laparoscopic cholecystectomy, especially if there are other risk factors or symptoms present 4, 8.
- A comprehensive evaluation, including carotid ultrasound and possibly angiography, may be necessary to determine the severity of carotid stenosis and guide management decisions 5, 6.