Is a patient with mild to moderate 50-60% proximal right Internal Carotid Artery (ICA) stenosis, mild up to 50% left ICA stenosis, and moderate stenosis in the left subclavian artery a contraindication to proceeding with surgical Aortic Valve Replacement (SAVR)?

Carotid and Subclavian Stenosis is NOT a Contraindication to Surgical Aortic Valve Replacement

The degree of carotid stenosis described (50-60% right ICA, <50% left ICA) and moderate left subclavian stenosis do not constitute contraindications to proceeding with surgical aortic valve replacement. These findings represent mild to moderate vascular disease that should be managed medically but do not preclude cardiac surgery.

Evidence Supporting Proceeding with SAVR

Carotid Stenosis Does Not Predict Stroke After Aortic Valve Replacement

• A large retrospective study of 996 patients undergoing SAVR or TAVR found no statistically significant association between carotid stenosis severity and procedure-related stroke (p=0.21 for SAVR, p=0.39 overall), leading investigators to conclude that universal carotid Doppler screening before isolated aortic valve replacement is unnecessary 1.

• The prevalence of ≥70% carotid stenosis in patients undergoing aortic valve replacement is only 5.2%, with an overall 30-day stroke incidence of 3.4%, and stenosis severity did not correlate with stroke risk 1.

• Even bilateral carotid stenosis ≥50% showed increased stroke risk only in TAVR patients (adjusted HR 8.4), not in surgical AVR patients, suggesting the mechanism of stroke differs between procedures 2.

Your Patient's Stenosis is Below Intervention Thresholds

• The right ICA stenosis of 50-60% is below the threshold where carotid intervention provides benefit. Guidelines explicitly state that carotid revascularization (either endarterectomy or stenting) is not indicated for stenosis <60% in asymptomatic patients 3.

• The left ICA stenosis of <50% requires only optimal medical therapy with no indication for revascularization (Class III recommendation, Level of Evidence A) 3, 4.

• The subclavian stenosis, while moderate, does not impact cardiac surgical risk and can be managed medically.

Management Algorithm for This Patient

Proceed with SAVR with the Following Perioperative Considerations:

1. Optimize medical therapy for carotid disease:

   • Initiate or intensify statin therapy to stabilize atherosclerotic plaques 4
   • Ensure single antiplatelet therapy (aspirin) is continued perioperatively per cardiac surgical protocols 3
   • Aggressively control blood pressure, targeting systolic <140 mmHg 3

2. Intraoperative neuroprotection strategies:

   • Maintain adequate cerebral perfusion pressure during cardiopulmonary bypass
   • Avoid hypotension (systolic blood pressure drops >20 mmHg should be corrected promptly) 3
   • Consider epiaortic ultrasound to assess aortic atheroma and guide cannulation strategy 3

3. Postoperative surveillance:

   • Monitor for neurological changes in the immediate postoperative period
   • Continue aggressive risk factor modification including smoking cessation and diabetes management 4

When Carotid Intervention Would Be Indicated Before SAVR:

Carotid endarterectomy or stenting should only be considered before SAVR in the following scenarios:

• Symptomatic carotid stenosis ≥50% (recent TIA or stroke in the carotid distribution) - these patients require urgent carotid revascularization within 14 days of symptoms 3

• Asymptomatic stenosis ≥70-80% in patients with high-risk features (contralateral occlusion, rapid progression, poor collaterals) and life expectancy >5 years 3

• Your patient meets neither criterion, as both carotid arteries show <70% stenosis and no symptoms are mentioned.

Important Clinical Pitfalls to Avoid

Do Not Delay Necessary SAVR for Mild-Moderate Carotid Disease

• Symptomatic severe aortic stenosis carries extremely high mortality if untreated (Class I indication for AVR regardless of other factors) 3, 5. Delaying surgery to address non-critical carotid stenosis exposes the patient to the substantial risk of sudden cardiac death or heart failure decompensation.

• The 30-day stroke risk from SAVR (approximately 2-3%) is far lower than the mortality risk of untreated symptomatic severe AS 3, 1.

Staged Carotid-Cardiac Surgery is Rarely Necessary

• Concomitant carotid endarterectomy with SAVR is only performed in highly selected cases with severe symptomatic bilateral disease or very high-grade unilateral stenosis (>80%) 6.

• For your patient with 50-60% stenosis, staged procedures would expose them to two separate anesthetic and surgical risks without proven benefit 1.

The Subclavian Stenosis is Clinically Irrelevant to SAVR

• Moderate left subclavian stenosis does not affect cardiac surgical risk or outcomes
• It does not compromise cerebral perfusion (vertebral artery collaterals are typically adequate)
• Medical management with antiplatelet therapy and statins is appropriate 4

Post-SAVR Follow-Up for Vascular Disease

• Annual carotid duplex ultrasound surveillance is reasonable given the 50-60% right ICA stenosis, as stenosis >50% has higher progression rates (adjusted OR 3.5-6.6 for progression) 7

• Patients with LDL cholesterol elevation have doubled risk of stenosis progression (adjusted OR 2.22), emphasizing the importance of aggressive lipid management 7

• Monitor for development of neurological symptoms that would prompt reassessment 4

In summary, proceed with the indicated SAVR without delay, optimize medical therapy for atherosclerotic disease, and arrange appropriate vascular follow-up postoperatively. 3, 5, 1