Is a patient with bilateral carotid artery stenosis (CAS) and a previous history of stroke on imaging a candidate for carotid endarterectomy (CEA) during coronary artery bypass grafting (CABG)?

CEA During CABG for Bilateral CAS with Prior Stroke on Imaging

Yes, a patient with bilateral carotid artery stenosis and previous stroke on imaging is a candidate for carotid endarterectomy during CABG, provided the stenosis is ≥50% and the procedure is performed by an experienced team achieving <6% combined death/stroke rates for symptomatic patients. 1

Guideline-Based Recommendation Framework

Primary Indication Criteria

The 2017 ESC/ESVS guidelines provide clear direction for this clinical scenario:

• Patients with recent (<6 months) history of TIA/stroke scheduled for CABG should be considered for carotid revascularization if stenosis is 50-99% (Class IIa, Level B). 1

• CEA should be considered as the first-choice method for carotid revascularization in symptomatic patients with 50-99% stenosis (Class IIa, Level B). 1

• The presence of bilateral 70-99% carotid stenosis in symptomatic patients strengthens the indication for intervention. 1

Critical Distinction: Symptomatic vs. Asymptomatic Disease

Your patient has symptomatic disease (previous stroke on imaging), which fundamentally changes the risk-benefit calculation:

• Symptomatic patients have Class IIa recommendations for carotid revascularization with stenosis as low as 50-69%, while asymptomatic patients require 70-99% bilateral stenosis and only receive Class IIb recommendations. 1

• The 2014 ESC/EACTS guidelines specifically state that CEA performed by experienced teams may reduce perioperative stroke or death risk in patients with previous TIA/stroke and carotid stenosis (50-99% in men; 70-99% in women). 1

• In contrast, isolated CABG should be performed in asymptomatic unilateral carotid stenosis due to minimal stroke risk reduction (only 1% per year) from concomitant carotid revascularization. 1

Mandatory Team Requirements

The procedure must be performed by teams achieving combined death/stroke rates at 30 days of <6% in symptomatic patients (Class I, Level A). 1, 2

• A multidisciplinary team discussion including a neurologist is mandatory (Class I, Level C) to determine indication, method, and timing. 1, 2

• Hospitals performing <100 CEA operations annually typically have poorer outcomes and should be avoided. 2

Timing Strategy: Synchronous vs. Staged

The timing should target the most symptomatic territory first, determined by local expertise and clinical presentation (Class IIa, Level C). 1, 2

Synchronous CEA + CABG Approach

• Recent RCT data shows that CABG followed by delayed CEA has the worst outcomes, with 90-day stroke/death rates of 8.8% versus 1.0% for CABG with previous or synchronous CEA (P=0.02). 1

• Synchronous procedures avoid the interstage myocardial infarction risk (0-1.9%) that occurs with staged approaches. 1

• However, the CABACS trial showed higher albeit non-significant stroke rates at 5 years following combined CABG+CEA versus CABG alone (29.4% vs 18.8%, P=0.25), though this study was underpowered. 3

Staged Approach Considerations

• If CEA is performed first, there is increased risk of interstage MI while awaiting CABG. 1

• If CAS is used instead of CEA, dual antiplatelet therapy delays cardiac surgery for at least 4 weeks, exposing the patient to MI risk during this interval. 1

• Staged CEA plus cardiac surgery incurred the highest risk in propensity-matched analysis, driven by interstage MI events. 1

Critical Risk Factors in Your Patient

Previous stroke on imaging is one of the most important predictors of increased perioperative stroke risk, along with bilateral carotid disease. 1

• The overall stroke rate after CABG is 1.6%, but rises to approximately 9% in patients with carotid stenosis >80%. 4

• Risk factors for all strokes include age, emergency surgery, previous stroke, pre-operative atrial fibrillation, and on-pump CABG with hypothermic circulatory arrest. 1

• Bilateral carotid stenosis with previous stroke represents high neurologic risk, though outcomes data comparing high versus low neurologic risk patients in combined procedures show no significant difference in stroke (4.9% vs 6.3%, P=0.76) or death (4.9% vs 6.3%, P=0.76). 5

Perioperative Medical Management

Aspirin is required immediately before and after carotid revascularization (Class I, Level A). 1, 2

• If CAS is chosen over CEA, dual antiplatelet therapy with aspirin and clopidogrel is required for at least 1 month (Class I, Level B). 1, 2

• Hemodynamic management is critical, as myocardial stunning after CABG can reduce cardiac output, leading to cerebral hypoperfusion in patients with significant carotid stenosis. 4

Common Pitfalls to Avoid

Do not perform CABG first followed by delayed CEA, as this strategy has the highest stroke/death rate (8.8% vs 1.0%, P=0.02). 1

• Do not assume routine prophylactic carotid revascularization is beneficial in asymptomatic patients—it is not recommended (Class III, Level B) for unilateral 70-99% stenosis. 1

• Do not delay intervention in symptomatic patients, as stroke risk is highest in the first 7 days after symptom onset. 2

• Recognize that most post-CABG strokes are not caused by hemodynamic hypoperfusion from carotid stenosis, but rather by microembolization from cardiopulmonary bypass, atrial fibrillation, and aortic atheromatous disease. 4

Practical Algorithm for Your Patient

1. Confirm stenosis severity ≥50% with duplex ultrasound (Class I, Level B for symptomatic patients). 1

2. Convene multidisciplinary team including neurologist, cardiologist, and vascular surgeon (Class I, Level C). 1

3. Verify surgical team achieves <6% combined death/stroke rate for symptomatic patients. 1, 2

4. Choose synchronous CEA + CABG or CEA followed by CABG, avoiding CABG-first strategy. 1

5. Initiate aspirin perioperatively and maintain indefinitely. 1, 2

6. Monitor for cerebral hypoperfusion with consideration of intraoperative neuromonitoring (Class IIb). 4