Choices in the Management of Patients with Carotid and Coronary Artery Disease

Abstract

Patients with disease of the coronary or carotid circulation often have disease in the other territory. As a result patients requiring coronary artery bypass graft (CABG) with carotid stenosis may be at increased risk for stroke; likewise, patients requiring carotid surgery may be at increased risk for myocar dial infarction. The decision concerning the correct sequence of surgery for patients with lesions in each territory—carotid first, CABG first, carotid and CABG together, is not easy. Despite many reports documenting results of each of the three strategies, a consensus based on high-level scientific information (randomized prospective trial) is not available. Six cases illustrate these difficul ties. In a practical sense each surgeon and institution has to work out its own protocols. Carotid surgery can usually be carried out safely before CABG when the coronary disease is not threatening or when the cardiac disease requires a complex, time-consuming, and risky reconstruction. Cardiac surgery can usually be carried out safely before carotid endarterectomy when the carotid disease is moderate and asymptomatic or the cardiac disease is severely threatening or complex. Combined procedures are attractive because they are psychologically and economically appealing. Not all surgeons agree that this is the safest approach. It is impossible to be dogmatic about the proper strategy for patients with combined disease. Hopefully, a well-designed trial will be funded and begun to provide scientific evidence of the appropriate sequence of procedures.