Carotid stenosis & coronary artery disease
Incidence of coronary artery disease in patients needing CEA
  • Patients with carotid stenosis frequently have coronary disease.
  • O'Donnell et al: 66% of patients undergoing Carotid Endarterectomy (CEA) had clinical evidence of coronary disease.
  • Hertzer et al: coronary artery bypass grafting (CABG) warranted in 37% of CEA patients.
  • Coronary disease was the cause of death in 24% of deaths occurring within 5 years of CEA.
  • CEA in patients with unstable coronary disease manifested by angina pectoris: 15% risk of myocardial infarction & 18% risk of death.
  • Brener et al: meta-analysis of 15 studies, 407 patients treated with CEA followed by CABG:  risk of stroke 5.3%, myocardial infarction 11.3%, and death 9.4%.
Stroke risk of patients in CABG
  • Hertzer et al: 9714 patients being prepared for CABG: 2.8% has symptomatic or high-grade carotid lesions.
  • Stroke risk for patients undergoing CABG is usually reported to be < 2%.
  • Stroke risk of CABG patients with hemodynamically significant carotid stenosis:  6% to 16%
CEA & CABG: combined vs staged operations
Hertzer et al: prospectively randomized patients to
  • Staged Surgery: CABG followed by CEA:
    • Unilateral asymptomatic patient: overall stroke risk of 14%
      • 58 patients underwent CABG with a 6.9% incidence of stroke.
      • Another 4 strokes occurred at the time of delayed CEA.
    • Symptomatic patients with unilateral stenosis: overall 13% had stroke
      • 8.8% stroke risk at CABG
      • 1 stroke at delayed CEA
  • Combined surgery: CABG & CEA
    • 71 patients with unilateral asymptomatic stenosis: 2.8% stroke rate
    • 60 symptomatic patients: 8.3% stroke rate.
    • Combined procedures have higher stroke and death rates than isolated CABG.
  • Rizzo et al: combined operations on 127 patients with severe coronary disease and carotid stenosis, with two thirds of the patients having carotid symptoms. The stroke rate was 6.3%, and 5.5% myocardial-related deaths.
  • The presence of bilateral hemodynamically significant carotid disease worsens the stroke risk of patients undergoing combined CABG and CEA and a delayed second carotid endarterectomy.
  • Meta-analysis of 11 series:
    • 6.9% stroke risk for combined procedures in patients with unilateral carotid stenosis
    • 12.7% risk for patients with bilateral disease.
  • Highest-risk group: an occluded carotid and contralateral stenosis: 29% stroke incidence with a combined procedure.
  • Patients with combined disease at low risk for cardiac events appear to be best served with carotid endarterectomy before CABG.
  • Patients with unstable angina or left main or three-vessel coronary disease may require CABG prior to CEA or need a combined approach. These patients appear to be at greater risk for cerebral events if the carotid lesion is symptomatic or bilateral. 
Further reading
Riggs, PN, DeWeese JA.  Carotid Endarterectomy. Surgical Clin of N America. Vol 78,  Num 5, Oct 1998

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