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. 2009 Feb 3;24(1):26–32. doi: 10.1002/clc.4960240105

Screening for carotid artery disease before cardiac surgery: Is current clinical practice evidence based?

R Andrew Archbold 1, Khalid Barakat 1, Patrick Magee 1, Nicholas Curzen 1,✉
PMCID: PMC6655147  PMID: 11195603

Abstract

Background: There is no clear consensus as to the correct screening procedure to identify patients undergoing cardiac surgery and who are at greatest risk of stroke because of the presence of significant carotid artery stenosis. Such screening is important because some patients benefit from combined carotid and cardiac surgery and, regardless of this, the information gained puts the cardiac surgeon in a position to provide an accurate assessment of surgical risk. Our objective was to examine current clinical practice of carotid artery investigation prior to urgent cardiac surgery and to review this illustrative practice in the context of the world literature.

Hypothesis: The study aimed to establish that current typical practice for screening cardiac surgical patients for carotid artery disease is illogical according to the evidence in the world literature.

Methods: The study consisted of a retrospective assessment of all patients undergoing urgent cardiac surgery and a Medline‐derived literature review, and included all patients undergoing urgent cardiac surgery at a tertiary cardiothoracic center between January 1 and December 31, 1997.

Results: Of 529 patients undergoing urgent cardiac surgery, 44 (8%) were screened preoperatively by duplex Doppler ultrasonography for carotid disease. The indications for screening were asymptomatic carotid bruit in 24 patients, history of stroke or transient ischemic attack (TIA) in 12 patients, and neither stroke, TIA, or bruit in 7 patients. The tests were requested either by the attending cardiologists or by the cardiac surgeon to whom they were referred. One patient had already been diagnosed as having carotid artery disease in the past. Thirteen patients underwent additional carotid investigations. Eleven patients were demonstrated to have internal carotid artery stenosis ≥ 60% and 3 patients underwent combined cardiac and carotid surgery. Review of the literature revealed the following groups to be at increased risk of future stroke unrelated to surgery, and of postoperative stroke: those with a history of stroke or TIA, those with carotid bruits, and, of importance, all patients with significant carotid stenosis. Recent data suggest that symptomatic patients and the elderly are at greatest risk.

Conclusions: Only 8% of patients undergoing urgent cardiac surgery in a 1‐year period were screened for carotid artery disease. We suggest that screening should definitely be performed in all patients with a history of stroke or TIA, all patients with a bruit, and all patients aged > 65 years. The literature suggests, however, that significant reductions in stroke rate could be achieved by screening the whole cardiac surgical population, although there is a paucity of data that are specifically pertinent to this patient subgroup. Further data are therefore required for the construction of a scientifically valid and medicolegally sound policy.

Keywords: carotid artery investigation, cardiac surgery; carotid endarterectomy

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References

  • 1. Antiplatelet Trialists' Collaboration : Collaborative overview of randomised trials of antiplatelet therapy. I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. Br Med J 1994; 308: 81–106 [PMC free article] [PubMed] [Google Scholar]
  • 2. Collins R, Peto R, MacMahon S, Hebert P, Fiebach NH, Eberlein KA, Godwin J, Qizilbash N, Taylor JO, Hennekens CH: Blood pressure, stroke, and coronary heart disease, part 2: Short‐term reductions in blood pressure. Overview of randomised drug trials in their epidemiological context. Lancet 1990; 335: 827–838 [DOI] [PubMed] [Google Scholar]
  • 3. SHEP Cooperative Research Group : Prevention of stroke by antihypertensive drug treatment in older persons with isolated systolic hypertension. Final results of the Systolic Hypertension in the Elderly Program (SHEP). J Am Med Assoc 1991; 265: 3255–3264 [PubMed] [Google Scholar]
  • 4. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study : Endarterectomy for asymptomatic carotid artery stenosis. J Am Med Assoc 1995; 273: 1421–1428 [PubMed] [Google Scholar]
  • 5. North American Symptomatic Carotid Endarterectomy Trial Collaborators : Beneficial effect of carotid endarterectomy in symptomatic patients with high‐grade stenosis. N Engl J Med 1991; 325: 445–153 [DOI] [PubMed] [Google Scholar]
  • 6. European Carotid Surgery Trialists' Collaborative Group : MRC European Carotid Surgery Trial: Interim results for symptomatic patients with severe (70–99%) or mild (0–29%) carotid stenosis. Lancet 1991; 337: 1235–1243 [PubMed] [Google Scholar]
  • 7. European Carotid Surgery Trialists' Collaborative Group : Endarterectomy for moderate symptomatic carotid stenosis: Interim results from the MRC European Carotid Surgery Trial. Lancet 1996; 347: 1591–1593 [PubMed] [Google Scholar]
  • 8. Rothwell PM, Warlow CP: Carotid endarterectomy in patients with recently symptomatic moderate (30–69%) carotid stenosis: No overall benefit. Eur Heart J 1997; 18: 355–356 [DOI] [PubMed] [Google Scholar]
  • 9. European Carotid Surgery Trialists' Collaborative Group : Randomised trial of endarterectomy for recently symptomatic carotid stenosis: Final results of the MRC European Carotid Surgery Trial (ECST). Lancet 1998; 351: 1379–1387 [PubMed] [Google Scholar]
  • 10. Barnett HJM, Taylor DW, Eliasziw M, Fox AJ, Ferguson GG, Haynes RB, Rankin RN, Clagett GP, Hachinski VC, Sackett DL, Thorpe K, Meldrum HE: Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. N Engl J Med 1998; 339: 1415–1425 [DOI] [PubMed] [Google Scholar]
  • 11. Chassin MR: Appropriate use of carotid endarterectomy. N Engl J Med 1998; 339: 1468–1471 [DOI] [PubMed] [Google Scholar]
  • 12. Akins CW, Moncure AC, Daggett WM, Cambria RP, Hilgenberg AD, Torchiana DF, Vlahakes GJ: Safety and efficacy of concomitant carotid and coronary artery operations. Ann Thorac Surg 1995; 60: 311–318 [DOI] [PubMed] [Google Scholar]
  • 13. Jahangiri M, Rees GM, Edmondson SJ, Lumley J, Uppal R: A surgical approach to coexistent coronary and carotid artery disease. Heart 1997; 77: 164–167 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14. Moore WS, Barenett HJM, Beebe HG, Bernstein EF, Brener BJ, Brott T, Caplan LR, Day A, Goldstone J, Hobson RW: Guidelines for carotid endarterectomy: A multidisciplinary consensus statement from the Ad Hoc committee, American Heart Association. Stroke 1995; 26: 188–201 [DOI] [PubMed] [Google Scholar]
  • 15. Biller J, Feinberg WM, Castaldo JE, Whittemore AD. Harbaugh R, Dempsey RJ, Capalan LR, Kresowik TF, Matchar DB, Toole JF, Easton JD, Adams HP, Brass LM, Hobson RW, Brott TG, Sternau L: Guidelines for carotid endarterectomy: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Circulation 1998; 97: 501–509 [DOI] [PubMed] [Google Scholar]
  • 16. Hines GL, Scott WC, Schubach SL, Kofsky E, Wehbe U, Cabasino O: Prophylactic carotid endarterectomy in patients with high‐grade carotid stenosis undergoing coronary bypass: Does it decrease the incidence of perioperative stroke? Ann Vasc Surg 1998; 12: 23–27 [DOI] [PubMed] [Google Scholar]
  • 17. Brener BJ, Brief DK, Alpert JA, Goldenkranz RJ, Parsonnet V: The risk of stroke in patients with asymptomatic stenosis undergoing cardiac surgery: A follow‐up study. J Vasc Surg 1987: 5: 269–279 [PubMed] [Google Scholar]
  • 18. Turnipseed WD, Berkoff HA, Belzer FO: Postoperative stroke in cardiac and peripheral vascular disease. Ann Surg 1980; 192: 365–368 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19. Faggioli GL, Curl GR, Ricotta JJ: The role of carotid screening before coronary artery bypass. J Vasc Surg 1990; 12: 724–729 [DOI] [PubMed] [Google Scholar]
  • 20. Lynn GM, Stefanko K, Reed JF, Gee W, Nicholas G: Risk factors for stroke after coronary artery bypass. J Thorac Cardiovasc Surg 1992; 104: 1518–1523 [PubMed] [Google Scholar]
  • 21. Benavente O, Moher D, Pham B: Carotid endarterectomy for asymptomatic carotid stenosis? Br Med J 1998; 317: 1477–1480 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22. Davies KN, Humphrey PRD: Do carotid bruits predict disease of the internal carotid arteries? Postgrad Med J 1994; 70: 433–435 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 23. Moore WS, Bean B, Burton R, Goldstone J: The use of ophthalmosonometry in the diagnosis of carotid artery stenosis. Surgery 1977; 82: 107–115 [PubMed] [Google Scholar]
  • 24. Malone JM, Bean B, Laguna J, Hamilton R, Labadie E, Moore WS: Diagnosis of carotid artery stenosis: Comparison of oculoplethysmography and Doppler supraorbital examination. Ann Surg 1980; 191: 347–354 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 25. Sauve JS, Thorpe KE, Sackett DL, Taylor W, Barnett HJ, Haynes RB, Fox A: Can bruits distinguish high‐grade from moderate symptomatic carotid stenosis? Ann Intern Med 1994; 120: 633–637 [DOI] [PubMed] [Google Scholar]
  • 26. Heyman A, Wilkinson WE, Heyden S, Helms MJ, Bartel AG, Karp HR, Tyroler HA, Hornes CJ: Risk of stroke in asymptomatic persons with cervical arterial bruits: A population study in Evans County, Georgia. N Engl J Med 1980; 302: 838–841 [DOI] [PubMed] [Google Scholar]
  • 27. Wolf PA, Kannel WB, Sorlie P, McNamara P: Asymptomatic carotid bruit and risk of stroke: The Framingham Study. J Am Med Assoc 1981; 245: 1442–1445 [PubMed] [Google Scholar]
  • 28. Chambers BR, Norris JW: Outcome in patients with asymptomatic neck bruits. N Engl J Med 1986; 315: 860–865 [DOI] [PubMed] [Google Scholar]
  • 29. Dennis M, Bamford J, Sandercock P, Warlow C: Prognosis of transient ischaemic attacks in the Oxfordshire Community Stroke Project. Stroke 1990; 21: 848–853 [DOI] [PubMed] [Google Scholar]
  • 30. The European Carotid Surgery Trialists Collaborative Group : Risk of stroke in the distribution of an asymptomatic carotid artery. Lancet 1995; 345: 209–212 [PubMed] [Google Scholar]
  • 31. Meissner I, Wiebers DO, Whisnant JP, O'Fallon WM: The natural history of asymptomatic carotid artery occlusive lesions. J Am Med Assoc 1987; 258: 2704–2707 [PubMed] [Google Scholar]
  • 32. Mackey AE, Abrahamowicz M, Langlois Y, Battista R, Simmard D, Bourque F, Leclerc J, Cote R: Outcome of asymptomatic patients with carotid disease. Neurology 1997; 48: 896–903 [DOI] [PubMed] [Google Scholar]
  • 33. Norris JW, Zhu CZ, Borstein NM, Chambers BR: Vascular risks of asymptomatic carotid stenosis. Stroke 1991; 22: 1485–1490 [DOI] [PubMed] [Google Scholar]
  • 34. Autret A, Pourcelot L, Saudeau D, Marchal C, Bertrand P, de Boisvilliers S: Stroke risk in patients with carotid stenosis. Lancet 1987; 1: 888–890 [DOI] [PubMed] [Google Scholar]
  • 35. Reed GL, Singer DE, Picard EH, DeSanctis RW: Stroke following coronary‐artery bypass surgery: A case‐control estimate of the risk from carotid bruits. N Engl J Med 1988; 319: 1246–1250 [DOI] [PubMed] [Google Scholar]
  • 36. Jones EL, Craver JM, Michalik RA, Murphy DA, Guyton RA, Bone DK, Hatcher CR, Reichwald NA: Combined carotid and coronary operations: When are they necessary? J Thorac Cardiovasc Surg 1987; 87: 7–16 [PubMed] [Google Scholar]
  • 37. Taylor GJ, Malik SA, Colliver JA, Dove JT, Moses HW, Mikell FL, Barchelder JE, Schneider JA, Wellons HA: Usefulness of atrial fibrillation as a predictor of stroke after isolated coronary artery bypass grafting. Am J Cardiol 1987; 60: 905–907 [DOI] [PubMed] [Google Scholar]
  • 38. Coffey CE, Massey EW, Roberts KB, Curtis S, Jones RH, Pryor DB: Natural history of cerebral complications of CABG surgery. Neurology 1983; 33: 1416–1421 [DOI] [PubMed] [Google Scholar]
  • 39. Rizzo RJ, Whittemore AD, Couper GS, Donaldson MC, Aranki SF, Collins JJ, Mannick JA, Cohn LH: Combined carotid and coronary revascularisation: The preferred approach to the severe vasculopath. Ann Thorac Surg 1992; 54: 1099–1108 [DOI] [PubMed] [Google Scholar]
  • 40. Tuman KJ, McCarthy RJ, Najafi H, Ivankovich AD: Differential effects of advanced age on neurologic and cardiac risks of coronary artery operations. J Thorac Cardiovasc Surg 1992; 104: 1510–1517 [PubMed] [Google Scholar]
  • 41. Gardner TJ, Horneffer PJ, Manolio TA, Hoff SJ, Pearson TA: Major stroke after coronary artery bypass surgery: Changing magnitude of the problem. J Vase Surg 1986; 3: 684–687 [PubMed] [Google Scholar]
  • 42. Trachiotis GD, Pfister AJ: Management strategy for simultaneous carotid endarterecomy and coronary revascularization. Ann Thorac Surg 1997; 64: 1013–1018 [DOI] [PubMed] [Google Scholar]
  • 43. Hertzer NR, Loop FD, Beven EG, O'Hara PJ, Krajenwski LP: Surgical staging for simultaneous coronary and carotid disease: A study including prospective randomization. J Vasc Surg 1989; 9: 455–463 [DOI] [PubMed] [Google Scholar]
  • 44. Daily PO, Freeman RK, Dembitsky WP, Adamson RM, Moreno‐Cabral RJ, Marcus S, Lamphere JA: Cost reduction by combined carotid endarterectomy and coronary artery bypass grafting. J Thorac Cardiovasc Surg 1996; 111: 1185–1193 [DOI] [PubMed] [Google Scholar]
  • 45. Warlow C: Endarterectomy for asymptomatic carotid stenosis? Lancet 1995; 345: 1254–1255 [DOI] [PubMed] [Google Scholar]

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