Does preoperative carotid stenosis screening reduce perioperative stroke in patients undergoing coronary artery bypass grafting?

Abstract

A number of institutions routinely perform carotid artery ultrasound screening before coronary artery bypass grafting (CABG) to identify carotid artery disease requiring revascularization before or during CABG, with the expectation of reducing perioperative neurologic events. The assumptions are that carotid disease is causally related to perioperative stroke and that prophylactic carotid revascularization decreases the risk of post-CABG neurologic events. Although carotid artery stenosis is a known risk factor for perioperative stroke in patients undergoing CABG, it might be a surrogate marker for diffuse atherosclerotic disease rather than a direct etiologic factor. Moreover, the benefit of prophylactic carotid revascularization in patients with asymptomatic unilateral carotid disease is uncertain. Therefore, we have reviewed the literature for evidence that preoperative carotid artery screening, by identifying patients with significant carotid artery stenosis and altering their management, reduces perioperative neurologic events in those undergoing CABG.

2018 ESC/EACTS Guidelines on myocardial revascularization

“…314 Therefore, indications for preoperative carotid bifurcation screening by duplex ultrasound are limited. 315 Also, there is no evidence that prophylactic revascularization of unilateral asymptomatic carotid stenoses in CABG candidates reduces the risk of perioperative stroke. It may be reasonable to restrict prophylactic carotid revascularization to patients at highest risk of postoperative stroke, i.e.…”

Sonolysis in prevention of brain infarction during cardiac surgery (Sonorescue): a randomized, controlled trial

“…33 Atherosclerosis in cervical and cerebral arteries is the other important etiopathogenetic factor of stroke in patients undergoing cardiac surgery. 34 Studies have identified carotid-artery stenosis as a risk factor for perioperative stroke. [35][36][37][38][39] Anticoagulation, turbulent blood flow, and hypertension during CABG could be responsible for an increased intraoperative risk of intraplaque hemorrhage and subsequent distal embolization.…”

“…[35][36][37][38][39] Anticoagulation, turbulent blood flow, and hypertension during CABG could be responsible for an increased intraoperative risk of intraplaque hemorrhage and subsequent distal embolization. 34 Impaired cerebral hemodynamic function distal to carotid-artery stenosis is another determinant of postoperative stroke.…”

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS)

“…Udar mózgu po CABG ma wieloczynnikową etiologię, która obejmuje zatorowość materiałem z aorty podczas manipulacji, kaniulacji/dekaniulacji oraz zespalania pomostów z aortą wstępującą, agregację płytek podczas stosowania krążenia pozaustrojowego i w stanach nadkrzepliwości, embolizację materiałem z tętnic szyjnych, AF w okresie pooperacyjnym oraz niestabilność hemodynamiczną, zwłaszcza u pacjentów z upośledzoną rezerwą naczyniową mózgu [346].…”