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Reis PFF et al.
1012 Rev Assoc Med Bras 2017; 63(11):1012-1016
REVIEW ARTICLE
Approach to concurrent coronary and carotid artery disease:
Epidemiology, screening and treatment
Patrícia Feitosa Frota dos Reis1, Pedro Vieira Linhares 1, Fábio Grunspun Pitta1, Eduardo Gomes Lima1*
1Department of Atherosclerosis, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da USP (InCor-HCFMUSP), São Paulo, SP, Brazil
Summary
Study conducted at Instituto do
Coração do Hospital das Clínicas da
Faculdade de Medicina da USP
(InCor-HCFMUSP), São Paulo, SP, Brazil
Article received: 4/13/2017
Accepted for publication: 4/15/2017
*Correspondence:
Address: Av. Dr. Enéas de Carvalho
Aguiar 44, 2º andar, sala 2
São Paulo, SP – Brazil
Postal code: 05403-000.
The concomitance between coronary artery disease and carotid artery disease is
known and well documented. However, it is a fact that, despite the screening
methods for these conditions and the advances in surgical treatment, little has
been achieved in terms of reducing the risk of complications in the perioperative
period. Publications are scarce, being mostly composed of reports or case series.
There is little agreement on the best initial therapeutic approach (myocardial
versus carotid revascularization) or the best technique to be used (surgery with
or without extracorporeal circulation, hybrid treatments, etc.). The authors
performed a review of the evidence in this clinical scenario, raising pragmatic
questions that help in the therapeutic decision.
Keywords: coronary disease, carotid artery diseases, myocardial revascularization.
Introduction
Cerebrovascular accident (CVA), or stroke, is a periopera-
tive complication that occurs in about 2% of myocardial
revascularization (CABG) surgeries.1 Evidence suggests
that the main etiology is the macroembolization of ath-
erothrombotic debris derived from the aortic arch.2
An important subgroup of risk for such complication
is that of patients with significant carotid stenosis (> 70%).
However, it has been demonstrated in some studies that
this is also a predictor of severe atherosclerotic disease in
the aortic arch.3 Therefore, the presence of significant
carotid stenosis seems to serve more as a marker of risk
for aortic arterial disease than as a causal relationship for
CVA in the perioperative period of CABG.4
Although carotid Doppler ultrasound (USG) screen-
ing is routinely performed for preoperative CABG as-
sessment in many institutions, the benefit of carotid
revascularization surgery (CAR) in asymptomatic pa-
tients is questioned. 5
Therapeutic choice in patients with coronary artery
disease (CAD) and concomitant carotid disease is also
controversial, based on few studies and the experience
of institutions. Therapeutic strategies include: 1. com-
bined surgery (CABG and CAR in the same procedure);
2. staged surgeries (CABG with subsequent CAR x CAR
with subsequent CABG); 3. hybrid procedure (CABG with
percutaneous carotid intervention – PCI). The strategies
can be simultaneous or staged, being performed in one
or two surgical times, respectively. 6,7
Carotid artery disease screening
in the preoperative period of
myocardial revascularization
Currently, there is a strong tendency to request USG ca-
rotid Doppler as part of preoperative assessment of CABG.
In patients undergoing CABG, the prevalence of major
carotid disease is known to range from 2.8 to 22%. On
the other hand, among patients undergoing endarterec-
tomy, the prevalence of coronary artery disease is between
28 and 40%. 8 Despite the strong association between dis-
eases, the incidence of CVA in patients submitted to CABG
is low, varying from 1.3 to 2.0%.5
The etiology of perioperative CVA is multifactorial, the
most common being embolism calcified plaques. Accord-
ing to a meta-analysis by Naylor and Bown,9 the incidence
of ipsilateral CVA combined with important asymptomatic
ipsilateral carotid stenosis is low, only 2%. Note that the
main etiologies are related to the procedure per se, such as
pressure control, diastolic pulmonary hypertension, ath-
erothrombotic macroembolization during aortic clamping
and cannulation, and microembolization of platelet aggre-
gates caused by a swirling flow in cardiopulmonary bypass.10
Risk factors for perioperative CVA are: previous CVA
or transient ischemic attacks (TIA), peripheral arterial