Endovascular Carotid Stenting in Patients Scheduled for Cardiac Surgery: If Yes, Which First?
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* Gianluca Rigatelli

While the debate about the effectiveness of staged or combined surgery for carotid and cardiac disease requiring cardiac surgery with extracorporeal circulation continues, there is another issue to consider: can carotid stenting replace carotid endatherectomy in patients scheduled for cardiac surgery? In the past, despite an extensive literature on the subject, there has been a failure to identify the correct management of carotid and coronary or cardiac valve disease. Some authors have suggested that stroke at coronary surgery is due to multiple risk factors, one of which is high-grade carotid stenosis, though embolism rather than flow limitation could be the primary mechanism.1 No significant difference in the overall stroke and mortality risk between the various strategies was found, but subgroup analysis suggested that, when carefully selected, patients with less severe cardiac disease do better when surgery is staged, whereas patients with more severe cardiac disease should be treated with combined surgery.2 The increased popularity of carotid artery stenting (CAS) with its the excellent results, especially in high-risk patients, raises the question about the effectiveness of CAS in reducing the stroke risk in patients scheduled for cardiac surgery.

Recently some authors have proposed CAS before cardiac surgery, especially in asymptomatic patients.3 Unfortunately, this strategy involves the problem of antiplatelet drug therapy that increases the risk of bleeding after cardiac surgery.4 In my experience, an answer to this problem is an approach to carotid and cardiac disease on the basis of neurologic symptoms and severity of the cardiac disease (Table). Although this strategy has not yet proved to be the most effective in managing combined carotid and cardiac disease, we have not observed any increase in bleeding and have noted a slight decrease in minor and major strokes after surgery in a small preliminary series of patients.

View this table:
[Table1](http://www.ajnr.org/content/27/1/11/T1)

**Treatment of carotid and cardiac disease in the author proposal** 

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#  {#article-title-2}

*Reply:* 

There are few subjects as singularly controversial as the treatment of carotid atherosclerotic stenosis. Conversely, treatment of coronary artery stenosis has an established history, though recent data indicate that this therapy is more useful for prevention of angina than of sudden cardiac death. Carotid artery stenosis associated with coronary atherosclerotic disease is increasing in frequency with the aging of the general population, and clinicians are faced with how best to manage this coexistent problem. Carotid stenting offers a therapeutic option for just such patients: those with associated carotid and coronary atherostenosis. Despite a large volume of data present in the literature, specific treatment indications relating to surgical and/or endovascular options for both, or either, remain unclear and/or controversial.

In Canada, a recent countrywide evaluation found that 0.51% of CABG procedures were combined with carotid endarterectomy (CEA). The adjusted stroke and death rate was 2.67-fold greater in the combined CEA-CABG group compared to CABG alone,1 a rate that would seem difficult to justify. There is no doubt that treatment of symptomatic carotid stenosis is necessary and is, moreover, required very soon after the signal event.2,3 Treatment by any method for asymptomatic carotid stenosis is only statistically beneficial in the long term (ie, several years).4 Treatment of coronary artery stenosis by bypass grafting is rarely “event” dependent; rather, it is “severity” dependent. Currently, with the lack of definitive benefit for treatment of asymptomatic carotid stenosis by means of carotid artery stenting (CAS), early indication from CREST that CAS is harmful for patients >80 years of age, and proof that CEA for asymptomatic carotid stenosis is not beneficial for anyone >75 years of age,5 recommending CAS for asymptomatic patients prior to CABG with the indication being “pre-CABG” would be questionable. It would seem most appropriate to treat the symptomatic territory first (coronary or carotid) and reserve “combined” procedures for patients with critical stenosis associated with symptoms in both territories. Further study is required before definitive therapeutic recommendations should be made for the clinical situation of concurrent carotid and coronary atherosclerotic stenosis.

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