The natural history of asymptomatic carotid disease in patients undergoing cardiovascular surgery.

Prospective screening of 449 patients undergoing coronary or peripheral arterial revascularization detected asymptomatic cervical bruits in 44 patients (9.8%) and carotid obstruction by Doppler ultrasound in 63 individuals (14.0%). There was poor correlation between cervical bruit and carotid obstsruction. No patient underwent prophylactic casrotid endarterectomy. Three patients had transient ischemic attacks (TIAs), and five had nonfatal strokes perioperatively, only one of which was in the territory appropriate to carotid obstruction. Of 72 surviving patients with asymptomatic carotid disease, 10 (13.9%) had TIAs and one (1.4%) died of stroke during a 2-year follow-up, during which time only two (0.8%) of 254 patients without carotid disease reported symptoms of TIAs. Patients with asymptomatic carotid disease had a significantly higher incidence of perioperative and late deaths (10.6% and 9.2%, respectively), usually of myocardial infarction, as compared to patients without carotid disease (0.3% and 0.8%, respectively, P less than 0.001). Asymp-tomatic carotid disease, although correlating poorly with perioperative stroke in patients undergoing cardiovascular operations, identifies patients at risk of late neurologic events and peroperative or late deaths from myocardial infarction. We do not recommend prophylactic carotid endarterectomy but favor operative intervention if patients develop TIAs during a period of careful follow-up .

Asymptomatic carotid disease in the cardiovascular surgical patient: is prophylactic endarterectomy necessary?

This prospective study used non-invasive techniques to screen for asymptomatic carotid occlusive disease in 314 patients who were to have coronary or peripheral arterial reconstruction. Hemodynamically significant carotid obstruction (greater than or equal to 50% stenosis or occlusion) was present in 54 arteries of 41 patients (13.1%), but only one-third of these lesions were accompanied by a cervical bruit. Among 48 carotid arteries where a bruit was heard, only 18 (37.5%) were associated with significant obstruction demonstrated by non-invasive screening. No prophylactic carotid endarterectomies were performed. There was only one perioperative TIA and one non-fatal stroke, neither of which was related to detectable carotid obstruction. In patients with peripheral vascular disease and detectable carotid obstruction or bruit, the perioperative mortality was higher than in patients without carotid obstruction or bruit (15.0% and 18.2 vs 3.1% and 2.1%, respectively). The deaths were primarily due to myocardial infarction. This study suggests that asymptomatic carotid occlusive disease, while common in patients with other cardiovascular disease, does not necessarily predispose to perioperative stroke and thus does not necessitate prophylactic carotid endarterectomy prior to indicated coronary or peripheral vascular reconstruction.