Clinical utility of carotid duplex ultrasound prior to cardiac surgery

International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024

The "International Society for Heart and Lung Transplantation Guidelines for the Evaluation and Care of Cardiac Transplant Candidates-2024" updates and replaces the "Listing Criteria for Heart Transplantation: International Society for Heart and Lung Transplantation Guidelines for the Care of Cardiac Transplant Candidates-2006" and the "2016 International Society for Heart Lung Transplantation Listing Criteria for Heart Transplantation: A 10-year Update." The document aims to provide tools to help integrate the numerous variables involved in evaluating patients for transplantation, emphasizing updating the collaborative treatment while waiting for a transplant. There have been significant practice-changing developments in the care of heart transplant recipients since the publication of the International Society for Heart and Lung Transplantation (ISHLT) guidelines in 2006 and the 10-year update in 2016. The changes pertain to 3 aspects of heart transplantation: (1) patient selection criteria, (2) care of selected patient populations, and (3) durable mechanical support. To address these issues, 3 task forces were assembled. Each task force was cochaired by a pediatric heart transplant physician with the specific mandate to highlight issues unique to the pediatric heart transplant population and ensure their adequate representation. This guideline was harmonized with other ISHLT guidelines published through November 2023. The 2024 ISHLT guidelines for the evaluation and care of cardiac transplant candidates provide recommendations based on contemporary scientific evidence and patient management flow diagrams. The American College of Cardiology and American Heart Association modular knowledge chunk format has been implemented, allowing guideline information to be grouped into discrete packages (or modules) of information on a disease-specific topic or management issue. Aiming to improve the quality of care for heart transplant candidates, the recommendations present an evidence-based approach.

Association of carotid duplex ultrasonography screening with stroke and mortality among patients undergoing coronary artery bypass grafting

OBJECTIVE

Selection criteria for carotid duplex ultrasonography screening (DUS) before coronary artery bypass grafting (CABG) is primarily based on limited observational analysis, and the risks associated with carotid artery stenosis (CAS) detected by this approach to preoperative DUS are uncertain. This study aimed to determine the association of carotid DUS with stroke and mortality among patients undergoing CABG.

METHODS

Adult patients with coronary artery disease who underwent isolated CABG or CABG with concomitant valvular or congenital procedure were identified. CHA2DS2-VASc score was assessed before CABG, and patients were recorded as high risk if they had a score of 3 or higher. The primary outcomes were stroke and all-cause mortality. Secondary outcomes included ischemic stroke, non-ischemic stroke, transient ischemic attack, and cardiovascular mortality.

RESULTS

Among 8958 patients who underwent CABG, 70.9% (n = 6347) received carotid DUS preoperatively (low-risk, 57.3%; high-risk, 42.7%). In the low-risk cohort, there was no significant difference in the risk of stroke (20.7 per 1000 patient-years for CAS vs 13.1 per 1000 patient-years for no CAS; adjusted hazard ratio [aHR], 1.14; 95% confidence interval [CI], 0.78-1.68) or mortality (20.5 per 1000 patient-years for CAS vs 16.8 per 1000 patient-years for no CAS; aHR, 1.33; 95% CI, 0.97-1.83) at 15 years. In the high-risk cohort, CAS was associated with significantly higher risks of stroke at 30 days (433.2 vs 279.5 per 1000 patient-years; aHR, 1.92; 95% CI, 1.00-3.70) and mortality at 15 years (38.4 vs 32.7 per 1000 patient-years; aHR, 1.25; 95% CI, 1.01-1.57) compared with no CAS.

CONCLUSIONS

CAS did not impact the incidence of stroke or mortality in the low-risk cohort who underwent CABG. However, in the high-risk cohort, CAS was associated with a significant increase in the risks of 30-day stroke and 15-year mortality, indicating selective carotid DUS is necessarily recommended for these patients.

Prevalence and Prognostic Impact of Carotid Artery Disease in Patients Undergoing TAVI

OBJECTIVE

To assess the prevalence of atherosclerotic carotid artery disease (ACAD) in patients undergoing transcatheter aortic valve implantation (TAVI) and postoperative cerebrovascular and evaluate its prognostic impact on post-operative cerebrovascular incidents (CVA).

METHODS

Retrospective review of all consecutive patients with severe symptomatic aortic valve stenosis (AVS) who underwent TAVI at a single tertiary university hospital (January 2008-December 2018). Patients with AVS scheduled for TAVI and concomitant carotid stenosis were evaluated for prophylactic carotid revascularization (carotid endarterectomy, CEA or carotid artery stenting, CAS).

RESULTS

771 consecutive patients (mean age 80 years, 52% males), were treated by TAVI procedures. Carotid stenosis >70% was detected in 69 patients (9%); it was unilateral in 47 (68%) and bilateral in 22 (32%). Prophylactic carotid revascularization was performed before TAVI in 45 patients (31%): in 63.1% of patients (30/47) with unilateral carotid stenosis >70%, and in 68.1% (15/22) with bilateral carotid stenosis >70%. Postoperative CVA following TAVI procedures were recorded in 25 patients (3.2%): 22 cases of stroke (2.8%) and 3 cases of transient ischemic attack (0.4%). At multiple logistic regression, only bilateral carotid stenosis >70% (OR 1.16, CI 95% 1.03-1.31; p=.0009) was found as independent predictors of periprocedural CVA.

CONCLUSIONS

In patients with severe symptomatic AVS undergoing TAVI, carotid stenosis was frequently observed. Unilateral carotid stenosis >70% did not show a significant association with early CVA following TAVI. However, in the cohort of patients with bilateral carotid stenosis >70%, a significant association with postoperative CVA was observed.

Prevalence and Risk Factors Analysis of Carotid Stenosis Among Ischaemic Heart Diseases Patient in Bangladesh: A Cross-Sectional Study

Purpose

This study aimed to evaluate the prevalence of carotid stenosis among ischaemic heart disease (IHD) patients undergoing coronary artery bypass graft (CABG) surgery and identify risk factors associated with carotid stenosis at a tertiary-level hospital in Bangladesh.

Patients and Methods

This cross-sectional study examined 200 IHD patients scheduled for isolated and elective CABG surgery, and multivariate regression analysis was used to determine the impact of independent variables on carotid stenosis with coronary artery disease. A vascular surgeon and sonographer assessed carotid stenosis, and the severity of stenosis was classified according to the current Grayscale and Doppler US diagnosis models.

Results

We observed that the prevalence of carotid artery stenosis was 13.5%, and the male was significantly higher (85.2%) in the carotid stenosis group. A multivariate regression analysis observed that age (OR 1.79), dyslipidaemia (OR 2.19), uncontrolled hypertension (OR 2.38), uncontrolled DM (OR 2.51), multivessel coronary artery disease (OR 3.79), and multiple comorbidities (OR 4.46) are potential predictors of having significant carotid stenosis in a patient undergoing CABG surgery.

Conclusion

In Bangladesh, multivessel coronary artery disease, especially in elderly patients with multiple comorbidities, are 4 (four) times higher risk to have significant carotid artery stenosis. Preoperative carotid duplex screening should be performed to curtail the risk of postoperative adverse cerebrovascular events, particularly those who have carotid stenosis associated potential risk factors.

A Systematic Review Supporting the Society for Vascular Surgery Guidelines on the Management of Carotid Artery Disease

BACKGROUND

To support the development of guidelines on the management of carotid disease, a writing committee from the Society for Vascular Surgery has commissioned this systematic review.

METHODS

We searched multiple data bases for studies addressing 5 questions: medical management vs. carotid revascularization (CEA) in asymptomatic patients, CEA vs. CAS in symptomatic low surgical risk patients, the optimal timing of revascularization after acute stroke, screening high risk patients for carotid disease, and the optimal sequence of interventions in patients with combined coronary and carotid disease. Studies were selected and appraised by pairs of independent reviewers. Meta-analyses were performed when feasible.

RESULTS

Medical management compared to carotid interventions in asymptomatic patients was associated with better early outcome during the first 30 days. However, CEA was associated with significantly lower long-term rate of stroke/death at 5 years. In symptomatic low risk surgical patients, CEA was associated with lower risk of stroke, but a significant increase in MI compared to CAS during the first 30 days. When the long-term outcome of transfemoral CAS vs. CEA in symptomatic patients were examined using pre-planned pooled analysis of individual patient data from four randomized trials, the risk of death or stroke within 120 days of the index procedure was 5.5% for CEA and 8.7% for CAS, which lends support that over the long-term, CEA has superior outcome than transfemoral CAS. When managing acute stroke, the comparison of CEA during the first 48 hours to that between day 2 and day14 did not reveal a statistically significant difference on outcomes during the first 30 days. Registry data show good results with CEA performed in the first week, but not within the first 48 hours. A single risk factor, aside from PAD, was associated with low carotid screening yield. Multiple risk factors greatly increase the yield of screening. Evidence on the timing of interventions in patients with combined carotid and coronary disease was sparse and imprecise. Patients without carotid symptoms, who had the carotid intervention first, compared to a combined carotid intervention and CABG, had better outcomes.

CONCLUSIONS

This updated evidence summary will support the SVS clinical practice guidelines for commonly raised clinical scenarios. CEA was superior to medical therapy in long-term prevention of stroke/death over medical therapy. CEA was also superior to transfemoral CAS in minimizing long-term stroke/death for symptomatic low risk surgical patients. CEA should optimally be performed between 2-14 days from the onset of acute stroke. Having multiple risk factors increases the value of carotid screening.

SOCIETY FOR VASCULAR SURGERY CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF EXTRACRANIAL CEREBROVASCULAR DISEASE

Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were published. Since that publication, several studies and a few systematic reviews comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2011 guidelines with specific emphasis on five areas: is carotid endarterectomy recommended over maximal medical therapy in low risk patients; is carotid endarterectomy recommended over trans-femoral carotid artery stenting in low surgical risk patients with symptomatic carotid artery stenosis of >50%; timing of carotid Intervention in patients presenting with acute stroke; screening for carotid artery stenosis in asymptomatic patients; and optimal sequence for intervention in patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) approach, as has been done with other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin 0-2), carotid revascularization is considered appropriate in symptomatic patients with greater than 50% stenosis and is recommended and performed as soon as the patient is neurologically stable after 48 hours but definitely before 14 days of onset of symptoms. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients who are at increased risk for carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. In patients with symptomatic carotid stenosis 50-99%, who require both CEA and CABG, we suggest CEA before or concomitant with CABG to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on clinical presentation and institutional experience.

Features of Antithrombotic Therapy in Patients with Multifocal Arterial Disease

Multifocal arterial injury is common in patients with atherosclerotic cardiovascular diseases and is associated with increased risk of cardiovascular complications and death. Administration of more intensive antithrombotic therapy, particularly combinations of acetylsalicylic acid and a "vascular" dose of rivaroxaban, in patients with multifocal arterial injury is characterized by a beneficial ratio of efficiency and safety due to a pronounced decrease in the risk of cardiovascular complications. Detection of peripheral artery diseases in patients with ischemic heart disease and atherosclerotic cerebrovascular pathology makes it possible to improve the risk stratification, optimize the diagnostic tactics and clarify indications for more intensive antithrombotic therapy.

Features of Risk Stratification, Diagnosis and Secondary Prevention in Patients with Multifocal Arterial Disease. Part 1: Risk Stratification and Diagnosis

Multifocal arterial disease is common in patients with atherosclerotic cardiovascular disease and is associated with an increased risk of cardiovascular complications and death. The possibility of improving the prognosis of patients with multifocal arterial disease is associated with a more efficient diagnosis of both the underlying disease and obstructive atherosclerotic lesions of other localizations and with a more intensive secondary prevention. According to observational studies, the presence of significant stenoses of the carotid arteries and, especially, lower extremities arterial disease can be predictorы of similar lesions in other vascular beds and their detection with screening methods available in clinical practice allows improvement of the diagnosis in patients with suspected coronary artery disease. On the other hand, screening of lower extremities artery diseases in patients with acute coronary syndrome can clarify indications for the use of invasive diagnostic and treatment strategy, in patients with chronic coronary artery disease it can justify more aggressive approaches to secondary prevention.

Role of Carotid Artery Ultrasound Duplex Prior to Cardiac Surgery in Adults in Predicting Neurocognitive Complications

Background Neurocognitive complications (NCCs) after cardiac surgery are one of the most devastating complications. Significant internal carotid artery stenosis is assumed to be a predictor of NCCs. Carotid duplex ultrasound (DUS) is a non-invasive imaging study that remains the modality of choice and is routinely used in many centers for screening adult cardiac surgery patients prior to surgery. This study aims to assess the utility of preoperative carotid DUS in the prediction of NCCs in adult patients undergoing cardiac surgery in our center. Methods We retrospectively reviewed the medical records of patients who underwent coronary artery bypass graft (CABG), valvular or combined surgery, at King Faisal Cardiac Center in Jeddah between January 2017 and December 2018 (n = 229). The preoperative carotid DUS findings were evaluated. Risk factors associated with NCC were analyzed. Results Over the study period, a total of 229 patients underwent 233 procedures. Median age was 60 years (interquartile range [IQR] = 51-67 years), of whom 71% were males. Out of the diabetic patients, 67% had an HbA1C level above 7% pre-operatively. Carotid DUS was performed on 63% of patients, but only 6.9% developed a post-operative NCC. Patients who were actively smoking were more likely to develop NCC compared to nonsmokers or ex-smokers (14.7% vs 4.6%; p = 0.02), with an odds ratio of 3.6 (95% CI = 1.2-10.5). Patients who developed NCC had a significantly higher median intensive care length of stay (7 vs. 5 days; p = 0.05). Conclusions Although international guidelines clearly define which patient should get preoperative carotid DUS screening, the level of evidence is low. Based on our findings, preoperative routine use of carotid DUS prior to cardiac surgery has low utility in predicting NCC. We recommend a more tailored approach based on signs, symptoms, and high-risk features to optimize the utilization of resources, avoid unwarranted delays, and personalize patient care.

Is carotid screening redundant for patients undergoing coronary artery bypass grafting?

OBJECTIVES

Stroke is a devastating complication following coronary artery bypass grafting, which thankfully occurs with low incidence. The role of preoperative carotid ultrasound remains unclear. Whilst it is a cheap and reliable way of diagnosing carotid stenosis (CS), it is unclear if and how this knowledge should impact on subsequent patient management.

METHODS

A systematic review of the literature was performed using the PRISMA guideline. A literature search was conducted on the MEDLINE database from 1950 to May 2020 using the OVID interface. Fifteen papers out of a total of 5931 were identified for inclusion.

RESULTS

The evidence overall suggests that patients with severe CS are likely to have an increased incidence of postoperative stroke-however, the prevalence of severe CS is low, and even in this cohort of patients, the incidence is not particularly high.

CONCLUSION

In screened patients identified to have severe CS, there appears to be a generally low appetite for undertaking carotid intervention internationally either before or concurrently with the coronary artery bypass grafting. Putting this all together, the widespread screening of asymptomatic patients would appear to not be justified.

Is Duplex carotid artery screening prior to CABG justified?

OBJECTIVE

To evaluate the use of duplex carotid artery screening in patients undergoing coronary artery bypass graft (CABG).

METHODS

This descriptive, observational study was conducted in Radiology Department at King Fahad Military Medical Complex, Dhahran, Kingdom of Saudi Arabia from April 2015-2018. All Saudi patients (n=178) who underwent duplex carotid sonography prior to CABG were retrospectively reviewed for essential morphologic and hemodynamic information to estimate severity of extra-cranial internal carotid artery (ICA) stenosis. Patients with combined CABG and cardiac surgery, and those with limited carotid studies were excluded. Advancing age (65 years or above), gender, smoking, obesity, diabetes (DM), hypertension (HTN), dyslipidemia, coronary vessel disease, cardiac disease and previous stroke were recorded. Post-coronary artery bypass graft neurologic event (namely, transient ischemic attack [TIA] or stroke) was recorded. Chi-square test was used to determine association of stenosis degree with post-CABG neurologic event.

RESULTS

One hundred twenty eight patients (72%) were having ICA disease, while significant carotid artery stenosis (>70%) was seen in 11 patients (6.2%). Post-coronary artery bypass graft neurologic event was seen in 4.5% of patients. Advancing age, significant ICA stenosis and multi-vessel coronary disease were seen associated with a post-CABG event.

CONCLUSION

Significant ICA stenosis on duplex screening in elderly patients with multi-vessel coronary artery disease or certain risk factors may predict post-CABG stroke.

Association between carotid artery stenosis and peripheral artery disease: Evaluation by screening carotid ultrasonography (cross-sectional study)

We aimed to investigate the association between carotid artery stenosis and peripheral artery disease (PAD) by screening carotid ultrasonography (CUS).From January 2012 to December 2015, 231 consecutive patients who had undergone preoperative CUS for PAD were included in this study. A radiologist assessed the degree of internal carotid artery (ICA) stenosis by using the North American Symptomatic Carotid Endarterectomy Trial (NASCET). Severe (>70%) ICA stenosis was evaluated based on the type of vascular surgery, PAD lesion, and ankle-brachial index (ABI). Data were analyzed using multiple logistic regression analysis and the χ test.Among 231 PAD patients, multilevel lesions revealed significantly higher incidence of severe ICA stenosis than iliac and infrainguinal lesion (22.5% vs 9.4% vs 8%: P = .016). Age (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.00-1.12: P = .035), chronic kidney disease (CKD, OR: 6.19, 95% CI: 2.04-45.04: P = .013), and cerebral vascular disease (CVD, OR: 4.08, 95% CI: 1.13-16.46: P = .037) were significant risk factors of severe ICA stenosis in multivariate analysis. Prevalence of severe ICA stenosis according to ABI in PAD was not significant.Preoperative screening by CUS provides valuable information onasymptomatic carotid artery stenosis (ACAS) that can identify severe ACAS patients who are at high risk of stroke and to consider more intensive management of carotid disease in PAD patients. CUS can be a useful noninvasive preoperative screening imaging tool for PAD patients with multilevel lesions, aged > 65 years old, with CKD and CVD.

Is baseline cerebral oximetry a better predictor than carotid scan for postoperative delirium in cardiac surgery?

Guidelines recommend screening patients for carotid-artery stenosis, but unfortunately, measurement of baseline cerebral oximetry levels is still not a routine practice prior to cardiac surgery. We report a 41-year-old woman who presented with a normal carotid scan and unexpectedly low baseline cerebral oximetry levels. She had delayed postoperative recovery and discharge from hospital following her coronary-artery bypass surgery. This case report reiterates the prognostic significance of cerebral oximetry in the preoperative checkup and the association of low intraoperative values to postoperative cerebral impairment. It can also be identified as a comparatively better tool for preventing cognitive disturbances after cardiac surgery.

Lack of Association Between Extracranial Carotid and Vertebral Artery Disease and Stroke After Transcatheter Aortic Valve Replacement

BACKGROUND

Carotid artery stenosis is a risk factor for stroke after surgical aortic valve replacement, but it is unknown whether carotid and vertebral artery disease impacts the risk of stroke after transcatheter aortic valve replacement (TAVR).

METHODS

We reviewed 294 consecutive cases of TAVR at a tertiary care medical centre. Thirty-one patients without preoperative carotid/vertebral duplex ultrasonograms were excluded. Carotid or vertebral artery disease was defined on the basis of >50% stenosis. Outcomes were stroke within 30 days after TAVR, 30-day mortality, and overall survival.

RESULTS

Fifty-one patients (19%) had at least 50% stenosis of a carotid or vertebral artery. The carotid and vertebral artery disease group had higher rates of coronary artery disease, previous coronary artery bypass surgery, and peripheral artery disease compared with the control group. Transfemoral access was less common in the carotid and vertebral artery disease group (55% vs 77%; P < 0.01). Stroke occurred in 6.8% of patients (n = 18) within 30 days after TAVR, but no patients in the carotid and vertebral artery disease group had a stroke. The presence of at least 50% stenosis of a carotid or vertebral artery was not predictive of stroke by logistic regression. There was no difference in 30-day mortality (10% vs 4%; P = 0.11) and overall survival (log-rank test P = 0.84) between the groups.

CONCLUSIONS

The presence or absence of carotid or vertebral artery stenosis was not significantly related to the occurrence of stroke after TAVR. Routine screening for carotid and vertebral artery disease before TAVR does not appear justified.