Carotid disease in patients scheduled for coronary artery bypass: analysis of 678 patients

The SYNTAX score does not predict presence of carotid disease in a multivessel coronary disease population

BACKGROUND

Numerous reports have shown the relationship between carotid artery atherosclerosis and coronary artery disease (CAD). However, the association between complex CAD evaluated by SYNTAX score (SxScore) and prevalence of carotid lesion (CL) has not been fully investigated. We sought to assess the prevalence of carotid atherosclerosis in patients with multivessel CAD assessed by SxScore and the relationship between SxScore severity and features of carotid atherosclerosis.

METHODS AND RESULTS

Subjects were 204 consecutive patients with multivessel CAD assessed by coronary angiography and no previous history of carotid atherosclerosis that underwent carotid ultrasound scan from June 2012 to 2013. Presence of CL, significant carotid disease (SCD) and carotid plaque morphology was evaluated. At least one CL was found in 159 patients (77.9%) with no significant difference among SxScore groups (P = 0.20 and P = 0.54, respectively). High prevalence of complex carotid plaque (CCP) was found without significant different distribution in SxScore groups (P = 0.69). Age was independently associated with the presence of CL [odds ratio (OR) 1.055; 95% confidence interval (CI): 1.015-1.097; P = 0.007] and SCD (OR 1.057; 95% CI: 1.008-1.097; P = 0.019). Age and diabetes were independently associated with CCP (OR 1.58; 95% CI: 1.023-1.095; P = 0.001; OR 1.848; 95% CI: 1.026-3.327; P = 0.041). SxScore was not independently associated with CL, SCD and CCP (all P > 0.2).

CONCLUSIONS

We found high prevalence of CL in patients with multivessel complex CAD. However, SxScore does not seem to correlate with carotid atherosclerosis.

Evaluation of the clinical utility of a carotid bruit

BACKGROUND

Uncertainty exists over whether listening for carotid bruits as part of the clinical examination is informative in terms of predicting the presence or severity of carotid stenosis.

AIM

We sought to undertake a comprehensive meta-analysis and meta-regression of all studies to date that have assessed the relationship between a carotid bruit and severity of degree of stenosis.

METHODS

Electronic databases were used to identify all published studies in humans evaluating the association between bruit and stenosis published until and including October 2011. Pooled sensitivity, specificity and diagnostic odds ratio (DOR) were calculated for each stenosis group. Summary receiver operating characteristic (SROC) curve analysis was performed in studies assessing clinically relevant (i.e. >70%) stenosis. Meta-regression was performed in all studies, using random effects.

RESULTS

We identified 26 studies evaluating the association between carotid bruit and stenosis, in 15 117 arteries. For clinically relevant stenosis (i.e. >70%), we found pooled sensitivity 0.53 [95% confidence interval (CI): 0.5-0.55], specificity 0.83 (95% CI: 0.82-0.84) and DOR 4.32 (95% CI: 2.78-6.66). SROC curve analysis gave an area under the curve of 0.73. Meta-regression analysis showed a (non-significant) (P = 0.067) inverse relationship between carotid bruit and stenosis.

CONCLUSION

The carotid bruit is of moderate value for detecting clinically relevant carotid stenosis. It gives high specificity but low sensitivity. The likelihood of a carotid bruit does not increase at increasing degrees of stenosis.

A high prevalence of carotid artery stenosis in male patients older than 65 years, irrespective of presenting clinical manifestation of atherosclerotic diseases

This study investigated the prevalence of carotid artery stenosis (CS) and the association with various risk factors in male patients (>65 years) diagnosed with cardiovascular diseases. Duplex sonography of the carotid arteries was performed in 434 of 473 eligible patients of whom 118 (27.8%) patients had significant CS ≥50%. The prevalence and severity of CS did not differ between patients who presented with neurological symptoms or acute coronary syndrome/peripheral artery disease (30.8% vs 25.9%, respectively). Among patients with CS, a higher rate of current smoking, a higher systolic blood pressure, and a lower glomerular filtration rate were observed compared with patients without CS. A history of coronary artery bypass graft was a significant predictor of the presence of CS (P = .003, odds ratio [OR] = 2.70 [1.40-5.19]). The prevalence of CS in elderly males with manifest atherosclerotic disease is high, irrespective of presenting clinical manifestation.

Therapeutic strategies for patients with internal carotid or middle cerebral artery occlusion complicated by severe coronary artery disease

BACKGROUND/OBJECTIVES

Ischemic stroke is one of major complications of cardiac surgery. Although a current American Heart Association (AHA) guideline states that carotid endarterectomy is probably recommended before or concomitant to coronary artery bypass grafting (CABG) for the carotid stenosis, there is no report that analyzed optimal strategies in cardiac surgery for patients with total occlusion of the internal carotid artery (ICA) or the middle cerebral artery (MCA). Therefore, this preliminary study was aimed to clarify whether preoperative blood flow measurements and prophylactic superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis could reduce the incidence of perioperative ischemic stroke during cardiac surgery in patients with total occlusion of the ICA or MCA.

METHODS

This prospective study included eight patients who were admitted to undergo cardiac surgery including CABG. All of them had total ICA or MCA occlusion on preoperative magnetic resonance (MR) examinations. Preoperative cerebral blood flow and its reactivity to acetazolamide were quantitatively determined in all eight patients using single photon emission computed tomography or positron emission tomography.

RESULTS

Preoperative blood flow measurements revealed that two (25%) of eight patients had normal cerebral hemodynamics because of well-developed collaterals. They safely underwent cardiac surgery. However, a marked impairment of cerebral perfusion reserve was identified in six (75%) of eight patients in the ipsilateral hemispheres. Of these, four patients underwent prophylactic STA-MCA anastomosis prior to CABG. Subsequently, they safely underwent CABG without perioperative ischemic stroke.

CONCLUSION

This is the first report suggesting that preoperative identification of hemodynamic compromise and prophylactic STA-MCA anastomosis may reduce perioperative ischemic stroke during cardiac surgery in patients with ICA or MCA occlusion, although further studies are needed to assess the validity.

Low prevalence of significant carotid artery disease on ultrasound in patients proceeding to coronary artery bypass surgery

BACKGROUND

Cardiothoracic surgery is associated with an increased risk of perioperative stroke. Preoperative carotid ultrasonography can identify significant stenosis, but there is debate about the value of screening. The aims of this study were to (i) determine the prevalence of significant carotid artery disease in screened patients undergoing cardiothoracic surgery and (ii) correlate their ultrasonographic findings with perioperative strokes.

METHODS

Retrospective analysis of 166 patients (118 men, 48 women) who underwent a preoperative carotid ultrasound and coronary artery bypass graft surgery (CABG) from 2004 to 2007. Perioperative strokes were recorded and compared with ultrasonographic and clinical data. A separate cohort of 1423 patients (1064 men, 359 women) who underwent CABG over the same period was also evaluated.

RESULTS

Only 11 screened patients (6.6%) had significant (>70%) carotid artery disease and two of these underwent simultaneous carotid endarterectomy. There were five perioperative strokes in screened patients, four of which occurred in individuals with <50% disease. Compared with the non-screened cohort, ultrasound screened patients were older and more likely to have a prior stroke or transient ischaemic attack, hypertension, hypercholesterolaemia, peripheral vascular disease and/or renal impairment than non-screened patients. There was no significant difference in perioperative strokes compared with non-screened patients (3% vs 1.2% respectively, P= NS).

CONCLUSION

There is a low prevalence of significant carotid artery disease in ultrasound screened patients. The risk of perioperative strokes in screened patients is low and not significantly different from non-screened patients.

Predictive value of asymptomatic cervical bruit for carotid artery disease in coronary artery surgery revisited

OBJECTIVE

To investigate the predictive value of asymptomatic cervical bruit for detecting internal carotid artery disease in consecutive patients undergoing coronary artery bypass grafting (CABG).

DESIGN

A prospective cohort study.

SETTING

Tertiary referral university hospitals.

PATIENTS

153 consecutive patients (mean age 57 years) undergoing CABG, without previous history of cerebrovascular events.

INTERVENTIONS

Patients underwent detailed pre-operative work-up, including coronary angiography and carotid artery duplex scanning. Internal carotid artery diameter stenosis was graded as A: normal; B: < 15%; C: 15%-50%; D: 50-80%; D+: > 80-99% and E=complete occlusion.

RESULTS

72 patients (47.1%) (95% CI: 39%, 55%) had no evidence of internal carotid artery stenosis; 81 (52.9%) (95% CI: 44.9%, 60.9%) had varying grades of disease, unilateral or bilateral. Cervical bruit was detected in 12/153 patients (7.8%) (95% CI: 3.5%, 12.1%) of whom all but one (0.7%) had varying grades of internal carotid artery disease; of these, 4 patients had bilateral cervical bruit (2.6%) (95% CI: 0.06%, 5.2%). The sensitivity, specificity, positive and negative predictive values and overall accuracy of cervical bruit for detection of > or = 50% internal carotid artery stenosis were 23.5%, 95.8%, 25%, 95.5% and 91.8%, respectively. The relative risk of > or = 50% stenosis ipsilateral to cervical bruit in 306 sides was 5.58 (95% CI: 2.0, 15.0) and the odds ratio 7.1 (95% CI: 2.0, 25.0).

CONCLUSIONS

Asymptomatic cervical bruit proved a highly specific clinical sign for detection of internal carotid artery stenosis, whether haemodynamically significant (> or = 50%) or otherwise, in patients undergoing myocardial revascularisation. This was matched by a high negative predictive value and overall accuracy for flow limiting atheroma (> or = 50% stenosis). Yet, steering carotid investigations on the basis of cervical bruit alone would result in > or = 80% internal carotid artery stenosis remaining undetected in 3% of overall patients, in whom cervical bruit is absent.

Mandatory versus selective preoperative carotid screening: a retrospective analysis

BACKGROUND

Extracranial internal carotid artery stenosis is a risk factor for perioperative stroke in coronary artery bypass (CAB) surgery. Although both selective and nonselective methods of preoperative carotid screening have been advocated, it is unclear which approach is most clinically efficacious.

METHODS

Hospital records for 1421 consecutive CAB patients from January 2000 through April 2002 were reviewed. Univariate and multivariate analyses were performed across selected parameters to identify risk factors for significant carotid stenosis (> or = 70%). Patients were retrospectively stratified into high- or low-risk groups based on risk factors common to carotid stenosis and perioperative stroke. The prevalence of carotid stenosis, surgical management, and perioperative stroke rates were determined for each group.

RESULTS

One-thousand one-hundred thirty-eight patients out of 1421 patients (80.1%) underwent preoperative carotid screening. The prevalence of significant carotid stenosis was 13.4%. Univariate risk factors for stenosis included an age of more than 65 years, peripheral vascular disease, prior cerebrovascular accident, history of cerebrovascular disease, left main coronary disease, carotid bruit, female gender, and hypertension. Carotid stenosis was a risk factor for stroke, neurologic injury, in-hospital mortality, and longer hospitalization. Prevalence of carotid stenosis was greater in high-risk patients (17.8%, N = 708) versus low-risk patients (6.1%, N = 426). Concomitant or staged carotid endarterectomy (CEA)/CAB was more commonly performed in the high-risk group (5.8% vs. 1%, p < 0.001). All nine patients with significant carotid stenosis who suffered perioperative strokes were in the high-risk group (9 out of 708 vs 0 out of 426, p = 0.016).

CONCLUSIONS

In our cohort, selectively screening only patients with either an age of more than 65, carotid bruit, or cerebrovascular disease would have reduced the screening load by nearly 40% with negligible impact on surgical management or neurologic outcomes.

[Carotid stenosis concomitant to coronary artery disease]

Carotid stenosis is frequent in patients with coronary artery disease (CAD). In the literature, 9-28% of patients with CAD have additional carotid artery stenosis, predictors of which are advanced age, smoking, diabetes mellitus, arterial hypertension, coronary multivessel disease, and peripheral arterial disease. Moreover, patients with unstable coronary syndromes and those with elevated inflammatory markers such as C-reactive protein or fibrinogen more often have concomitant CAD and carotid artery stenosis. The long-term prognosis of these patients is worse than with CAD only. Therefore, patients with CAD should be screened for additional carotid artery stenosis, especially if coronary artery bypass grafting is planned. Continuous wave Doppler sonography and color-coded duplex sonography are suitable methods to screen for carotid artery stenosis.

Simultaneous stenting of the carotid artery and other coronary or extracoronary arteries: does a combined procedure increase the risk of interventional therapy?

Simultaneous interventions in carotid and other extracarotid arteries are not performed on a routine basis up to now. In 67 out of 295 consecutive patients (23%) undergoing elective stenting of the internal carotid artery, additional interventions in the coronary arteries (n = 65), the iliac artery (n = 3), renal artery (n = 1), left subclavian artery (n = 3), vertebral artery (n = 4), or a combination thereof were performed. Primary stenting was done in 51 (74%) out of 69 carotid arteries, in 48 (74%) of 65 coronary arteries, and in 10 (91%) of 11 other targeted vessels. Neurological complications consisted of two (2.9%) transient ischemic attacks and one (1.5%) minor stroke. In addition, one (1.5%) myocardial infarction occurred during coronary artery intervention. In comparison, 16 (6.6%) transient ischemic attacks, 1 minor stroke (0.4%), 5 (2.2%) major strokes, and 3 (1.2%) deaths were observed in 228 patients without combined procedures. Simultaneous percutaneous interventions including carotid arteries and other extracarotid arteries are feasible, relatively safe, and cost-effective.

Ocular and systemic findings and their correlation with hemodynamically significant carotid artery stenosis: a retrospective study

BACKGROUND

Optometrists often encounter patients with ocular signs and/or symptoms suggestive of carotid artery disease, but criteria for eye care practitioners concerning when to order carotid studies are not well established. A retrospective study in an optometry clinic was performed to determine if certain ocular findings and associated systemic risk factors were associated with hemodynamically significant carotid artery stenosis (HSCAS).

METHODS

A retrospective analysis was performed on all patients examined in the optometry clinic at the Sepulveda Ambulatory Care Center from January 1, 1998 through December 31, 1999 to identify all patients who had carotid studies ordered. Charts were then reviewed to determine the ocular finding that prompted the carotid study. Statistical analysis using an odds-ratio was performed to determine whether any ocular sign/symptom or systemic risk factor was associated with HSCAS.

RESULTS

Of 3822 patients, 48 (1.26%) had carotid studies ordered. Eight (17%) had HSCAS of >50% and symptomatic patients were 1.6 times more likely to have HSCAS than asymptomatic patients. Patients with HSCAS were 1.8 times more likely to have retinal vascular occlusions, 1.9 times more likely to have normotensive glaucoma, 2.4 times more likely to have peripheral retinal hemorrhages, and 2.6 times more likely to be smokers, although none of these factors were found to be a statistically significant indicator of HSCAS. However, the number of systemic diseases tended to be greater for the HSCAS patients compared with the non-HSCAS patients (HSCAS median = 3.5 and the non-HSCAS median = 2, p = 0.049).

CONCLUSION

Although no single ocular or systemic risk factor was found to be a statistically significant indicator of HSCAS, the number of systemic disease risk factors tended to be greater for the HSCAS patients compared with the non-HSCAS patients (p = 0.049). An extensive literature review was also performed to help establish guidelines for when to order carotid studies on the basis of ocular signs and/or symptoms as well as the presence of additive associated systemic risk factors.

Carotid artery disease and stroke during coronary artery bypass: a critical review of the literature

OBJECTIVES

to determine the role of carotid artery disease in the pathophysiology of stroke after coronary artery bypass (CABG).

DESIGN

systematic review of the literature.

RESULTS

the risk of stroke after CABG was 2% and remained unchanged between 1970-2000. Two-thirds occurred after day 1 and 23% died. 91% of screened CABG patients had no significant carotid disease and had a <2% risk of peri-operative stroke. Stroke risk increased to 3% in predominantly asymptomatic patients with a unilateral 50-99% stenosis, 5% in those with bilateral 50-99% stenoses and 7-11% in patients with carotid occlusion. Significant predictive factors for post-CABG stroke included; (i) carotid bruit (OR 3.6, 95% CI 2.8-4.6), (ii) prior stroke/TIA (OR 3.6, 95% CI 2.7-4.9) and (iii) severe carotid stenosis/occlusion (OR 4.3, 95% CI 3.2-5.7). However, the systematic review indicated that 50% of stroke sufferers did not have significant carotid disease and 60% of territorial infarctions on CT scan/autopsy could not be attributed to carotid disease alone.

CONCLUSIONS

carotid disease is an important aetiological factor in the pathophysiology of post-CABG stroke. However, even assuming that prophylactic carotid endarterectomy carried no additional risk, it could only ever prevent about 40-50% of procedural strokes.

The utility of preoperative routine carotid artery duplex scanning in patients undergoing aortic valve replacement

Patients with aortic valve disease (AVD) typically have a cardiac murmur that radiates to the neck and may be indistinguishable from a cervical bruit secondary to carotid artery occlusive disease. The purpose of this report was to determine the prevalence of significant asymptomatic carotid artery occlusive disease in patients undergoing aortic valve replacement (AVR). All patients scheduled for AVR were prospectively studied. Preoperative carotid artery color-flow duplex was performed in all patients. A total of 204 patients were included in the study and significant carotid disease (>50% stenosis of the internal carotid artery) was found in 17 (8%). In patients with isolated aortic valve disease, 4/129 (3%) had significant stenosis. Of the patients with concurrent aortic valve and coronary artery disease, 13/75 (17%) had significant stenosis. The incidence of significant carotid stenosis in patients with aortic valve disease was over five fold higher in patients with concurrent coronary artery disease (3% vs. 17%, p <0.001). The yield of routine carotid duplex scanning for patients undergoing isolated AVR is low. However, in the subset of patients with concurrent coronary disease, the yield is higher. This finding supports the use of routine carotid duplex scanning in patients with coexistent aortic valve and coronary artery disease.

Combined right transradial coronary angiography and selective carotid angiography: safety and feasibility in unselected patients

We evaluated the safety and feasibility of ad hoc carotid angiography following the right transradial coronary angiography. Selective carotid angiography was performed subsequent to coronary angiography in 213 consecutive patients. A 5 Fr Simmons catheter was reformed in descending or ascending aorta, then, withdrawn and rotated to cannulate the left and right carotid artery. Both carotid angiography was performed selectively in 211 (99%) patients. In two patients with severely tortuous subclavian artery, selective cannulation of the left carotid artery failed. There was no thromboembolism or arterial dissection. After the learning phase of 50 patients, the time to reform the catheter in aorta and to cannulate the left and right carotid artery was 50 +/- 77, 66 +/- 68, and 58 +/- 57 sec, respectively. Total procedural time was 195 +/- 145 sec. In conclusion, ad hoc carotid angiography can be performed reliably and safely following the right transradial coronary angiography. It might be useful for evaluation of an isolated or associated carotid artery stenosis. Cathet Cardiovasc Intervent 2001;53:380-385.

Carotid disease is a risk factor for stroke in coronary bypass operations

The purpose of this study was to investigate the risk of perioperative major cerebrovascular events (MCVEs) in patients undergoing coronary artery bypass grafting (CABG) and to develop preventive therapy. After excluding the patients with marked ascending aortic atheromas and those with combined intracardiac procedures such as valve replacement and aneurysmectomy, 722 consecutive patients who had carotid artery duplex scanning (CADS) and CABG were studied. The results of the study showed the correlation of advanced age, smoking, previous major cerebrovascular event (MCVE), and severe coronary artery disease with high grade carotid artery stenosis of 80-99% (p < 0.05). A total of 13 patients had perioperative MCVE and an analysis of risk factors showed that the MCVE correlated with carotid stenosis of > 60% and reduced cardiac output requiring inotropic support (p < 0.01). Prophylactic carotid endarterectomy (CEA) in patients with 80% to 99% carotid stenosis notably decreased the incidence of MCVE (p < 0.01), and the use of the "pump off" technique instead of standard cardiopulmonary bypass decreased MCVE (p = 0.056). On the basis of these data, prophylactic carotid endarterectomy is effective in averting perioperative MCVE in subjects with carotid stenosis of 80% to 99%, and for those with 60% to 79% carotid stenosis, the pump off technique decreases MCVE.