Myocardial revascularization before carotid endarterectomy

• Published in: Journal of cardiovascular surgery Vol. 44; no. 3; pp. 371 - 382
• Main Author: Krupski, W C
• Format: Journal Article
• Language: English
• Published: Italy Edizioni Minerva Medica 01.06.2003
• Subjects: Carotid Stenosis - mortality; Carotid Stenosis - surgery; Combined Modality Therapy; Coronary Artery Disease - mortality; Coronary Artery Disease - surgery; Endarterectomy, Carotid; Humans; Myocardial Infarction - mortality; Myocardial Infarction - prevention & control; Myocardial Revascularization; Postoperative Complications - mortality; Postoperative Complications - prevention & control; Randomized Controlled Trials as Topic; Risk Assessment; United States; United States
• ISSN: 0021-9509; 1827-191X

Diffuse atherosclerosis involving more than 1 vascular bed is a challenging problem. The natural histories of carotid and coronary atherosclerosis are clearly intertwined. The optimal strategies for treatment of patients who present with carotid artery stenoses and co-existent coronary artery disease (CAD) remain controversial. Minimally invasive screening tests for CAD are often unreliable, and patients presenting with significant extracranial carotid artery stenoses should usually be assumed to harbor some degree of CAD. Numerous studies have confirmed, however, that in contrast to peripheral artery stenoses, hemodynamically significant stenoses of the coronary arteries are not necessarily the index lesions that produce myocardial infarctions (MIs). Although there are some anecdotal reports that myocardial revascularization prior to carotid endarterectomy (CEA) improves the short- and long-term cardiac outcomes of patients after CEA, no prospective, randomized, controlled studies have proven this hypothesis. Numerous adverse cardiac events can occur in the perioperative period including congestive heart failure (CHF), arrhythmias, unstable angina pectoris and both nonfatal and fatal MIs. Of these, only MIs are truly "hard" endpoints. The incidence of MI after CEA is much lower than after other commonly performed peripheral arterial operations such as aortic or infrainguinal procedures. The perioperative nonfatal and fatal MI rates after CEA average about 1.0% and 0.4%, respectively. The Coronary Artery Revascularization Prophylaxis (CARP) study is currently ongoing in the United States as a multicentered randomized prospective controlled trial sponsored by the Department of Veterans Affairs. In this study, patients with significant CAD who are undergoing operations for peripheral arterial disease are randomized to myocardial revascularization versus best medical care; however, CEA procedures are excluded from this study because cardiac morbidity is low. Based on the low incidence of adverse cardiac events in CEA patients, it is generally prudent to treat their CAD with best medical care rather than routine prophylactic myocardial revascularization.