Management of Combined Severe Carotid and Coronary Artery Disease
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Patients with severe carotid and coronary disease—especially if they require coronary artery bypass grafting (CABG)—are at high risk of cardiac events and stroke. Carotid revascularization should be considered for patients with symptomatic carotid disease and bilateral severe asymptomatic carotid stenosis. In patients with unilateral asymptomatic carotid stenosis, decision to proceed to revascularization should be based more on a perspective of long-term stroke prevention than of perioperative stroke reduction. Compared with endarterectomy, carotid artery stenting is associated with a lower incidence of periprocedural myocardial infarction, an event linked to long-term mortality. This observation may be particularly relevant for patients with advanced coronary artery disease such as those undergoing CABG. Irrespective of the carotid revascularization strategy, a broad disease management approach based on lifestyle modification and pharmacologic cardiovascular prevention is more likely to affect both the quality and duration of life than revascularization itself.
KeywordsCarotid artery disease Coronary artery disease Coronary artery bypass grafting Carotid endarterectomy Carotid artery stenting Perioperative stroke Stroke prevention Perioperative myocardial infarction Multilevel arterial disease
Conflicts of interest: M. Roffi: none; F. Ribichini: none; F. Castriota: has received grant support from Medtronic and Boston Scientific; has received a consulting fee or honorarium from Medtronic and Boston Scientific; and has received travel/accommodations expenses covered or reimbursed from Medtronic and Boston Scientific; A. Cremonesi: has received grant support from Medtronic and Boston Scientific; has received a consulting fee or honorarium from Medtronic and Boston Scientific; and has received travel/accommodations expenses covered or reimbursed from Medtronic and Boston Scientific.
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