Revascularization of carotid stenosis before cardiac surgery.

Carotid artery stenosis is often associated with advanced coronary artery disease. The coexistence of carotid and coronary artery disease adds complexity to the medical decision process and brings increasing challenge to the perioperative management of coronary artery bypass graft (CABG) surgery. Postoperative stroke remains one of the most devastating complications of CABG, thereby contributing to the increased risk of mortality following CABG. Carotid artery disease causes approximately a third of post-CABG stroke and thus needs to be addressed while preparing a patient for CABG. While carotid endarterectomy (CEA) has been the gold standard of carotid artery revascularization, carotid artery stenting may be noninferior to CEA in patients with increased surgical risks. Thus, a consensus as how to best revascularize patients with carotid artery stenosis before CABG is yet to emerge. We have reviewed the current literature and have addressed the pros and cons of the two modalities of carotid artery revascularization. Based on the current literature, the best management strategy for patients with concomitant surgical coronary artery disease in need of CABG and significant carotid artery stenosis should be based on individual patient characteristics, urgency of revascularization, prioritization based on the symptomatic vascular territory, local expertise with an integrated team approach by interventionalists, neurologists and cardiothoracic surgeons, preferably in high-volume centers.