Staged carotid endarterectomy under local anaesthetic in patients requiring cardiac surgery.

INTRODUCTION

There is no clear guidance as to the management of carotid stenotic disease prior to cardiac surgery. We aimed to review the results of a single centre performing carotid endarterectomy (CEA) under local anaesthesia prior to cardiac surgery.

PATIENTS AND METHODS

All patients referred for cardiac surgery in our tertiary referral unit between January 1998 and August 2008 were identified and data relating to those 100 undergoing CEA prior to cardiac surgery were reviewed. Eighty had coronary artery bypass grafting (CABG) alone, 15 combined valve surgery and CABG and three underwent isolated valve surgery. Two patients died prior to cardiac surgery.

RESULTS

One hundred patients were prospectively identified after screening by clinical features and carotid duplex scanning to require CEA from a total of 11,394. The stroke rate was 1% between CEA and cardiac surgery, 2% following cardiac surgery and 3% in total. Ninety-eight patients proceeded to cardiac surgery (two deaths post-CEA). The cumulative event rate (stroke, myocardial infarct [included in view of the nature of the patients in our cohort] and/or death) was 10.2% following all cardiac surgery (CABG and valve). In 80 patients undergoing CABG only, the cumulative event rate was 7.5% after CABG. Including the two deaths pre-cardiac surgery, the rates were 12% and 8%. The risk of peri-operative stroke and 30-day mortality were reduced to that of patients undergoing cardiac surgery without significant carotid arterial disease, 3% versus 3.3% and 5.1% versus 6.5%, respectively.

CONCLUSIONS

This study demonstrates that a policy of selective screening for significant carotid artery disease in cardiac surgical patients combined with a strategy of CEA under local anaesthesia prior to unselected cardiac surgery (CABG with or without valve surgery) leads to rates of peri-operative CVA, myocardial infarction and death comparable to rates published for CEA prior to isolated CABG surgery. Furthermore, it reduces the risk of peri-operative stroke and 30-day mortality to that observed in patients undergoing cardiac surgery without significant carotid arterial disease.