Carotid and coronary disease: staged or simultaneous management?

Up to 12% of patients presenting for coronary bypass have critical carotid disease, and more than 50% of patients presenting for carotid endarterectomy have significant coronary disease. Patients requiring surgery for both carotid and coronary disease may be managed with carotid endarterectomy followed by coronary bypass (staged approach), with coronary bypass followed by carotid endarterectomy (reversed staged approach), or with simultaneous coronary bypass-carotid endarterectomy. There are no compelling data proving superiority of any of these three approaches. The staged approach is usually associated with lower stroke rates but higher myocardial infarction and mortality rates; the reversed staged approach with higher stroke rates but lower myocardial infarction and mortality rates; and the simultaneous approach with intermediate stroke, myocardial infarction, and mortality rates. Unfortunately, reported series vary widely in stroke and mortality rates because of wide variability in patient selection criteria, especially for simultaneous procedures. Management decisions in these patients should be based on the relative severity of their carotid and coronary lesions. Management guidelines are discussed in detail.