Is Carotid Revascularization Necessary Before Cardiac Surgery?

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1 Is Carotid Revascularization Necessary Before Cardiac Surgery? Siavash Saadat, MD April 27, 2015 Rutgers, The State University of New Jersey

2 Disclosures No financial disclosures

3 Background Optimal management of patients with asymptomatic carotid stenosis undergoing cardiac surgery remains controversial Carotid Endarterectomy (CEA) or Carotid artery stenting (CAS) prior to cardiac surgery Synchronous carotid / cardiac surgery Cardiac surgery prior to carotid interventions

4 Background CEA followed by coronary artery bypass grafting (CABG) may lead to a higher rate of myocardial infarction (MI) CABG followed by CEA may have a higher stroke rate No consensus concerning indications for combining procedures correct sequence of operations surgical outcomes for each respective treatment

5 Background While controversy exists in patients found to have severe stenosis, most studies rarely include patients with moderate stenosis, which has yet to be implicated as a clear risk factor for increased stroke after cardiac surgery.

6 Objectives We analyzed cardiac surgery outcomes in patients with unilateral and bilateral asymptomatic moderate to severe carotid stenosis at a single university affiliated hospital.

7 Methods Data Collection: Rutgers - Robert Wood Johnson University Hospital Cardiac Surgery Database A total of 1,781 patients underwent cardiac surgery Duration: January 2012 to June 2013

8 Methods 1,357 patients had preoperative screening with carotid duplex ultrasonography Degree of Stenosis (NASCET)- Moderate: 50-69% Severe: 70-99% All patients with asymptomatic carotid stenosis

9 Statistical Analysis Chi-square and logistic regression analysis were performed using SAS 9.4 software (SAS Institute, Cary, NC).

10 Optional Robert Wood Presentation Johnson Medical TitleSchool

11 Results Asymptomatic stenosis found in 403/1357 patients (29.7%). Moderate Stenosis: 355 / 1357 (26.2%) (88% of patients with asymptomatic stenosis) Severe Stenosis: 48 / 1357 (3.5%) (12% of patients with asymptomatic stenosis)

12 Results Patients with asymptomatic stenosis were older (71.7±11 years vs 66.3±12 years; P<0.01). Females were more likely to have stenosis (OR=1.7; 95%CI ).

13 Optional Robert Wood Presentation Johnson Medical TitleSchool

14 Results Total postoperative TIA occurred in 3/1357(0.2%) Only one had moderate asymptomatic stenosis. In-hospital stroke occurred in 21/1357 (1.5%) patients; stroke rates were 2.3% (8/355) with moderate stenosis and 2.1% (1/48) severe stenosis.

15 Results There were 59/1357 (4.3%) deaths; patients with stenosis had a mortality rate of 4.2% (17/403), while patients without stenosis had a mortality rate of 4.4% (42/954). However, no postoperative stroke lead to death.

16 Results Multivariable logistic regression analysis with adjustment for age, gender, race, comorbidities and postoperative complications did not show an impact of carotid stenosis on postoperative mortality and development of stroke after cardiac surgery.

17 Conclusions In this study, we evaluated all cardiac surgery patients with carotid duplex screening and their postoperative outcomes without CEA. Our findings demonstrate no difference in morbidity and mortality in asymptomatic carotid stenosis vs. no carotid stenosis.

18 Conclusions This study suggests patients with asymptomatic carotid stenosis undergoing cardiac surgery are not at increased risk of postoperative complications and mortality; thus, prophylactic carotid revascularization may not be indicated.

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