Choosing Wisely:

Don’t initiate routine evaluation of carotid artery disease prior to cardiac surgery in the absence of symptoms or other high-risk criteria.

Rationale and Comments: Studies show that the presence of asymptomatic carotid disease in patients undergoing cardiac surgery does not justify preoperative screening in more than the subgroup of ”high-risk” patients. Carotid stenosis with symptoms (stroke or transient ischemic attacks) is a known risk for cardiovascular accident and appropriate for preoperative testing. High-risk patients have been defined as patients with left main coronary disease, peripheral artery disease, hypertension, smoking, diabetes mellitus, or age older than 65 years due to a higher rate of asymptomatic carotid stenosis in these patients. The presence a carotid bruit does not equate to an increased risk of stroke after cardiac surgery. Patients with carotid stenosis have a higher rate of cerebrovascular complications after cardiac surgery, but there is no evidence that prophylactic or concomitant carotid surgery decreases this rate of complications in asymptomatic patients. Although controversial, the cumulative risk of carotid surgery and cardiac surgery, either sequentially or concomitantly, may exceed the benefit in asymptomatic patients.
Sponsoring Organizations:
  • Society of Thoracic Surgeons
  • Sources:
  • ACC/AHA guidelines
  • Disciplines:
  • Surgical
  • Cardiovascular
  • References: • Hillis LD, et al. 2011 ACCF/AHA guideline for coronary artery bypass graft surgery. Circulation. 2011;124(23):e652-e735.
    • Stansby G, et al. Asymptomatic carotid disease and cardiac surgery consensus. Angiology. 2011;62:457-60.
    • Tarakji KG, et al. Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA. 2011;305:381-90.
    • Naylor AR, et al. Stroke after cardiac surgery and its association with asymptomatic carotid disease: An updated systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2011;41:607-24.
    • Cournot M, et al. Accuracy of the screening physical examination to identify subclinical atherosclerosis and peripheral arterial disease in asymptomatic subjects. J Vasc Surg. 2007;46:1215-21.
    • Ratchford EV, et all. Carotid bruit for detection of hemodynamically significant carotid stenosis: the Northern Manhattan Study. Neurol Res. 2009;31:748-52.

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