Asymptomatic carotid disease in the cardiovascular surgical patient: is prophylactic endarterectomy necessary?

This prospective study used non-invasive techniques to screen for asymptomatic carotid occlusive disease in 314 patients who were to have coronary or peripheral arterial reconstruction. Hemodynamically significant carotid obstruction (greater than or equal to 50% stenosis or occlusion) was present in 54 arteries of 41 patients (13.1%), but only one-third of these lesions were accompanied by a cervical bruit. Among 48 carotid arteries where a bruit was heard, only 18 (37.5%) were associated with significant obstruction demonstrated by non-invasive screening. No prophylactic carotid endarterectomies were performed. There was only one perioperative TIA and one non-fatal stroke, neither of which was related to detectable carotid obstruction. In patients with peripheral vascular disease and detectable carotid obstruction or bruit, the perioperative mortality was higher than in patients without carotid obstruction or bruit (15.0% and 18.2 vs 3.1% and 2.1%, respectively). The deaths were primarily due to myocardial infarction. This study suggests that asymptomatic carotid occlusive disease, while common in patients with other cardiovascular disease, does not necessarily predispose to perioperative stroke and thus does not necessitate prophylactic carotid endarterectomy prior to indicated coronary or peripheral vascular reconstruction.