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Eur J Vasc Endovasc Surg. 2011 May;41(5):607-24. doi: 10.1016/j.ejvs.2011.02.016. Epub 2011 Mar 10.

Stroke after cardiac surgery and its association with asymptomatic carotid disease: an updated systematic review and meta-analysis.

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1
The Department of Vascular Surgery at Leicester Royal Infirmary, Leicester LE2 7LX, UK. ross.naylor@uhl-tr.nhs.uk

Abstract

OBJECTIVES:

(i) Prevalence of stroke in neurologically symptomatic/asymptomatic patients with unilateral/bilateral carotid disease (including occlusion) undergoing cardiac surgery without prophylactic carotid endarterectomy (CEA) or carotid stenting (CAS). (ii) Prevalence of stroke in asymptomatic patients with unilateral/bilateral carotid disease (excluding occlusion) who underwent isolated cardiac surgery. (iii) Prevalence of stroke in the hemisphere ipsilateral to a non-operated asymptomatic stenosis in patients with severe bilateral carotid disease undergoing a synchronous unilateral CEA + cardiac procedure.

METHODS:

Systematic Review and meta-analysis.

RESULTS:

Cardiac surgery patients with a symptomatic/asymptomatic 50-99% stenosis or occlusion incurred a 7.4% stroke risk (95%CI 4.8-9.9), increasing to 9.1% (95%CI 4.8-16) in those with 80-99% stenoses or occlusion. After excluding patients with a history of stroke/TIA and those with isolated/bilateral occlusions, the stroke risk fell to 3.8% (95%CI 2.0-4.8) in patients with asymptomatic 50-99% stenoses and 2.0% in those with 70-99% stenoses (95%CI 1.0-5.7). The prevalence of ipsilateral stroke in patients with a unilateral, asymptomatic 50-99% stenosis was 2.0% (1.0-3.8), while the risk of any stroke was only 2.9% (2%-5.7%). These risks did not increase with stenosis severity (70-99%, 80-99%). Patients with bilateral, asymptomatic 50-99% stenoses or a 50-99% stenosis + contralateral occlusion incurred a 6.5% stroke risk following cardiac surgery, while the risk of death/stroke was 9.1% (3.8%-20.6%). Patients with bilateral 80-99% stenoses undergoing a unilateral synchronous cardiac/carotid revascularisation incurred a 5.7% risk of stroke in the hemisphere ipsilateral to the non-operated, contralateral stenosis.

CONCLUSIONS:

There is no compelling evidence supporting a role for prophylactic CEA/CAS in cardiac surgery patients with unilateral asymptomatic carotid disease. Prophylactic CEA/CAS might still be considered in patients with severe, bilateral asymptomatic carotid disease, but such a strategy would only benefit 1-2% of all cardiac surgery patients.

PMID:
21396854
DOI:
10.1016/j.ejvs.2011.02.016
[Indexed for MEDLINE]
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