August 5th, 2013
Poll: What Would You Recommend?
Richard A. Lange, MD, MBA
Your 69-year-old female patient with low-level exertional angina is referred for coronary angiography that reveals three-vessel CAD. After a lengthy discussion, the “heart team” (involving an interventional cardiologist and a cardiac surgeon) determines that CABG is the best revascularization option for this patient. A carotid Doppler study, conducted in preparation for CABG, reveals 80% stenosis of the right common carotid artery, although the patient has never had a TIA or neurologic symptoms.
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13 Responses to “Poll: What Would You Recommend?”
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I would consider first a CT scan Of the brain if normal open heart surgery without carotid procedure.
If there are evidence of previous ischemic event(s), carotid artery surgical revascularisation during open heart surgery would be my recommandation.
I just had a patient undergo CAE and CABG as part of the same anesthetic around one month ago and he did very well. The CAE was done first. My first choice if it were me undergoing the procedure would be carotid stenting (if possible) followed by CABG (if CABG were the only reasonable option). Each case must be individually evaluated for the benefits and risks of whatever algorithm is to be used.
carotid stenting follow by CABG
carotid stenting first, followed by CABG
Very controversial issue …
In the absence of neurologic symptoms, I wouldn’t recommend any carotid intervention.
I would consider Combined CAE & CABG on the same session, rather than stenting followed by CABG to avoid Antiplatlet medication discontinuation during CABG.
Stenting is the best option, you can performed in very severe cases. If you can’t wait 2 or 3 weeks to complete dual antiplatelet therapy after stenting then combined CAE and CABG option is the best. Any way in this area you need to have the complete picture to decide.
Carotid stenosis is associated with an increased incidence of stroke but is not a direct cause of postoperative stroke this paradox probably is related to aortic atheromatosis so is important to preoperative evaluate the Aorta.
This poll is raising a lot of interesting responses – and votes. Would be great for everyone who votes to leave a comments and mention why they think that is the best recommendation – and what issues were most important to them in making that recommendation.
Wow…quite a divergence of opinions. I agree with Harlan. I’m interested in why you think the treatment option you chose is the best.
Cabg only, preferably off pump
Not a compelling indication for carotid intervention in absence of symptoms
I voted CABG without carotid intervention. Although I agree with previous comments that we need to know more about the patient, and about the coronary anatomy.
Assuming the 3vd is not critical, the trade off is the procedural risk of carotid intervention versus excess risk of stroke during cabg (the excess risk may be small, since many peri-CABG strokes are not caused by carotid disease). We often tend to regret more adverse events caused by “commission” of an act rather than “omission”, which makes me weigh the procedure risk a bit more.
I think the other part of this is how we make decisions when evidence is mixed, and where there is great uncertainty. Should we discuss, and how, with patients that there are no clear cut answers, and that another doctor might reasonably make the opposite recommendation? Lisa Rosenbaum had an excellent article about this in the New Yorker recently:
http://www.newyorker.com/online/blogs/elements/2013/07/how-should-doctors-share-impossible-decisions-with-their-patients.html
I am always in serious doubt when I find an asymptomatic problem in a patient who comes for a symptomatic one.
This is the reason why I would consider to treated (first) the ‘speaking disease’.
Choosing that way will, for me, prevent side effets, always possible, of surgery or medical treatment of an asymptomatic lesion…
Of course I read the last paper In NEJM In which the analysis prones toward treating first the carotid artery lesion to prevent a more important debilitating situation (we judge hemiplegia been more serious than MI or death, but this is another discussion)
So I stay with my first point of view: go to by-pass coronary artery and I will explain to the patient and his family , why I’ll forget incidental carotid lésion.