Stroke, Vol 24, 1115-1118, Copyright © 1993 by American Heart Association
RP Gerraty, PC Gates and JC Doyle
BACKGROUND AND PURPOSE: The management of asymptomatic carotid stenosis
found before vascular or coronary surgery is unclear from the literature.
We aimed to define the relation of carotid stenosis to perioperative stroke
in all patients, symptomatic and asymptomatic, and so determine a policy
for the management of asymptomatic carotid stenosis in patients requiring
major surgery. METHODS: We conducted a prospective clinical and Duplex
ultrasound study of 358 consecutive noncarotid major vascular or coronary
artery bypass operations, with a moratorium on endarterectomy for
asymptomatic carotid stenosis. RESULTS: There were 145 vascular and 213
coronary bypass operations. Ten of the 49 cases with prior symptoms of
cerebral ischemia (38 carotid, 11 vertebrobasilar) had symptomatic stenosis
of 50% or greater or occlusion, and 3 of these (30%) had ipsilateral
perioperative cerebral infarction (95% confidence interval, 6.67% to
65.25%). Two of these occurred ipsilateral to symptomatic carotid
occlusions, and 1 occurred ipsilateral to an 80% symptomatic stenosis. One
symptomatic patient with bilateral 30% stenosis had a perioperative infarct
in the asymptomatic hemisphere. Among the 309 asymptomatic patients, 1
perioperative infarct occurred ipsilateral to carotid stenosis of 30%. In
all there were 5 (1.4%) perioperative (within 72 hours) and 2 late (after
18 days) strokes. All strokes were hemisphere infarcts confirmed by
computed tomography. There were 53 cases with 50% or greater asymptomatic
carotid stenosis or occlusion, including 28 with 80% or greater stenosis or
occlusion. None had an ipsilateral perioperative stroke (95% confidence
interval, 0% to 6.72%). CONCLUSIONS: We conclude that the risk of
perioperative stroke related to symptomatic carotid stenosis may be high,
but for asymptomatic carotid stenosis the risk is low and does not justify
preoperative prophylactic carotid endarterectomy.
ARTICLES
Carotid stenosis and perioperative stroke risk in symptomatic and asymptomatic patients undergoing vascular or coronary surgery
Department of Clinical Neurosciences, St Vicent's Hospital, Melbourne, Australia.
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