Carotid artery stenting before cardiac surgery: A promising path down a muddy road?

摘要

The management of synchronous carotid disease and coronary or valvular disease requiring surgical repair has been a constant challenge to clinicians for decades and for a variety of reasons. First, although it is a vexing problem, it is relatively infrequent, such that any single institution/ operator experience in management will always be clouded by "the last case I did" syndrome, more reflective than definitive. Second, even in patients without carotid stenosis, the risk of stroke inherent in cardiac surgery from other sources (atheroembolic from aortic manipulation, air em-boli, and so on) clouds the assessment of the neurological "natural" history of the unoperated carotid stenosis in this setting. However, it seems clear enough that the patient with symptomatic carotid disease is at most risk and requires further management consideration, but that most asymptomatic patients with unilateral disease can withstand a cardiac operation with little increase in overall stroke risk and, therefore, should not be subjected to carotid revascu-larization risks (2). Next, the published database that generally helps guide such decisions in practice comprises largely single-center reports, and usually retrospectively analyzed. A recent Cochrane attempt to review all the published randomized data on the subject could not be completed, because there were no such studies in existence (3).