The Society of Thoracic Surgeons

View all recommendations from this society

Released February 21, 2013

Don’t initiate routine evaluation of carotid artery disease prior to cardiac surgery in the absence of symptoms or other high-risk criteria.

  • Carotid stenosis with symptoms (stroke or transient ischemic attacks [TIA]) is a known risk for cardiovascular accident and appropriate for preoperative testing.
  • The presence of a carotid bruit does not equate to an increased risk of stroke after cardiac surgery.
  • Patients with carotid stenosis have a higher rate of cerebrovascular complications after cardiac surgery, but there is no evidence that prophylactic or concomitant carotid surgery decreases this rate of complications in asymptomatic patients.

ACC/AHA 2011 guidelines for coronary artery bypass graft surgery indicate carotid artery duplex scanning is reasonable in selected patients who are considered to have high-risk features. However, this was based on a consensus and a low level of evidence. In addition, a recent consensus report from the United Kingdom questioned whether neurologic sequellae developing in cardiac surgery patients with asymptomatic carotid disease are due to the carotid artery disease or rather act as a surrogate for an increased stroke risk from atherosclerotic issues with the aorta.

The Northern Manhattan Stroke Study concluded that carotid auscultation had poor sensitivity and positive predictive value for carotid stenosis and so decisions on obtaining carotid duplex studies should be considered based on symptoms or risk factors rather than findings on auscultation.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The Society of Thoracic Surgeons (STS) list development process was led by the First Vice-President, and involved input from multiple workforces, including the Workforce on Adult Cardiac and Vascular Surgery, Workforce on General Thoracic Surgery, and Workforce on Evidence Based Surgery, and was staffed by STS’ Director of Quality. The initial 17 recommendations from these Workforces were narrowed down to eight based upon frequency, clinical guidelines and potential impact. STS leadership approved these eight recommendations for presentation to members in an online survey. The results of the survey, as well as research and systematic literature review by the Workforce on Evidence Based Surgery, were presented to the STS Executive Committee, which approved the five final recommendations.

Sources

American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery. Circulation. 2011;124(23):e652-e735.

Stansby G, Macdonald S, Allison R, de Belder M, Brown MM, Dark J, Featherstone R, Flather M, Ford GA, Halliday A, Malik I, Naylor R, Pepper J, Rothwell PM. Asymptomatic carotid disease and cardiac surgery consensus. Angiology. 2011;62:457-460.

Tarakji KG, Sabik JF, Bhudia SK, Batizy LH, Blackstone EH. Temporal onset, risk factors, and outcomes associated with stroke after coronary artery bypass grafting. JAMA. 2011;305:381-390.

Naylor AR, Bown MJ. Stroke after cardiac surgery and its association with asymptomatic carotid disease: An updated systematic review and meta-analysis. Eur J Vasc Endovasc Surg. 2011;41:607-624.

Cournot M, Boccalon H, Cambou JP, Guilloux J, Taraszkiewicz D, Hanaire-Broutin H, Chamontin B, Galinier M, Ferrières J. Accuracy of the screening physical examination to identify subclinical atherosclerosis and peripheral arterial disease in asymptomatic subjects. J Vasc Surg. 2007 Dec;46:1215-21.

Ratchford EV, Jin Z, Di Tullio MR, Salameh MJ, Homma S, Gan R, Boden-Albala B, Sacco RL, Rundek T. Carotid bruit for detection of hemodynamically significant carotid stenosis: The Northern Manhattan Study. Neurol Res. 2009;31:748–752.