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Carotid artery surgery for people with existing coronary artery disease
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  1. Ian Lane,
  2. John Byrne
  1. Correspondence to:
    Mr Ian Lane, Cardiff Vascular Unit, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK;
    ian.lane{at}cardiffandvale.wales.nhs.uk

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Carotid artery surgery for neurological symptoms was first reported by Eastcott and colleagues in 1954 following earlier recognition that extracranial atheroma was associated with ischaemic stroke.1 Carotid endarterectomy rapidly established itself as one of the most frequently performed procedures in the USA, largely based on surgery for asymptomatic atherosclerosis or a carotid bruit. Practice in the UK was more cautious, awaiting the results of European and US trials to clarify management of symptomatic disease with carotid stenosis of over 70%.

DIAGNOSIS OF CAROTID ARTERY DISEASE

Atherosclerosis is a generalised disease, and while symptoms may be site specific, inevitably disease elsewhere will influence the overall management of a patient. The risk of stroke is increased during coronary artery surgery for angina in the presence of asymptomatic carotid disease; conversely the risks of carotid endarterectomy are higher in patients with silent myocardial ischaemia. Early carotid artery wall disease is a predictor for coronary atherosclerosis and subsequent coronary vascular events.2

The primary symptoms of carotid atherosclerosis are neurological events and amaurosis fugax caused by embolisation from a plaque. Neurological events include transient ischaemic attacks and stroke and must be related to the contralateral side of the body from that of the stenosis. Events may be sensory, motor, or combined and on occasion are confined to intermittent dysarthria. Classically transient ischaemic attacks last less than 24 hours with full recovery. The 24 hour watershed is an epidemiological tool and does not necessarily imply the absence of permanent brain damage. Imaging by computed tomographic scan has demonstrated multiple cerebral infarcts in patients showing full recovery after transient ischaemic attacks. The frequency of attacks is variable and weeks or months may elapse between events. Multiple events within a timescale of hours (crescendo transient ischaemic attacks) carry a high risk of stroke as they may precede carotid artery thrombosis. Loss …

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