The prevalence of significant asymptomatic carotid artery disease in 1250 coronary patients was 7.36% (92 patients). Furthermore, the prevalence of severe asymptomatic disease increased significantly with age. It was 2.14% in patients under 60 years old, rising to 5.23% in patients over 60 years old. In contrast, the prevalence of severe symptomatic carotid artery disease was almost the same in patients with stable angina as in those with unstable angina: 3.95% in 930 patients with stable angina and 3.42% in 320 patients with unstable angina. Staged intervention (carotid before coronary) was performed on 74 patients (80.4%) with stable angina. They all had either bilateral severe stenosis (>70%) or ipsilateral severe stenosis and contralateral occlusion. Combined or synchronous intervention was carried out on 13 patients (14.2%). All were suffering from unstable angina, and had ipsilateral severe stenosis of >70% and contralateral occlusion. Reverse staged intervention was performed on five patients only with unstable angina. Coronary angioplasty was not recommended and CABG surgery was urgently needed. A staged procedure in stable angina was preferred because it is safer and more sensible. Its main advantage is a significant reduction in perioperative CABG stroke risk. Its main disadvantage is the necessity for two general anaes-

Fig. 2.8.5 Carotid endarterectomy performed with and without shunt and patch

thetics in a short period of time and longer hospitalization with an increased economic burden. Synchronous and reverse staged carotid endarterectomy was adopted in cases with unstable angina. Mortality in these cases was significantly higher. Carotid endarterectomy was the only intervention used in this study. It was performed without a shunt in 92.2% of cases, and using a patch graft in 94.8% of cases (Fig. 2.8.5).

Perioperative complications of carotid endarterec-tomy were found in 6.2% of cases and were mild and short lived. Total mortality was 2.2% (0% for staged intervention, 7.1% for synchronous intervention and 20% for reverse staged intervention). Suggested options to the adopted protocol are:

• Off-pump coronary revascularization particularly in the elderly.

• Carotid angioplasty and stenting under cerebral protection, which may become the treatment of choice in polyvascular patients requiring myocardial revascu-larization.

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