Does the risk of post-CABG stroke merit staged or synchronous reconstruction in patients with asymptomatic carotid disease?

The management of patients with combined carotid and coronary artery disease remains controversial, largely because of a lack of high quality natural history studies in patients with asymptomatic carotid disease undergoing isolated coronary artery bypass surgery. To date, practice ranges from never recommending additional intervention to a more aggressive policy of prophylactic carotid endarterectomy. For surgeons in the latter group, the only remaining debate is whether CEA should be staged or synchronous. This paper reviews the rationales and available evidence for managing the cardiac patient with asymptomatic carotid disease and is largely based on the findings of 2 recently published systematic reviews on the subject. These reviews suggest that a reappraisal of practice is necessary before the indiscriminate implementation of carotid angioplasty further complicates interpretation of the already poor quality data available.