carotid stenosis or by the presence of an ulcerated plaque. Overall average perioperative complication rates were stroke in 3 percent (range 0 to 9 percent), https://www.uptodate.com/contents/coronary-artery-bypass-grafting-in-patients-with-cerebrovascular-disease/print 12/22 7/5/23, 11:39 AM Coronary artery bypass grafting in patients with cerebrovascular disease - UpToDate myocardial infarction in 2.2 percent (range 0 to 6 percent), and death in 4.7 percent (range 2.6 to 8.9 percent). Five- to six-year survival among 492 subjects in the three studies that reported long-term survival was 73 to 91 percent. One study evaluated CEA before CABG and included 297 patients with stable coronary heart disease. The perioperative complication rates were stroke in 1.9 percent, myocardial infarction in 4.7 percent, and death in 1.6 percent. Based on these retrospective data, the AAN concluded that perioperative complication rates were probably similar with combined CEA and CABG compared with CEA before CABG. A 2013 single-center retrospective analysis evaluated the outcome of 350 patients with severe coronary and carotid stenosis who underwent combined CEA and cardiac surgery (n=195), staged CEA followed by cardiac surgery (n=45), or staged CAS followed by cardiac surgery (n=110) [58]. Most of the cardiac procedures (92 percent) involved CABG, either alone or combined with other cardiac interventions such as valve surgery. Carotid disease was asymptomatic in 81 percent; there was a contralateral carotid stenosis (80 to 99 percent) in 9 percent, and a contralateral carotid occlusion in 13 percent. The following outcomes were reported: There was a significantly lower risk of interstage myocardial infarction (MI) for the staged CAS/cardiac surgery group compared with the staged CEA/cardiac surgery group (3 versus 11 percent), although the rates were similar for stroke (1 versus 2 percent) and death (5 versus 7 percent). For the composite endpoint of death, MI, and stroke, the staged CAS/cardiac surgery group and the combined CEA/cardiac surgery group had lower rates compared with the staged CEA/cardiac surgery group at 30 days after cardiac surgery (10 versus 10 versus 31 percent, respectively) and at one year (16 versus 17 versus 40 percent, respectively). These results were driven largely by the higher interstage (ie, precardiac surgery) MI event rate for the staged CEA/cardiac surgery group. During the period beyond one year after cardiac surgery, the staged CAS/cardiac surgery group had a lower composite event rate compared with the combined CEA/cardiac surgery group and staged CEA/cardiac surgery group (12 versus 39 versus 27 percent, respectively). These data suggest that staged CAS followed by CABG is the optimal strategy for patients with high-grade carotid stenosis who do not require urgent coronary revascularization, https://www.uptodate.com/contents/coronary-artery-bypass-grafting-in-patients-with-cerebrovascular-disease/print 13/22 7/5/23, 11:39 AM Coronary artery bypass grafting in patients with cerebrovascular disease - UpToDate while combined CEA and cardiac surgery is optimal for those who do require urgent coronary intervention. One of the relative strengths of this study is that patients in the staged CAS/cardiac surgery group were evaluated by a neurologist before and after CAS, suggesting that the stroke event rate for this group is reliable; by contrast, patients in the CEA groups were examined by a neurologist on an as-needed basis, as is true of nearly all such studies. However, limitations to this study, particularly the lack of randomization and retrospective methodology, precluded definitive conclusions. Surgical techniques of combined CEA and CABG Once the decision has been made to perform a combined CEA and CABG procedure, does it make a difference whether the CEA is done before or during cardiopulmonary bypass? As noted previously (see 'Comparative studies' above), retrospective data suggest that perioperative complication rates are probably similar with combined CEA and CABG compared with CEA before CABG. In addition, performing CEA during cardiopulmonary bypass does not appear to increase the incidence of bleeding or prolong hospital stay [59-61]. Our preference is to perform the CEA before cardiopulmonary bypass. After general anesthesia is induced and the patient is prepared for operation and draped, the CEA team proceeds to expose the carotid artery. Simultaneously, the cardiac team is harvesting the saphenous vein or the radial artery, if such grafts are necessary. The CEA is performed using systemic heparinization and a shunt. Once the CEA is completed, the heparin is not reversed, and the neck wound is packed but not closed. The chest is opened, the internal mammary artery is harvested, and the patient is placed on cardiopulmonary bypass, and the revascularization is completed. After the heparin is reversed, the neck excision is carefully checked for bleeding and the wound is closed. TIMING OF CABG AFTER STROKE Patients with a prior history of stroke or transient ischemic attack (TIA) have an increased risk of perioperative stroke with coronary artery bypass graft surgery (CABG) (see 'Risk factors' above), which may be as high as 8.5 percent [46]. The optimal timing of CABG surgery following a stroke has not been systematically addressed and depends upon multiple factors, including how recently the stroke occurred, the size of the stroke, the risk of stroke recurrence (which is in turn dependent on the stroke mechanism), and the urgency of cardiac intervention. A study of 14,030 patients undergoing surgical aortic valve replacement in Denmark, including 616 with prior stroke, reported a high risk of adverse events if the surgery was performed early after stroke, but the risk declined over time and stabilized after three months [62]. Unless urgent cardiac revascularization is necessary, surgery should be delayed pending a thorough work-up for the https://www.uptodate.com/contents/coronary-artery-bypass-grafting-in-patients-with-cerebrovascular-disease/print 14/22 7/5/23, 11:39 AM Coronary artery bypass grafting in patients with cerebrovascular disease - UpToDate stroke mechanism, including evaluation for large artery stenosis and any cardioembolic source, to clarify the risk of subsequent stroke and ensure appropriate stroke prevention therapies. (See "Overview of secondary prevention for specific causes of ischemic stroke and transient ischemic attack".) Optimal timing of cardiac surgery should also include a sufficient delay to allow for poststroke recovery of autoregulatory capabilities of the cerebral vasculature prior to exposure to periprocedural hypotension, and for sufficient remodeling of the damaged parenchyma to decrease the risk of hemorrhagic transformation of the infarct. Deferral of cardiac surgery for several weeks is suggested, although patients with large strokes (ie, those with damage involving the majority of a vascular territory or a sizeable portion of multiple territories) would likely benefit from additional delay. SOCIETY GUIDELINE LINKS Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Stroke in adults".) SUMMARY AND RECOMMENDATIONS The main mechanisms of ischemic stroke associated with coronary artery bypass graft surgery (CABG) are atheroembolization, particularly from the aortic arch, and cerebral hypoperfusion, which is less common. (See 'Stroke associated with CABG' above.) Atherosclerosis of the ascending aorta may be a more important cause of perioperative stroke than carotid artery stenosis. (See 'Risk factors' above and 'Aortic atherosclerosis' above.) The presence of a symptomatic carotid artery stenosis probably increases the risk of a perioperative stroke in patients undergoing CABG. In addition, the presence of bilateral 50 to 99 percent carotid stenoses or total carotid occlusion on one side combined with a 50 to 99 percent carotid stenosis on the other side may be associated with an increased stroke risk. However, patients with an asymptomatic unilateral carotid artery stenosis are likely to have little or no increased risk of carotid-related perioperative stroke during CABG and, therefore, we do not recommend carotid intervention in this population prior to CABG. (See 'Carotid stenosis' above.) https://www.uptodate.com/contents/coronary-artery-bypass-grafting-in-patients-with-cerebrovascular-disease/print 15/22 7/5/23, 11:39 AM Coronary artery bypass grafting in patients with cerebrovascular disease - UpToDate Strategies for prevention of stroke with CABG include (see 'Prevention of perioperative stroke' above): Preoperative evaluation for identification and potential treatment of preexisting stroke risk factors, including aortic atherosclerosis and carotid stenosis Medical therapy, including the use of aspirin, antiarrhythmic drugs, and statins, and antihypertensive therapy For patients undergoing CABG who have carotid stenosis, we suggest carotid revascularization rather than no carotid intervention for the following subgroups only (Grade 2C) (see 'Prophylactic carotid intervention' above): A recently symptomatic carotid stenosis (50 to 99 percent stenosis in men or 70 to 99 percent stenosis in women) Bilateral asymptomatic 80 to 99 percent carotid stenoses A unilateral asymptomatic stenosis of 70 to 99 percent combined with a contralateral total (100 percent) carotid occlusion For patients undergoing CABG who have an isolated unilateral asymptomatic 50 to 99 percent carotid artery stenosis, we suggest not performing prophylactic carotid revascularization (Grade 2C). (See 'Prophylactic carotid intervention' above.) For patients undergoing CABG who are selected for carotid revascularization, we suggest a combined procedure with carotid endarterectomy (CEA) plus CABG, rather than a staged procedure, for those who have severe left main coronary artery disease, diffuse coronary heart disease without satisfactory collaterals, or unstable angina (Grade 2C). We suggest a staged carotid revascularization with CEA or carotid artery stenting (CAS) before CABG, rather than a combined procedure, for patients with chronic stable angina in the absence of a recent myocardial infarction (Grade 2C). (See 'Carotid treatment options' above.) For patients undergoing CABG who require carotid revascularization, we recommend not performing CAS immediately prior to CABG (Grade 1C). We make this recommendation because dual antiplatelet therapy is required following stenting, a factor that likely increases the perioperative risk of bleeding with the CABG procedure. However, CAS is an alternative to CEA if the CABG is not urgent. Such patients could receive a carotid stent with antiplatelet therapy for several weeks, followed by CABG surgery. (See 'Method of carotid revascularization' above.) https://www.uptodate.com/contents/coronary-artery-bypass-grafting-in-patients-with-cerebrovascular-disease/print 16/22 7/5/23, 11:39 AM Coronary artery bypass grafting in patients with cerebrovascular disease - UpToDate Timing of cardiac surgery after a stroke should include sufficient delay to allow identification of the cause of stroke, restoration of cerebral autoregulatory mechanisms, and remodeling of the parenchymal damage to minimize the risk of hemorrhagic transformation. Unless emergent cardiac surgery is warranted, we suggest a delay of at least a month and preferably up to three months, particularly for strokes involving larger territories. (See 'Timing of CABG after stroke' above.) Use of UpToDate is subject to the Terms of Use. REFERENCES 1. 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Consultant/Advisory Boards: Boston Scientific [steering committee for PROTECTED-TAVR trial of embolic protection during TAVR]; EmStop [embolic protection during TAVR]; WL Gore [DSMB for post marketing study of PFO closure for secondary stroke prevention]. Other Financial Interest: Novo Nordisk [ONWARDS trial event adjudication committee]; Terumo [Patient selection committee, Relay Branch trial]. All of the relevant financial relationships listed have been mitigated. Scott E Kasner, MD Grant/Research/Clinical Trial Support: Bayer [Stroke]; Bristol Meyers Squibb [Stroke]; Medtronic [Stroke]; WL Gore and Associates [Stroke]. Consultant/Advisory Boards: Abbvie [Stroke]; AstraZeneca [Stroke]; BMS [Stroke]; Diamedica [Stroke]; Medtronic [Stroke]. All of the relevant financial relationships listed have been mitigated. John F Dashe, MD, PhD No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/coronary-artery-bypass-grafting-in-patients-with-cerebrovascular-disease/print 22/22