A Paradigm Shift in Managing Carotid Artery Disease Associated with Coronary Artery Bypass Grafting

Carotid artery obstructive disease is highly prevalent and directly associated with advancing age.After the age of 60 years, an estimated 12% of men and 7% of women have moderate or severe asymptomatic carotid stenosis (CS) ( 50%) [1] .Likewise, the relationship between carotid and coronary artery disease has been extensively studied in recent decades.Consistent data indicate that the prevalence of ischemic heart disease ranges from 40% to 60% among patients with severe CS [2] .On the other hand, in patients undergoing evaluation for coronary artery bypass grafting (CABG), the rate of moderate or severe CS reaches 20% [3] .For decades, CS was considered the primary cause of ischemic neurological events in the postoperative period of CABG, leading to the widespread practice of "prophylactic" carotid endarterectomy performed concurrently with CABG.However, contemporary evidence from multiple controlled studies has changed this paradigm, prompting a shift in management strategies.In the treatment of carotid artery disease, intervention is primarily guided by the presence of focal neurological symptoms ipsilateral to the lesion and the degree of stenosis.For patients who have experienced a transient ischemic attack (TIA) or ischemic stroke within the past six months, the evidence supporting intervention is well established, dating back over three decades.Landmark trials, including the North American Symptomatic Carotid Endarterectomy Trial (or NASCET) and the European Carotid Surgery Trial (or ECST), demonstrated that patients with stenosis 50% benefit from carotid surgery, as long as they do not have comorbidities that limit five-year survival and the institution's perioperative risk of death and/or stroke is < 6% (level of evidence: 1a).Furthermore, carotid intervention is recommended within 15 days of diagnosis due to the high risk of recurrent cerebrovascular events [4] .However, in neurologically asymptomatic patients, advances in optimized clinical treatment of atherosclerosis have significantly reduced the need for carotid intervention.The Asymptomatic