• A R Naylor, Z Mehta, and P M Rothwell.
• The Department of Vascular Surgery, Clinical Sciences Building, Leicester Royal Infirmary, Infirmary Square, Leicester LE2 7LX, UK. ross.naylor@uhl-tr.nhs.uk
• Eur J Vasc Endovasc Surg. 2009 Apr 1;37(4):379-87.

ObjectivesTo determine the overall operative risk of cardiovascular events in patients with combined cardiac and carotid artery disease undergoing staged carotid artery stenting (CAS) and coronary artery bypass grafting (CABG).DesignSystematic review of operative risks reported in all published studies of CAS plus CABG procedures.ResultsEleven eligible, published studies were identified which reported data on 760 CAS plus CABG procedures. The majority of patients (87%) were neurologically asymptomatic and 82% had unilateral carotid stenoses. Overall mortality was 5.5% (95% confidence interval, CI: 3.4-7.6), the risk of suffering an ipsilateral stroke was 3.3% (95% CI: 1.6-5.1) and the risk of suffering 'any' stroke was 4.2% (95% CI: 2.4-6.1), while the 30-day risk of myocardial infarction (MI) was only 1.8% (95% CI: 0.5-3.0). However, the 30-day death and ipsilateral stroke rate was 7.5% (95% CI: 4.5-10.5) and the 30-day risk of death and any stroke was 9.1% (95% CI: 6.1-12.0), while the 30-day of death/stroke/MI was 9.4% (7.0-11.8). Cumulative risks in studies where patients underwent CABG within 48 h of CAS were not higher than in comparable studies where CABG was delayed by more than 2 weeks.ConclusionsIn a cohort of predominantly asymptomatic patients with unilateral carotid disease, the 30-day risk of death/any stroke was 9.1%. These data are comparable to previous systematic reviews evaluating the roles of staged and synchronous carotid endarterectomy (CEA) plus CABG, and suggest that staged CAS plus CABG is an attractive and less invasive alternative to CEA plus CABG. However, it remains questionable whether the observed 9% risks can be justified in any asymptomatic patient with unilateral carotid disease.

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