Atherosclerosis is a generalized disease affecting not only the carotid arteries but often concomitantly the coronary arteries, the abdominal aorta and the peripheral arteries. This is especially true for the elderly, a population segment which is rapidly growing. Many patients who initially presented for carotid artery stenosis actually have significant morbidity or mortality due to diseases of other vascular beds mandating a more comprehensive evaluation by additional imaging studies. In three months of admission for TIA or cerebral infarction the risk for myocardial infarction and cerebrovascular death is 2 to 5% and about 30% within two years. Asymptomatic coronary artery disease in this population is high with about 20-40% and up to 25-60% of patients with symptomatic and asymptomatic carotid artery stenosis having inducible myocardial ischemia
Asymptomatic patients selected for CEA must undergo a thorough preoperative cardiac evaluation and if significant disease is found, patients should be considered for percutaneous angioplasty and possibly stenting prior to CEA. Whether these patients should undergo carotid stenting, simultaneous CABG and CEA or staged surgeries and which if either procedure should be performed first is controversial , .
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