Stroke after cardiac surgery: Preventive and treatment strategies. the role of endovascular interventions

Stroke is the most important non-cardiac complication of cardiac surgery. The reported incidence of stroke post coronary artery bypass graft (CABG) surgery varies between 0.9% and 3.2% and has an important impact on in-hospital and late mortality post CABG. Some of stroke mechanisms following CABG are well recognized (embolism associated with arrhythmia or aortic atherosclerotic plaque, hypoperfusion and embolic phemomena caused by carotid atherosclerotic disease) while others are seriously underestimated (intracranial atherosclerotic disease, hypercoagulable state). Carotid stenosis is a common comorbidity of coronary artery disease; patients with significant carotid stenosis have a 4-fold increases relative risk of stroke post CABG when compared with patients without significant carotid disease. Combined carotid-coronary revascularization emerged as a preventive measure of stroke post CABG. Carotid endarterectomy (CEA) in combination with CABG has been associated with high rate of postoperative death, stroke, and myocardial infarction (10.2-11.5%), particularly in high risk patients. Carotid angioplasty and stenting (CAS) is emerging as a possible preferred alternative to synchronous or staged CEA in patients undergoing CABG. Endovascular revascularization with mechanical thrombolysis is the only therapy available for stroke following CABG in patients with large vessel occlusion, as long as recent surgery is a major contraindication for systemic thrombolysis with intravenous tissue plasminogen activator. Endovascular therapies might play a role as a preventive therapy for stroke after CABG in patients with large vessel (intracranial or extracranial) stenoses or acute occlusions.