DOPPLER OF CAROTID ARTERY ASSESSMENT IN EVALUATION …

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Zaki et al. World Journal of Pharmacy and Pharmaceutical Sciences

DOPPLER OF CAROTID ARTERY ASSESSMENT IN EVALUATION

OF PATIENTS INDICATED FOR CORONARY ARTERY BYPASS

GRAFT

Dr. Farah Abdul- Khalik Zaki* and Dr. Hana Abdul Ridha Ali AL.Dynori

1,2

M.B.Ch.B, MDRD.

ABSTRACT

Background: Atherosclerosis is a generalized disease, mainly

manifested in all vascular trees. An association between carotid artery

stenosis and coronary artery disease has been well established. Carotid

artery stenosis is an important etiologic factor for cerebrovascular

accidents, is associated with coronary artery disease. Methods: A

prospective study of 86 patients, who were scheduled for CABG, was

done at radiology department, Medical city Baghdad, Gazzi Al-Harirri

hospital from Nov.2016 to July 2017. The majority were males, (73)

and (13) were Females. All patients, after a clinical history was taken

by the cardiac surgery team, they underwent a physical examinations, and investigations;

chest x-ray, ECG, blood was taken for fasting blood suger and cholesterol study, Doppler

ultrasonography for bilateral carotid arteries were performed by aspescailized radiologist for

carotid artery atherosclerosis. Results: The majority of the patients were above 50 years of

age, 73 patients (84.45%) and only 15% were below the age of 50 years. ale affected by

carotid artery atherosclerosis, (76.7%) more than females above the age of 50 years, while

below the age of 50 years females (46.7%) more affected than males (9.58%). Risk factors

were significantly correlated with both carotid and coronary artery stenosis like age, sex,

smoking hypertension, cholesterol and diabetes mellitus. Doppler Ultrasonography was

performed to screen the presence of carotid artery stenosis. Carotid artery atherosclerosis was

present in 66 patients, (76.7%). Ten patients (15.1%) with one coronary artery disease,

17(25.75%) with two coronary artery disease, and 39 patients (59.09%) with three coronary

artery disease. The location of atherosclerosis is mostly in ICA, (53%), of which 15% in the

bulb, in the CCA (32%). Conclusions: Our finding indicated significant associations between

WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES

SJIF Impact Factor 7.632

Volume 10, Issue 6, 1877-1900 Research Article ISSN 2278 – 4357

*Corresponding Author

Dr. Farah Abdul- Khalik

Zaki

M.B.Ch.B, MDRD.

Article Received on

20 April 2021,

Revised on 10 May 2021,

Accepted on 31 May 2021

DOI: 10.20959/wjpps20216-18968


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carotid artery atherosclerosis and coronary artery disease. There is strong association between

increase in intma media thickness of carotid arteries and the presence of coronary artery

disease.

INTRODUCTION

Doppler ultrasound is the most common technology used for evaluation and characterization

of blood vessels, the Doppler effect was named after Christian Johann Doppler (1803_1853),

an Austrian mathematician and physicist, who theorized that the sound waves from a moving

source would be closer together as the sound came closer (have a higher pitch), and further

apart as the sound went away (lower pitch).

It’s a real time imaging technique with no risk of radiation.[1]

1. 1. Anatomy of the carotid arteries

There are two main arteries, the common carotid arteries on both side of the neck, Figure (1).

The right common carotid artery arises from brachiocephalic artery behind the right

sternoclavicular joint; the left common carotid arises from aortic arch in the superior

mediastinum. Each common carotid artery runs upward through the neck, from the

sternoclavicular joint to the upper border of the thyroid cartilage, where it divides into the

external and internal carotid arteries. At its point of division the common carotid artery shows

a localized dilatation, having thin tunica media but thick tunica adventitia, it is called carotid

sinus.[2]

1.1.1 External carotid artery

It is one of the terminal branches of the common carotid artery, it supplies structures in the

neck face, scalp. And also supplies the tongue and the maxilla. At its origin where its

pulsation can be felt, the artery lies within the carotid triangle, medial to the internal carotid

artery as it Ascends in the neck, it passes backward and laterally.

It gives many branches, to the thyroid gland, lingual, facial, and to the scalp.[3]

1.1.2 Internal carotid artery

It is one of the terminal branches of common carotid artery, the artery begins at level upper

border of the thyroid cartilage and ascends in the neck to the base of the skull, and it enters

the cranial cavity through the cranial canal in the petrous part of temporal bone it lies

embedded in the carotid sheath with the internal jugular vein and vagus nerve. At its


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beginning it lies superficially in the carotid triangle and then ascends deep to the parotid

gland and enters the cranial cavity through the carotid canal. It gives no branches in the neck.

Figure 1: Main arteries of the head and neck; Snell R.S.; clinical anatomy for medical

student, 2007, eight editions.[3]

1.1.3 Vertebral arteries

Vertebral artery is a branch of the 1st part of subclavian artery; it ascends the neck through the

foramina in the transverse processes of the upper six cervical vertebrae. It enters the skull

through foramen magnum, at lower border of Pons it joins the opposite side vessel to form

Basilar artery.[4]

1.1.4 Cerebral blood supply

The brain is supplied by the two carotid arteries and the basilar artery.[4]

Theses arteries feed

into an anastomotic ring at the base of the skull called the circle of Willis, (Figure 2), The

Anatomy of circle of Willis is variable in many people, and it cannot provide definite

protection from ischemia due to carotid, vertebral or basilar arteries occlusion.

Stroke is a leading cause of acquired disability, a major cause of morbidity after Myocardial

infarction or after coronary artery bypass surgery (CABG).[5,6]


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The incidence of cerebral infarction after CABG is 2% Cerebral ischemia and infarction, after

CABG, is mostly due to carotid plaque or intra cardiac clot and decrease in perfusion

pressure to below 60 mm Hg, are the possible cases of stroke associated with CABG.[7]

Detecting carotid stenosis due to atherosclerosis in patient undergoing CABG is important,

by using Doppler ultrasonography to diagnose the atherosclerosis preoperatively and

managed at same time of CABG surgery or soon later.[8-10]

Urgent evaluation after stroke is needed because many recurrent events occur, brain imaging,

using MRI, and arterial imaging with the use of carotid ultrasound are mandatory for

diagnosis and management.[11]

1.2 Associations between coronary artery and carotid atherosclerosis

Studies by many authors have found an associations between symptoms and signs of carotid

artery disease and coronary artery atherosclerosis, also have shown an increased risk of

cerebrovascular stroke and statistically significant correlations between atherosclerosis of the

coronary artery and carotid artery have been noted in there study.[5,12,13,14]

1.2.1 Risk factors of carotid atherosclerosis

It is very important to find carotid atherosclerosis by using Doppler ultrasound before CABG

surgery, also it is mandatory to know history of peripheral arterial diseases, a cervical bruit

and age of the patient (50-70) all are strong predictor of carotid artery atherosclerosis. It was

found that carotid stenosis was closely related to the occurrence of stroke post CABG surgery

being both as an independent risk factor for and the cause of significant proportion of

stroke.[11,14,15]

1.2.2 The risk factors

1- Age and sex (old age, male sex is at more risk).

2- Family history (patient with positive family history of coronary artery disease are at more

risk).

3- Smoking.

4- Hypertension.

5- Hyperlipidemia

6- Diabetes mellitus.


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7- Obesity and physical activity (obese patient and those with low active life style like bed

ridden is at more risk of developing atherosclerosis).

8- Excessive alcohol.

The risk factors are variable for each patient. However there are, three important risk factors

are appropriate for nearly all the patients; High blood pressure, High cholesterol and long

duration of smoking.[11,15]

Figure 2: circle of Willis; courtesy of Clifford –jones (radiology handbook of clinical

medicine).[4]

1.2.3 Pathophysiology of atherosclerosis

It is a progressive inflammatory process of arterial wall, atherosclerosis begins early in life.

The causes are unknown; the response to injury is the most accepted hypothesis.

At the sites of arterial stress such as bifurcation of the artery, fatty streaks occurs associated

with abnormal endothelial function, the Monocytes bind to receptor and migrate into intimae.

Take up low density lipoprotein (LDL), and become foam Cells or macrophages, when the


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foam cells die release their lipid contents and Lipid pool appear in the intimae. The smooth

muscle cells migrate from the media to the intimae in response to cytokines and growth factor

produced by macrophages, the lipid will be covered by smooth muscle and matrix, producing

atherosclerotic plaque.[17]

Due to effect of cytokines such as interleukin-1, interferon and other factors, the plaque

become active and complicated by ulceration and thrombus formation (Figure 3), The plaque

will expose to the mechanical stress, this lead to fissuring or rupture of the plaque, that lead

to aggregation of platelets and thrombosis, this may cause partial or complete occlusion of

arterial lumen, or distal embolization.[18,19,20,21,22]

Figure 3: Pathogenesis of atheroma.[19]

1.3 Carotid Doppler ultrasound overview

Carotid Doppler ultrasound is a useful diagnostic tool for assessing cervical carotid artery

disease.[6]

It is an imaging test that uses ultrasound to examine carotid arteries in the neck, the

test can show narrowing or blockage due to plaque buildup in association with coronary

artery disease, it is highly reliable has no radiation risk, Well tolerated by all patients

including those who are phobic in MRI machine.[11,19,23]

It relies on the properties of longitudinal sound waves, Doppler ultrasound of 2 Steps

procedure, the 2 steps are first is imaging then spectral analysis.[24]


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1.3.1 Physics and hemodynamics[25,26]

A- Pulse echo technique used to image the vessel

1. An initial signal (pulse), is generated in the computer, sent through the transducer on the

patient’s neck, and then bounced off a variety of tissues boundaries.

2. The transducer detects a returning signal (echo).

3. The direction of the pulse and the time elapsed until the signal return, determine the

position of tissues boundary.

4. The echogenicity of an object on the image determines its brightness. Changes in the

plaque echogenicity as measured by the quantitative computer assisted ultrasound index

in some ultrasound machines could be a marker of plaque instability as well as an

indicator of plaque remodeling, thereby providing the means for monitoring anti-

atherosclerosis drugs.

5. An object that rebounds very little of the pulse such as fluid in a cyst is hypoechoic.

6. An object that rebounds much of the signal like heavily calcified plaque, is Hyperechoic.

7. Evaluation of intima media thickness.

8. Flow direction demonstrated in colored modality and in spectral waveform.[24,27]

B-Hemodynamic

1- The velocity changes on spectral analysis reflect the changes in hemodynamics.

2- The greater the degree of stenosis, the higher the velocity.

C- Doppler phenomenon used to assess the velocity of the blood as it moves past the

vessel.[28,30]

1.3.2 Mathematical basics in Doppler ultrasounds

Transducer produces an increase in the reflected ultrasonic frequency of the RBCS that

moves towards the probe, whereas motion a way gives a reduction in the frequency. The

system electronic note whether the detected ultrasound has a higher or lower frequency than

that transmitted and hence extracts information on the direction of motion relative to the

transducer.

When the line of movement of the reflector is at an angle Ө to the transducer beam, then the

Doppler shift, ƒƊ.

The Doppler is shift there for:

ƒḎ=ƒt-ƒʳ =ƒt.2.u.cosӨ/c


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Doppler frequency (fd) =2.F1.V.COSӨ/C

FD= Doppler shift

F1=transmitted beam

C = speed of sound in tissue

V= velocity of blood

Ө=angle of incidence between the ultrasound beam and the direction of the objected RBCs.

The value of (c) differs from medium to medium but always constant in particular medium.

In tissue the value of (c) for ultrasound is 1540 m/s. Because c is constant, the wave length

increases as the frequency decreases; the converse is also true.[30]

Frequency is measured in cycle per second, called hertz (Hz). In ultrasounds the emitted

frequency is millions of cycles per second, therefore, it is measured in megahertz (MHz), the

Doppler shift is 1000 fold less than the emitted frequency therefore, it is measured in

kilohertz (kHz), and it’s with in audible range that’s why we can hear it.

Sometime the term spatial pulse length (SPL) is used; it is equal to the number of cycles in a

pulse multiplied by wave length. It is important in determining Resolution.[28,30]

1.3.3 Tissue attenuation

As ultrasound passes through tissue some of the signal is lost through scattering, reflection,

and absorption in tissue, attention = 0.5 x frequency x path length, decibels (dB). There for

the higher the frequency the greater the attenuation and the less can be imaged at greater

distance from the probe, on other hand, higher frequencies means shorter wavelength and

better resolutions.[31-34]

1.3.4 Artifacts

At least 18 artifacts have been identified in carotid ultrasound.

1- Reverberations result in unreal image on the screen as echogenic layers inside the artery.

2- Refraction, lead to improper position of the object on the screen.

3- Shadowing due to strong reflector like calcified plaque.

4- Enhancing the opposite object shadowing.

5- Aliasing occurs during spectral analysis; spectrum is wrapped around so that the top of

the waveform is seen at bottom of the screen. (This reverse color in color Doppler

mode).[34]


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1.3.5 Common uses of Carotid Doppler ultrasound[36,37]

Doppler ultrasounds of the two carotid arteries, which are located on each side of the neck

and carry blood from the heart to the brain, provides detail pictures of these blood vessels and

information about blood flow through them, and gives information about the presence of

carotid atherosclerosis which is a risk factor for patient with transient ischemic attack or

minor stroke.[35]

A Doppler ultrasound study is usually an integral part of carotid artery ultrasound

examination, most frequently performed to detect carotid artery atherosclerosis and intima

media thickness a condition that increases the risk of stroke.

1- The major goal of carotid Doppler ultrasound remains to screen for the narrowing or

blockage of carotid artery, which if present adequate treatment may be initiated.

2- Also Doppler ultrasound performed if the patient having hypertension or diabetes mellitus

or presence of bruits in neck and also in presence any other risk factors.

3- Doppler Ultrasound of carotid artery also is performed in preparation for CABG Surgery.

4- Other uses are

a. Locate a hematoma that may slow or eventually stop blood flow in the artery.

b. Check the state of carotid artery after surgery to restore normal blood flow.

c. Using two dimensional (gray-scale) to measure the thickness of intima and media which a

good marker for atherosclerosis and can aid in plaque characterization, the morphology of

plaque is related to risk of stroke.

1.3.6 Techniques of Doppler ultrasound

A-mode; it is standing for amplitude, gives a 1D trace, it depicats the depth of an interface

and the strength of the reflected signal.

B-mode it is the most common used techniques, it gives brightness and gives 2D sliced

image.

M-mode, it displays a trace of movements of structures within the sound beam line, it used

for imaging the heart valves for example[24]

, Duplex ultrasound; it is useful in arterial and

venous study, it helps to determine flow characteristic of circulation in areal time moving B

mode image.[38]

1.3.7 Performing the ultrasound test;[32,39,40,41]

A. Patient preparation; Wearing comfortable, loose, fitting clots, remove jewels and may

need to remove all clothing in area to be examined. A loose fitting open necked shirt or


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blouse is ideal. Doppler ultrasound is very sensitive to motion so patient should be quite.

And other preparation if needed.

B. Equipment: Ultrasound scanners consist of computer, and electronics, a video display

screen and transducer that is used to do the scanning, the transducer is a small hand held

device that resembled a microphone, attached to the scanner by a cord. Some examiners

may use different transducer (with different capabilities), during a single examination.

The principle involved in the sonar is similar to that used by bat, ships, and a fisherman,

when a sound wave strikes an object it bounces back as echoes by measuring these echoes

waves, it is possible to determine how far away the object, as well as its size, shape, and

consistency.

In medicine, ultrasound is used to detect changes in appearance, size, character of organs,

tissues and vessels or to detect abnormal masses (tumor).

In the ultrasound examination, the transducer both, sends the sound wave and receives the

echoing waves. The transducer directs small pulses of inaudible, high frequency waves in to

the body. As the waves become bounce off internal organ, fluids and tissues, the sensitive

microphone in the transducer record the tiny changes.

In the sound pitch direction, that waves are instantly measured and displayed which in turn

reacts a real time picture on the monitor. One or more frame of the moving pictures is

typically captured as still images. Short video loops of the images usually saved.[2,24,40,41]

1.3.8 The procedure performance

The patient is lying face up on the examination table that can be tilted or moved, patient may

be turned to either side to improve the quality of the images. A clear water based gel is

applied to the skin of the neck being studied, to help transducer make secure contact with the

body and eliminate air pocket between the transducer and the skin that can block the sound

waves from passing in to the body.

The sonographer or the radiologist then places the transducer on the skin in various locations

keeping over the area of interest or angling the sound beam from different location to better

see the area of concern.

At the end of examination, the patient dresses and wait while the ultrasound images are

reviewed, the examination will completed within 30-45 minutes. Figure 4.[40]


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Figure 4: Standard ultrasound probe setting and production of ultrasonographic

images (courtesy of Ryan WD, Komaiko MS, Pressman BD.).[2]

13.9 Advantages and Disadvantage

1- Noninvasive and painless.

2- Available and easy to perform.

3- Safe not use radiation.

4- Give clear picture of soft tissues.

5- If block of the artery found treatment can be done to restore the blood flow.

6- It is free from risk.

Disadvantage

Extreme operator dependent and need expert examination to be performed in the right way to

give confident, dependable, Qualitative, quantitative and statistically standard measures.[40]

1.3.10; Identification of the Carotid arteries

1-Detecting internal and external arteries;[42]

External carotid artery (ECA) has small caliber than, internal carotid artery(ICA) which lies

posterolateral to ECA, the ECA may have superior thyroid artery branch coming off., also

ECA has low diastolic flow, also ECA has positive temporal tap test (Fig 5).[34,42]


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Figure.5; ultrasonographic image of CCA, ECA and ICA, normal image, courtesy of

Dr. Shephard, int med. Educ.[41]

2- Identification of Common Carotid Arteries

Having pulsatile wall and its caliper is smaller than internal jugular vein.

3-Determination the degree of stenosis

The commonly used methods are by measuring the peak systolic velocities (PSV) and end

diastolic velocities, also by measuring the ratio between ICA and CCA,(ICA PSV / CCA

PSV) normal<2 and ICA EDV <40cm/sec, the degree of stenosis is determined in term of

exact percentage. A range of 50-69% is more accurate however the measurement vary from

lab to lab, depends on many factors that affect these measurements, these include the

equipment used, the person performing and the sites normal velocity of CCA is 30-40 cm/sec,

increase velocity above the normal level means there is stenosis in which ICA psv is 125-230

cm/sec and plaque is visible sonographically additional criteria include ICA/CCA psv ratio of


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2-4 and ICA EDVof 40-100 cm/sec, in ≥70% stenosis of the CCA PSV is more than ≥230

/sec with visible plaque seen at gray scale and colour Doppler ultrasound, additional criteria

include ICA /CCA psv ratio >4 and ICA EDV > 100 cm/sec, in near occlusion of ICA

velocity parameters may not apply,since velocities may be high, low, or undectatable

diagnosis established primarily by demonstrating amarkedly narrowed lumen by gray scale

and coloured Doppler ultrasonography. In presence of < 50% stenosis in ICA the PSV Is 125

cm/sec and presence plaque and intimal thickening (>0.8 mm consider abnormal and highly

associated with atherosclerosis).[30,34]

Also cross sectional area measurement is acurrate and more sensitive than dimensional

measurement in assessment of degree of stenosis, dimensional scale can be used to measure

the intima – media thickness which a good marker for atherosclerosis and can aid in plaques

characterization.[29,42]

Figure 6: Ultrasound images of the intima-media thickness A normal intima media

thickness, and B (showing increase in intma media (0.9cm).


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Figure 7: Echogenic Atheromatic plaque in CA bulb, a; longutidinal section; B; coronal

section.

1.4. Aim of the study

To evaluate the association between carotid artery atherosclerosis as finding out the presence

of athermanous plaque in the carotid arteries and significant increment in intima-media

thickness and coronary artery atherosclerosis by Carotid Doppler ultrasound.

RESULTS

84.88% of the patients were males while 16% were females, the Majority Were males above

the age of 50 years. Table I, shows the age and sex incidence.

Table 1: Age and sex incidence.

Sex No. % Age < 50 Age > 50

Males 73 84.88 7 66

Females 13 16% 6 7

Total 86 100 13 73

93% of the patients were smoker or ex-smoker, including males and Female (73 males and 7

females). While 75, (87%) having hypercholesterolemia, 63 patients with hypertension

(61%), those with Diabetes mellitus were 26 patients (30%), family history of coronary

cardiac disease was obtained in 18 patients (20.9 %), as shown in Table 2.

Table 2: Risk factors for atherosclerosis.

Risk factor No. % < 50 years > 50 years

Age 86 100 13 73

Smoking 80 93 7 73

Hypercholesterolemia 75 87 5 70

Hypertension 51 61 8 45

Diabetes 26 30 6 20

Family history 18 20.9 12 6


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Carotid artery atherosclerosis was found in 66 patients (76.7%), while 20 patients (23.25%),

had normal right and left carotid arteries, as shown in table 3 and Figure(8) a, b,c.

Table 3: Association between risk factors of atherosclerosis and plaque and Intima-

media thickness.

Risk factors Plaque and IMT %

Age>50years 60 69.76%

Age<50 years 6 6.97%

Smoking 66 76.74%

Hypertension 30 34.88%

Diabetes mellitus 20 23.25%

Table IV: Association between plaque and IMTwith age,smooking,hypertension and

diabetes mellitus.

Plaque and IMT Odd's ratio P-value*

Yes% No%

Age ≥50years 60(90.9)% 13(65.0%)

5.38 0.004 <50years 6(9.1)% 7(35.0)%

Smoking +ve 66(100.0)% 14(70.0)%

_ 0.000** -ve 0(0.0)% 6(30.0)5

Hypertension +ve 46(69.7)% 17(85.0)%

0.40 0.175 -ve 20(30.3)% 3(15.0)%

Diabetes mellitus +ve 20(30.3)% 6(30.0)%

1.014 0.97 -ve 46(69.7)% 14(70.0)%

*Chi-square

**Fisher exact

There was significant stastical association between plaqueand IMTwith age,as there was

60(90.9)% patient older than 50with plaque and IMTcompared to 6(9.1)%patients younger

than 50years old and there was 5.38times more riskfor patient equal or older than 50 years to

develop plaque and IMT. There was significant statistical association between plaque and

IMTwith smoking as all 66(100%)smoker had plaque and IMT. niether hypertension nor

diabets mellitus showed astatistically significant association with plaque and IMT.


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A B

C

Figure 8,A, Isoechoic plaque seen at the end of the ICA post 2.1×5.3 mm Causing 62%

area stenosis, B, cross sectional area stenosis measure with Plaque seen in ICA, C;

Atherosclerotic plaque seen at the CCA, causing 52% stenosis.


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A B

C

Figure, 9: A: atherosclerotic plaque seen in the CCA Causing 59% stenosis. B:

atherosclerotic plaques Seen in the bulb causing 72% stenosis. C: calcified plaque seen

at the beginning of the ICA.

Regarding the location of atherosclerotic plaques in carotid arteries, the common site was

ICA, with 35 lesions (53%), followed by CCA, 21 lesions (32 %), and the bulb with 10

lesions (15%) as shown in Figure(9), a, b c Majority of the patients had unilateral plaques, 61

patients (92.4%) only 5 patients with bilateral (7.6%).

The severity of carotid atherosclerosis was associated with numbers of coronary arteries

diseases, carotid artery stenosis was present in 15.1% when one coronary vessel was


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stenosed, 25.75 % stenosis when 2 coronary vessels and 59.09 % when 3 vessels was

diseased.

Figure 10; Carotid artery disease according to the extent of coronary artery disease.

Extent of coronary artery disease

Carotid artery atherosclerotic disease was present in, 10 patients,(15,1%) with 1- vessel

coronary artery disease, 17 (25.75 %) with 2- vessels and 39 patients (59.09%) with 3-

vessels disease as shown in Figure 10.

Those 20 patients without carotid atherosclerosis, we found thickened Intimae media between

1_1.2cm, (normal value ≤0.81), and they were associated with coronary artery

Atherosclerosis.

DISCUSSION

Eighty six patients with coronary artery atherosclerosis who were Scheduled for CABG,

underwent carotid arteries Doppler ultrasonography to Detect carotid artery atherosclerosis.

Majority of our patients were male (84.8 %), while 15% only were Females. this is similar to

that results obtained by other studies, Craven TE, Ryuje, Espeland MA Kahl FR, et al.[14,19]

Sixty six out of 73 male patients with age above 50 years (90.4%), While 7 0ut of 13 patients

with age above 50 years (53 %), were Female, (Table I), Kim JS, Song P, Park GH, Lee TY,

et al.[5,10,23]


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In our study, we found that the accepted risk factors of significance in Carotid artery

atherosclerotic changes and coronary artery stenosis are, old age above 50 Years old,

smoking, hypercholesterolemia, diabetes mellitus, hypertension and family history of

previous heart attack, (Table II) this in agreement with other author studies, Kim JS, Song P,

Park GH, Lee TY, et al.[5-6,8,45]

In our study, we found similarities between risk factors for coronary artery disease and

carotid artery disease, Shirani S. Boroumand MA. Abbasi SH. Maghsoodi N, et al, however

we found less difference in the effect of each risk factor, the effect of high cholesterol is less

than hypertension which has profound effect on both carotid and coronary arterial

stenosis.[14,45-47]

We agree with Craven TE et al that because carotid and coronary atherosclerosis share a

certain number of these risk factors.[14]

Ultrasonography of carotid arteries had shown the presence of carotid atherosclerosis in 66

patients, (76.7%), 20 patients had normal carotid arteries, (23.25%). Table II, Davis SM,

Donnan GA, et al.[11,13-14]

Also we found; male with age above 50 years (76.7%) had a significantly more carotid

atherosclerosis than female of same age Female patients with age of less than 50 years having

atherosclerosis six patients out of 13,(46 %), more than male having the same age.

Seven patients (9.58 %) out of the total 73 patient who had carotid atherosclerosis were

females, this is the same finding obtained by other authors, LemoloF. MartinikA.

StienmanDA. Spens JD; et al. This suggesting that differences in sex hormones may affect

remodeling of atherosclerosis.[48,49]

We found the carotid artery intima –media thickness in 20 patients without carotid

atherosclerosis is correlated with extent and severity of coronary artery disease, this is in

agreement with Solonen.[49]

And Solonen finding that stated; the carotid artery intima-media

thickness values in men may associate with higher coronary artery diseases (table III).

Regarding the location of atherosclerotic plaques in carotid artery, it occurs in 61 patients at

one site (unilateral, 93.4%), only 5 patients had bilateral (7.6%), The common site was ICA,

in 51 patients (53%), then the CCA in 21 patients. (5%), the bulb affected in 10 patients (15


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%)Fig (7) and Fig (8), this is different than Kallikazaros et al findings, they found bulb is the

commonest site (77.4%) next was the ICA, (53.6%), and the least was the CCA, 48.7%.[13]

We had found a significant correlation between carotid and coronary atherosclerosis, as there

was a stepwise increase in the number of patients with increase severity of those with

coronary artery disease.

As patients with 1, 2, and 3- vessels disease, carotid artery disease was present in 15.1%,

25.75%, 59.09% respectively, (Fig 10). This indicated a strong correlation between carotid

artery disease and severity of coronary artery atherosclerosis, this is similar to result obtained

by other authors, Pozniak MA. Allen PL; et al.[13,51]

Also we agree with those authors, Kallikazaros I, Tsioufs C, Sideris S, Stefandis C,

Toutouzas P; et al; that this classification may not precise but it is very useful and common in

clinical practice.[13]

CONCLUSIONS

There is a significant association between Carotid artery atherosclerotic changes and

coronary artery stenosis. In those patients who scheduled for Coronary artery bypass surgery,

ultrasonography and Doppler are Gold standard for detection carotid artery disease. The

presence of carotid atherosclerosis is strongly related to presence and severity of coronary

artery disease.

The evaluation of intima – media thickness is a useful marker for presence of coronary artery

stenosis.

Recommendations

1- Any patient having a history heart disease should referred for carotid Doppler

ultrasonography to find out the state of his carotid artery

2- Carotid artery Doppler Ultrasonography would be mandatory for all patients who have

coronary artery diseases before cardiac surgery to avoid cerebral vascular complications

like Transient ischemic attack or stroke.

3- Follow the patient post operatively after Coronary artery bypass graft and check for any

brain ischemic insult had occurred with searching for the exact cause of it. Then correlate

the number of brain insulted patient with those who had preoperative carotid artery

atherosclerotic changes to find its significance.


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4- Doppler ultrasound should be available in all Hospitals and there should be training

courses in carotid Doppler ultrasound.

5- A join committee between cardiologist, cardiovascular surgeon and radiologist will

increase the detection and diagnosis of associated carotid stenosis and Coronary artery

disease and proper arrangement of management.

REFERENCES

1. Owen Kang, Yurangyweerakkody, etal.

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