As a result, they strongly recommend a selective approach to the use of preoperative noninvasive carotid screening, allowing for a decrease in the number of unnecessary tests but exerting little effect on the detection of significant carotid disease. In patients undergoing carotid endarterectomy, the rates of periprocedural stroke have been reported to be as high as 2.5% in those with asymptomatic carotid stenoses861 and 5% in those with previous cerebrovascular symptoms.862 In CABG patients with 50% unilateral carotid stenoses in whom carotid endarterectomy is not performed concomi- tantly with CABG, the peri-CABG stroke rate is reportedly 3%, rising to 5% in those with bilateral carotid artery stenoses and 11% in those with an occluded carotid artery.860 In light of these data, the issue of combined carotid and coronary revascularization (performed simultaneously or in a staged, sequential fashion) as a strategy to reduce the postoperative stroke risk in CABG patients with known carotid artery disease has received substantial attention. The lack of clarity about the optimal approach to the management of such patients is the result of several factors: To date, no published randomized, prospective study has addressed this important clinical scenario.863 The etiology of postoperative stroke often is multifac torial (eg, ascending aortic calcifications with resultant atherothrombotic embolization, preexisting carotid ar- tery disease, air or debris cerebral embolization associ- ated with CPB, episodes of transient intraoperative hypotension). Many risk factors for stroke coexist in CABG patients. The rates for postoperative stroke and death for carotid endarterectomy and for CABG, independent of or in conjunction with one another, vary considerably in different patient populations (eg, young versus old, male versus female, etc.). 