Patient with a retained bullet near the carotid bifurcation: simultaneous carotid endarterectomy and beating-heart LIMA-LAD bypass in a 70-year-old man.

Introduction and importance: Significant carotid artery stenosis (CAS) in patients requiring coronary artery bypass grafting (CABG) confers a combined risk of perioperative stroke and myocardial ischemia. Management must therefore be individualized, particularly in the presence of uncommon anatomical challenges such as retained ballistic fragments adjacent to major cervical vessels. We report a rare case of synchronous carotid endarterectomy (CEA) with bullet extraction followed by off-pump CABG. Case presentation: A 70-year-old man presented with exertional chest pain and dyspnea. Coronary angiography demonstrated an 85% proximal left anterior descending (LAD) artery stenosis. Preoperative carotid duplex ultrasonography and computed tomography angiography revealed approximately 90% stenosis of the right internal carotid artery, associated with a metallic foreign body at the carotid bifurcation consistent with a retained bullet from a gunshot injury sustained 30 years earlier. After multidisciplinary evaluation, a simultaneous surgical strategy was adopted. The patient underwent right CAE with careful extraction of the ballistic fragment, immediately followed by off-pump (beating-heart) left internal mammary artery to LAD bypass. The postoperative course was uneventful, with early extubation and no neurological deficits. Follow-up duplex ultrasonography confirmed a widely patent carotid reconstruction. Clinical discussion: Patients with coexisting high-grade CAS and critical coronary artery disease require careful balancing of cerebrovascular and cardiac risks. In selected cases, synchronous CEA and CABG may be an appropriate strategy. An off-pump coronary approach may further reduce embolic risk by avoiding aortic manipulation, particularly in patients with significant carotid pathology. Retained bullets near the carotid bifurcation are exceptionally rare and substantially increase operative complexity due to fibrosis, altered tissue planes, and proximity to neurovascular structures. Conclusion: This case illustrates that simultaneous CEA with ballistic fragment extraction followed by off-pump LIMA-LAD bypass can be considered in carefully selected patients. The presence of a long-standing retained bullet at the carotid bifurcation highlights the importance of meticulous preoperative planning, detailed anatomical assessment, and multidisciplinary decision-making.