Delays in Carotid Endarterectomy: The Process is the Problem

Abstract

INTRODUCTIONPatients who have a transient ischemic attack (TIA) or minor stroke are at high risk of recurrent stroke, with risks of as high as 12% within one week of the inciting event 1-3 Carotid endarterectomy (CEA) for symptomatic stenosis is one of the most effective interventions in neurology, with an NNT of 3 for stenosis greater than 70% and an NNT of 6 for stenosis between 50 and 70% when the procedure is performed within two weeks of a TIA or minor stroke, [4][5][6][7][8] . Canadian and international guidelines recommend surgery within this timeframe for maximal benefit. Diagnosis, assessment of etiology and management in this setting requires coordination between multiple physicians; however, in the absence of a welldeveloped process, these steps may result in substantial delay to surgery, minimizing its beneficial effect. ABSTRACT:Background: Current recommendations for carotid endarterectomy (CEA) for symptomatic carotid stenosis state benefit is greatest when performed within two weeks of symptoms. However, only a minority of cases are operated on within this guideline, and no systematic examinations of reasons for these delays exist. Methods: All CEA cases performed at our institution by vascular surgery for symptomatic carotid stenosis after neurologist referral in 2008-2009 were reviewed. Dates of symptom onset, initial presentation, referral to and evaluation by neurology and vascular surgery, vascular imaging, and CEA were collected, and the length of time between each analysed. Reasons for delays were noted where available. Results: Of 36 included patients, 34 had CEA more than two weeks after symptom onset. Median time to CEA from onset was 76 days (IQR,. Longest intervals were between surgeon assessment and CEA (14 days; IQR, 9-21 days), neurology referral and neurologist assessment (9 days; IQR, 2-26 days), vascular imaging and referral to vascular surgery (9 days; IQR, 2-35 days) and vascular surgery referral and assessment (8 days; IQR, 6-15 days). Few patients (44.1%) had reasons for delays identified; of these, process-related delays were related to delayed vascular imaging, delayed referral by primary care physicians, or multiple conflicting referrals. Conclusions: There are significant delays between symptom onset and CEA in patients referred for CEA, with delay highest between specialist referral and evaluation. Strategies to reduce these delays may be effective in increasing the proportion of procedures performed within two weeks of symptom onset.RÉSUMÉ: Retards à effectuer l'endartérectomie carotidienne : le problème réside dans le processus. Contexte : Selon les recommandations actuelles pour l'endartérectomie carotidienne (EC) effectuée pour une sténose carotidienne symptomatique, on obtient les meilleurs résultats lorsque l'intervention est effectuée dans les deux semaines suivant l'apparition des symptômes. Cependant, seulement une minorité de patients sont opérés dans le délai recommandé par les lignes directrices et aucun examen systématique des raisons du délai n'a été effec...

An institutional study of time delays for symptomatic carotid endarterectomy

“…[2][3][4][5] Current American Heart Association (AHA) practice guidelines recommend that CEA should be performed as soon as possible in the first 2 weeks following a primary ischemic event, with rapidly decreasing benefits after this period. 6 As per recent Canadian and European data, only a minority of patients with symptomatic carotid stenosis are treated within the recommended time interval, [7][8][9][10][11][12] with various potential causes and solutions elicited. Therefore, the aim of this study was to assess time delays from the first cerebrovascular symptoms until the CEA procedure in a single-institution in Montreal, Quebec, following implementation of centralized care for cerebrovascular accidents.…”

Early vascular imaging and key system strategies expedite carotid revascularization after transient ischemic attack and stroke

“…This result is consistent with previous research that identifies presentation to a nonemergency setting is associated with significant delays in carotid intervention. 18,22 Although a substantial proportion of the delay among patients presenting to a nonemergency setting relates back to gaps in patient knowledge or slower response times in seeking medical attention after a TIA or stroke event, limited access to diagnostic services, including vascular imaging, in the primary care or other nonemergency settings is another important gap.…”

Transient ischemic attack: management in the emergency department and impact of an outpatient neurovascular clinic

“…14,15 Timely vascular imaging is needed to identify patients with 50%-99% carotid stenosis so that they can receive carotid endarterectomy surgery within 2 weeks of symptom onset, the time frame in which the greatest benefit is seen. 16,17 New to the updated Canadian Best Recommendations (2014) is the recommendation to use CT angiography at the time of brain CT as the first-line vascular imaging method. 6 For patients in whom a cardioembolic mechanism is suspected, but the ECG does not show atrial fibrillation, prolonged ECG monitoring is recommended in selected patients (older patients with recent embolic stroke of undetermined source who are potential candidates for anticoagulation therapy) for the detection of paroxysmal atrial fibrillation.…”