Prior Intravenous Stroke Thrombolysis Does Not Increase Complications of Carotid Endarterectomy

Abstract

Background and Purpose- Carotid endarterectomy (CEA) is recommended within 14 days after carotid artery stroke to prevent recurrence. However, the optimal timing of CEA after intravenous thrombolysis (IVT) remains unclear. We studied the safety of CEA after IVT while taking into account both stroke recurrence and CEA-related complications. Methods- Patients who underwent IVT followed by CEA in Helsinki University Hospital 2005 to 2016 were withdrawn from prospectively collected registers. The incidence of stroke recurrence during the time between IVT and CEA, peri/postoperative stroke, hyperperfusion syndrome or drug-resistant high blood pressure, and 3-month outcome measured by modified Rankin Scale was recorded. Stroke patients treated with CEA without preceding IVT were used as controls. Results- Altogether 128 CEAs with preceding IVT and 777 CEAs for stroke without IVT were identified. The median time from IVT to CEA was 9 days (range, 0-349 days; interquartile range, 16). Seven patients (5.5%) underwent CEA within 24 hours, 20 (15.6%) within 48 hours and 87 (68.0%) within 2 weeks from IVT. Stroke recurrence in IVT-CEA patients was 5.5% at median 4 days after IVT (range, 0-8 days). Outcome from CEAs performed within 48 hours from IVT did not differ from CEAs performed later with respect to peri/postoperative ischemic strokes (5.0% and 3.7%), hemorrhagic strokes (5.0% and 1.9%), neck hematomas (5.0% and 8.3%), myocardial infarctions (0.0% and 0.9%), or 3-month modified Rankin Scale. There was a tendency toward higher incidence of hyperperfusion syndrome in the patients operated within 48 hours from IVT (20.0% versus 6.5%; P=0.070). The CEA-related stroke rate was similar to that of the operation without thrombolysis. Only smoking was significantly associated with peri/postoperative stroke (odds ratio, 21.82; 95% confidence interval, 1.08-439.58). Conclusions- Time between IVT and CEA was not associated with CEA-related complications. The high rate of stroke recurrence during the waiting time for CEA underscores the importance of shortening surgery delays.

Risk of Stroke Recurrence After Intravenous Thrombolysis in Patients with Symptomatic Carotid Stenosis

“…Compared to the previous similar study that found a 5.5% risk of preoperative stroke in IVT-treated, 8 our risk was slightly more than double (12%). By our Kaplan-Meier approach, we took the variable timing to CEA/CAS into account, the previous study did not.…”

“…Indeed, an association between IVT and early clinical worsening was recently shown for all-cause carotid occlusion (including embolic occlusion) within 3 hours of baseline imaging. 7 To date, a single study has been presented and showed a 5.5% risk of preoperative stroke recurrence, 8 lower than the ≈ 15% risk seen in other studies. 2,3 However, this study had no control group without IVT treatment and possible selection bias as only cases that subsequently underwent carotid endarterectomy (CEA) were included.…”

“…2,3 However, this study had no control group without IVT treatment and possible selection bias as only cases that subsequently underwent carotid endarterectomy (CEA) were included. 8 Also, IVT treatment possibly increases the risk of perioperative stroke/death with CEA or stenting (CAS) performed within 7 days of IVT treatment. 9 Therefore, to enable assessment of optimal timing of CEA/CAS in IVT-treated patients, additional assessments of preoperative risk of stroke in IVT-treated patients were called for in recent guidelines.…”

Safety and efficacy of symptomatic carotid artery stenting performed in an emergency setting

“…Ijas et al found that early CEAs (within 48 hours from IV thrombolysis) did not differ from CEAs performed later regarding peri/postoperative strokes, neck hematomas, MI, or 3-month modified Rankin Scale. 14 Similarly, despite our emergency CAS group included patients with tandem occlusions during thrombectomy (24%) and had a significantly higher number of ipsilateral carotid occlusions (17% vs. 2%) and patients undergoing general anesthesia (19% vs. 4%), there were no differences in the primary and secondary outcomes with the elective CAS group. These findings provide additional evidence that early carotid revascularization (CAS or CEA) in high-risk groups such as thrombectomy patients might be safe.…”

The Efficacy of Carotid Surgery by Subgroups: The Concept of Stroke Prevention Potential

“…29 In a series of operations after thrombolysis, seven of 128 (5.5%) patients had a recurrent stroke prior to surgery a median of four days (interquartile range 0e8 days) after the thrombolysis, whereas the 30 day peri-/post-operative stroke rate was six of 128 (4.7%). 30 This means that operating promptly remains important, despite improved medication.…”