The different scenarios of urgent carotid revascularization for crescendo and single transient ischemic attack

Abstract

Objective Carotid stenosis with crescendo-transient-ischemic-attack (cTIA) requires a prompt intervention to reduce the stroke risk. Few data are reported in literature about cTIA suggesting a different perioperative risk compared with patients with single TIA (sTIA). This study aimed to compare the outcome of carotid endarterectomy (CEA) in patients with TIA (single/crescendo) and evaluate the outcome risk-factors. Methods Data from two tertiary hospitals for vascular treatment were analyzed from 2007 to 2016. All patients with TIA subjected to CEA were considered, comparing the 30-day postoperative stroke and stroke/death in patients with cTIA and sTIA, particularly in the urgent (≤48 h) setting. Results On a total of 3866 CEA, 888 (23%) were performed in symptomatic patients and 515 for TIA: 365 (71%) patients with sTIA and 150 (29%) with cTIA. When compared with sTIA, cTIA patients were younger and less frequently affected by coronary disease, dyslipidemia, and chronic pulmonary disease; however, contralateral carotid occlusion was more common (20% vs. 10%, P = .004; 56% vs. 46, P = .03; 16% vs. 7%, P = .01; >80 years 26% vs. 16%, P = .01 and 2% vs. 10%, P = .001; respectively). Postoperative stroke and stroke/death were significantly higher in cTIA compared with sTIA (5.3% vs. 1.6%, P = .02 and 6.0% vs. 2.2%, P = .03; respectively). Urgent CEA was performed in 58% ( n: 87) cTIA and in 11% ( n: 56) sTIA( P<.01). The urgent setting did not influence the stroke and stroke/death rate of CEA for sTIA (3.6% vs. 1.3%, P = .21 and 3.6% vs. 1.9%, P = .44, respectively), but was associated with lower rate of events in cTIA (1.1%vs. 11.1%, P = .01 and 2.3% vs. 11.1%, P = .03, respectively). This beneficial effect in patients with cTIA treated within 48-h was confirmed also by multivariate analysis (OR: 0.09, 95% CI: 0.76-0.01, P=.02). Conclusions cTIA subjected to CEA have a higher stroke and stroke/death risk compared with patients with sTIA. The urgent setting seems to reduce the stroke/death rate cTIA; for sTIA with a stable neurological condition, the timing of CEA did not influence the outcome.

Diabetes mellitus and adverse outcomes after carotid endarterectomy: A systematic review and meta-analysis

“…A total of 624 records were identified from 5 databases and 19 studies were included for final quantitative synthesis [Figure 1]. [927]…”

“…A total of 624 records were identified from 5 databases and 19 studies were included for final quantitative synthesis [Figure 1]. [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] Characteristics of the included studies Among the 19 studies in this meta-analysis, 122,003 patients undergoing CEA were included. All CEA procedures were performed after the year 2000, and studies were based on clinical registries, public medical databases, or single-center databases.…”

Carotid Endarterectomy and Carotid Artery Stenting for Patients With Crescendo Transient Ischemic Attacks

“…The comparable end points for SIE are even higher, and these include rates of combined stroke and death of 16.9% (95% CI, 9.2%-26.2%) and a combined rate of stroke, myocardial infarction, and death of 20.8% (95% CI, 13.2%-29.6%) . Only a few reports have studied outcomes of intervention in patients with cTIA (Table 2). Since patients with cTIA and SIE have similarly high risks of complication, they are usually combined into a single acute-syndrome group, and thus analysis of this subgroup of patients is challenging.…”

“…The authors concluded that postoperative complications after urgent CEA for cTIA are higher than expected after elective surgery but still acceptable, considering the natural history of patients with unstable neurologic symptoms . All of the studies from 1985 to 2018 reporting CEA in patients with cTIA have been summarized in Table 2. The wide range in practice patterns reflects patient heterogeneity and lack of standard selection criteria for intervention.…”

Impact of cerebral ischemic lesions on the outcome of carotid endarterectomy

“…However, a dichotomy between symptomatic and asymptomatic patients is not accurate enough to precisely identify the risk of new symptoms or recurrences or to define the perioperative risk in patients submitted to carotid revascularization. As a matter of fact, the stratification of symptomatic patients according to the type of symptoms is important to identify those at higher risk of stroke and also to evaluate the risk of a revascularization procedure (1), since it is well known that patients with stroke in evolution or transient ischemic attack (TIA) in crescendo are more prone to perioperative complications compared with patients with a single stable TIA (2)(3)(4). Other than the clinical status, the presence and extension of cerebral ischemic lesions (CIL) is increasingly used as a stratification tool of these patients (5).…”