Timing of Carotid Endarterectomy for Symptomatic Carotid Stenosis: A Snapshot of Current Trends and Systematic Review of Literature on Changing Paradigm towards Early Surgery

Savardekar, Amey; Narayan, Vinayak; Patra, Devi Prasad; Spetzler, Robert F.; Sun, Hai

doi:10.1093/neuros/nyy557

Cited by 26 publications

(12 citation statements)

References 73 publications

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“…A systematic review conducted by Savardekar et al . 19 noted a changing paradigm towards early carotid surgery, specifically targeted within 48 h if the index event is TIA, and within 7 d if the index event is stroke.…”

Section: Discussionmentioning

confidence: 99%

In-hospital recurrence in a Chinese large cohort with acute ischemic stroke

Fan

Liu

Yang

et al. 2019

Sci Rep

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Acute ischemic stroke (AIS) has a high risk of recurrence, particularly in the early stage. The purpose of this study was to assess the frequency and risk factors of in-hospital recurrence in patients with AIS in China. A retrospective analysis was performed of all of the patients with new-onset AIS who were hospitalized in the past three years. Recurrence was defined as a new stroke event, with an interval between the primary and recurrent events greater than 24 hours; other potential causes of neurological deterioration were excluded. The risk factors for recurrence were analyzed using univariate and logistic regression analyses. A total of 1,021 patients were included in this study with a median length of stay of 14 days (interquartile range,11–18). In-hospital recurrence occurred in 58 cases (5.68%), primarily during the first five days of hospitalization. In-hospital recurrence significantly prolonged the hospital stay (P < 0.001), and the in-hospital mortality was also significantly increased (P = 0.006). The independent risk factors for in-hospital recurrence included large artery atherosclerosis, urinary or respiratory infection and abnormal blood glucose, whereas recurrence was less likely to occur in the patients with aphasia. Our study showed that the patients with AIS had a high rate of in-hospital recurrence, and the recurrence mainly occurred in the first five days of the hospital stay. In-hospital recurrence resulted in a prolonged hospital stay and a higher in-hospital mortality rate.

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Section: Discussionmentioning

confidence: 99%

In-hospital recurrence in a Chinese large cohort with acute ischemic stroke

Fan

Liu

Yang

et al. 2019

Sci Rep

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“…Procedural risks are higher when CEA is performed within 48 hours after ischemic stroke. 47 The risk of stroke recurrence is also high initially and decreases over time, reducing the benefit of CEA. The optimal timing of CEA should, therefore, balance the risk of recurrent events and procedural risks.…”

Section: Discussionmentioning

confidence: 99%

External Validation of Risk Prediction Models to Improve Selection of Patients for Carotid Endarterectomy

Poorthuis

Herings

Dansey

et al. 2022

Stroke

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Background and Purpose: The net benefit of carotid endarterectomy (CEA) is determined partly by the risk of procedural stroke or death. Current guidelines recommend CEA if 30-day risks are <6% for symptomatic stenosis and <3% for asymptomatic stenosis. We aimed to identify prediction models for procedural stroke or death after CEA and to externally validate these models in a large registry of patients from the United States. Methods: We conducted a systematic search in MEDLINE and EMBASE for prediction models of procedural outcomes after CEA. We validated these models with data from patients who underwent CEA in the American College of Surgeons National Surgical Quality Improvement Program (2011–2017). We assessed discrimination using C statistics and calibration graphically. We determined the number of patients with predicted risks that exceeded recommended thresholds of procedural risks to perform CEA. Results: After screening 788 reports, 15 studies describing 17 prediction models were included. Nine were developed in populations including both asymptomatic and symptomatic patients, 2 in symptomatic and 5 in asymptomatic populations. In the external validation cohort of 26 293 patients who underwent CEA, 702 (2.7%) developed a stroke or died within 30-days. C statistics varied between 0.52 and 0.64 using all patients, between 0.51 and 0.59 using symptomatic patients, and between 0.49 to 0.58 using asymptomatic patients. The Ontario Carotid Endarterectomy Registry model that included symptomatic status, diabetes, heart failure, and contralateral occlusion as predictors, had C statistic of 0.64 and the best concordance between predicted and observed risks. This model identified 4.5% of symptomatic and 2.1% of asymptomatic patients with procedural risks that exceeded recommended thresholds. Conclusions: Of the 17 externally validated prediction models, the Ontario Carotid Endarterectomy Registry risk model had most reliable predictions of procedural stroke or death after CEA and can inform patients about procedural hazards and help focus CEA toward patients who would benefit most from it.

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“…Despite the high quality of this work, in symptomatic patients the postoperative long-term life expectancy assessment is unnecessary in the majority of cases, because in these patients CEA or stenting is strictly indicated to avoid recurrent stroke, which happened within the first two weeks from symptom onset. 7,24 Conversely, the CEA-8 risk score was proposed by Cavillo-King and coworkers to create a multivariate model of risk of death and/or stroke within 30 days of CEA for asymptomatic disease in 6553 Medicare beneficiaries. 25 Female sex, nonwhite race, severe disability, J o u r n a l P r e -p r o o f 15 congestive heart failure, coronary artery disease, valvular heart disease, a distant history of stroke or transient ischemic attack, and a non-operated stenosis ≥50% were the items used to score each patient.…”

Section: Discussionmentioning

confidence: 99%