Urgent Carotid Endarterectomy for Patients with Unstable Symptoms: Systematic Review and Meta-Analysis of Outcomes

Abstract

Current evidence suggests that carotid endarterectomy (CEA) performed within 2 weeks of symptoms produces better long-term results than if it is delayed. Urgent endarterectomy following unstable presentations such as crescendo transient ischemic attack (cTIA) or progressive stroke has been associated with variable results. The evidence for this treatment strategy required reviewing. A systematic review of articles related to urgent CEA between 1980 and 2008 was performed. For cTIA, there was an odds ratio of 5.6 (95% confidence interval 3.3-9.7, p < or = .0001) for combined stroke or death compared with surgery for "standard" indications. For unstable stroke, the odds ratio was 5.5 (95% confidence interval 3.1-9.3, p < or = .0001). Patients with unstable neurologic presentations are at higher risk of complications if operated on urgently. Clearer definitions would help more precise patient selection to avoid inadvertently operating on patients with an unacceptably high risk of poor outcome.

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

“…Randomized clinical trials have shown CEA to be effective at stroke prevention in patients with symptomatic carotid artery stenosis, and published guidelines cite the benefits of CEA when a surgeon determines perioperative risk to be less than 6% . Reviews of small retrospective studies over long periods have demonstrated a higher risk for postoperative death and stroke in patients presenting with unstable neurological symptoms, and systematic reviews quote a 6.5% (95% CI, 3.4%-10.4%) rate of stroke and death, as well as a 10.9% (95% CI, 5.5%-17.9%) combined rate of stroke, myocardial infarction, and death. 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%) .…”

Comments regarding ‘Carotid Endarterectomy within Seven Days after the Neurological Index Event is Safe and Effective in Stroke Prevention’

“…Similar findings have been published in a meta-analysis of Patterson and coworkers (odds ratio of 5.6 for combined stroke/death in patients with crescendo TIAs in comparison with CEA for stable patients, and an odds ratio of 5.5 for patients with unstable stroke). 3 Therefore, the decision whether or not to perform urgent CEA must be more individualized. Several important aspects have to be taken into account and tackled.…”

Urgent Carotid Endarterectomy Does Not Increase Risk and Will Prevent More Strokes

“…Three systematic reviews have demonstrated that patients with unstable neurologic presentations (crescendo TIA and stroke-in-evolution) are at higher risk of complications if operated on urgently compared to symptomatic patients with stable symptoms. [9][10][11] Nevertheless, urgent CEA may be justified even in these patients due to the high rate of recurrent events if they do not undergo CEA. 4 The recommendations of the UK National Stroke Strategy 12 were more aggressive than the other guidelines.…”

“…14 As mentioned earlier, these patients are at higher risk of complications if operated on urgently. [9][10][11] An international multicenter study recently reported that the stroke risk associated with CEA in symptomatic patients does not differ when the procedure is performed within 2 days versus within 2 weeks from symptom onset. 15 Patients were divided into 2 groups-those who underwent urgent CEA (0-2 days after symptom onset; n ¼ 20) and those who underwent early CEA (3-14 days after symptom onset; n ¼ 145).…”

“…14 As mentioned earlier, these patients are at higher risk of complications if operated on urgently. 9 –11…”