Very Urgent Carotid Endarterectomy Confers Increased Procedural Risk

Strömberg, Sofia; Gélin, J; Österberg, Torun; Bergström, Göran; Karlström, Lars; Österberg, Klas

doi:10.1161/strokeaha.111.639344

Cited by 163 publications

(30 citation statements)

References 36 publications

(34 reference statements)

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“…23,24 In accordance with the present analysis, neither study found any significant association between the time interval and the 30-day risk of any stroke or death. In contrast, the Swedish register study by Strömberg et al 10 found a significantly increased perioperative risk of stroke or death when the procedure was performed within the first 2 days after the index event. Patients treated within the first 2 days had a 4-fold increased risk (risk ratio, 4.24; 95% confidence interval, 2.07-8.70) compared with patients treated between 3 and 7 days.…”

Section: Discussionmentioning

confidence: 79%

“…However, no differences were found on comparing the reference group (3-7 days) to the other time interval groups (8-14 days: risk ratio, 1.12; 95% confidence interval, 0.62-2.02; 15-180 days: risk ratio, 1.90; 95% confidence interval, 1.12-3.22). 10 One reason for the different findings may be the fact that at least some emergency procedures such as crescendo-TIA or stroke-in-evolution, which carry a markedly higher risk of stroke or death, 22,25 were not excluded from the latter study. In this regard, a systematic review revealed a pooled absolute risk of stroke and death after CEA in patients with crescendo-TIA of 11.4% (95% confidence interval, 6.1-16.7; n=301) and 20.2% (95% confidence interval, 12.0-28.4; n=135) in patients with strokein-evolution.…”

Section: Discussionmentioning

confidence: 99%

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Short Time Interval Between Neurologic Event and Carotid Surgery Is Not Associated With an Increased Procedural Risk

Tsantilas¹,

Kuehnl²,

König³

et al. 2016

Stroke

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Background and Purpose— Guidelines recommend that carotid endarterectomy should be performed within 2 weeks in patients with a symptomatic carotid stenosis. Because a Swedish register study indicated that patients treated within the first days after a stroke or transient ischemic attack might have an increased perioperative stroke and mortality risk, this study aimed to find out whether these findings are also true under everyday conditions in Germany. Methods— Secondary data analysis including 56 336 elective carotid endarterectomy procedures performed for symptomatic carotid stenosis under everyday conditions between 2009 and 2014. The patient cohort was divided into 4 groups according to time interval between index event and surgery (I: 0–2, II: 3–7, III: 8–14, and IV: 14–180 days). Primary outcome was any in-hospital stroke or death. For risk-adjusted analyses, a multilevel multivariable regression model was used. Results— Mean patients’ age was 71.1±9.6 years; 67.5% were men. Overall rate of any stroke or death was 2.5% (n=1434). Risk of any in-hospital stroke or death was 3.0% in group I, 2.5% in group II, 2.6% in group III, and 2.3% in group IV. Multivariable regression analysis revealed that the time interval was not significantly associated with the primary outcome. Conclusions— The time interval between the index event and carotid endarterectomy was not associated with the risk of any in-hospital stroke or death in patients with symptomatic carotid stenosis in Germany. In clinically stable patients, carotid endarterectomy might, therefore, be performed safely as soon as possible after the neurological index event.

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Section: Discussionmentioning

confidence: 79%

Section: Discussionmentioning

confidence: 99%

Short Time Interval Between Neurologic Event and Carotid Surgery Is Not Associated With an Increased Procedural Risk

Tsantilas¹,

Kuehnl²,

König³

et al. 2016

Stroke

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“…In our population, there were no recurrent strokes or ischemic events prior to endarterctomy, but delays to CEA are associated with a higher risk of preoperative stroke, many of which can be disabling or fatal 9 . These must be balanced against the risk of stroke associated with too-early intervention, as CEA within two days of the event has been associated with a higher risk of stroke than CEA performed between 3-14 days 16,17 . The risk of early intervention must be further balanced against the risk of recurrent strokes, particularly in neurologically unstable patients 18 .…”

Section: Discussionmentioning

confidence: 99%

Delays in Carotid Endarterectomy: The Process is the Problem

Blacquiere

Sharma²,

Jetty³

2013

Can. J. Neurol. Sci.

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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...

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“…15 An analysis of the Swedish Vascular Registry found that the procedural risk of stroke was 11.5% between days 0 and 2 after stroke compared with a risk of approximately 4% from days 3 to 14. Therefore, the optimal timing for treatment of a symptomatic carotid artery may be between days 3 and 14.…”

Section: Risk Of Stroke After Tiamentioning

confidence: 99%

TIA Management

Mijalski

Silver

2015

The Neurohospitalist

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Transient ischemic attack (TIA) has gained increasing attention over the last 2 decades with the realization that the condition is common, portends potentially serious consequences, and, when identified early, can be evaluated and treated to modify future risk. In this review, we examine the issues of whether all TIA patients need admission and whether such patients should receive short-term dual antiplatelet therapy. Not all patients require admission if evaluation and treatment are done promptly. There may be a role for dual antiplatelet therapy, but the results of further clinical trials will help provide better clarity on which patients are the best candidates for this treatment.

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Very Urgent Carotid Endarterectomy Confers Increased Procedural Risk

Cited by 163 publications

References 36 publications

Short Time Interval Between Neurologic Event and Carotid Surgery Is Not Associated With an Increased Procedural Risk

Short Time Interval Between Neurologic Event and Carotid Surgery Is Not Associated With an Increased Procedural Risk

Delays in Carotid Endarterectomy: The Process is the Problem

TIA Management

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