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Outcomes of Preferential Early Carotid Endarterectomy following Recent Stroke

Published:March 04, 2022DOI:https://doi.org/10.1016/j.avsg.2022.02.015

      Background

      With the risk of recurrent ischemic stroke being highest in the first week following transient ischemic attack or stroke, the current guidelines of “early” endarterectomy within 2 weeks still leave potential vulnerability for patients with a significant bifurcation lesion and a new stroke. The intent of this analysis is to determine the safety of carotid endarterectomy even earlier than the current guidelines, based on a single surgeon experience of more than 12 years.

      Summary background data

      Although there has been a progressive movement toward earlier intervention following acute ischemic stroke in the presence of a culprit bifurcation lesion, most of the recommendations still are for performance of endarterectomy within two weeks following the event. This compression is welcome but given that the risk of recurrent stroke is highest within the first week following stroke, there is a reason to evaluate an earlier time frame for carotid endarterectomy (CEA).

      Methods

      A retrospective review of all CEA performed by a single surgeon over a 12-year period was performed. Patient demographics, Modified Rankin score (mRS) whenever documented, degree of internal carotid artery (ICA) stenosis, and preoperative neurologic symptoms were recorded. The 30-day outcomes including stroke, transient ischemic attack, death, and other major complications were tabulated.

      Results

      A total of 444 patients (mean age 74 ± 10.1) underwent a total of 465 CEAs. Two hundred and twenty-eight (49%) CEAs were for a symptomatic disease: of these, 194 had a documented stroke. One hundred and eighty-one stroke patients (93%) underwent CEA within 72 hr and the remaining 13 patients within 5 days. Of the stroke cohort, for whom the mRS was available, the mean preCEA mRS was 3.4. One patient in the stroke cohort had a postoperative stroke (0.5%, 1/194). In the total CEA cohort, there were 3 total postoperative strokes (0.6%, 3/465). There was one death in the total cohort (0.2%). The mean operative time was 45 min ± 4 min.

      Conclusions

      Early CEA for recurrent stroke prevention can be performed safely, at an earlier time frame than current recommendations. Given the safety of early CEA and the risk of recurrent stroke, CEA for stroke is best done early with no additional increase in morbidity or mortality.
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      References

      1. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST).
        Lancet. 1998; 351: 1379-1387
        • Barnett H.J.
        Symptomatic carotid endarterectomy trials.
        Stroke. 1990; 21: III2-III5
        • Barnett H.J.
        • Taylor D.W.
        • Eliasziw M.
        • et al.
        Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators.
        N Engl J Med. 1998; 339: 1415-1425
        • Barnett H.J.M.
        • Taylor D.W.
        • Haynes R.B.
        • et al.
        • North American Symptomatic Carotid Endarterectomy Trial C
        Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.
        N Engl J Med. 1991; 325: 445-453
        • Johansson E.
        • Cuadrado-Godia E.
        • Hayden D.
        • et al.
        Recurrent stroke in symptomatic carotid stenosis awaiting revascularization: a pooled analysis.
        Neurology. 2016; 86: 498-504
        • Johansson E.P.
        • Arnerlov C.
        • Wester P.
        Risk of recurrent stroke before carotid endarterectomy: the ANSYSCAP study.
        Int J Stroke. 2013; 8: 220-227
        • Meyer B.C.
        • Lyden P.D.
        The modified National Institutes of Health stroke scale: its time has come.
        Int J Stroke. 2009; 4: 267-273
        • Laredo C.
        • Zhao Y.
        • Rudilosso S.
        • et al.
        Prognostic significance of infarct size and location: the case of insular stroke.
        Sci Rep. 2018; 8: 9498
        • Brott T.G.
        • Howard G.
        • Roubin G.S.
        • et al.
        Long-term results of stenting versus endarterectomy for carotid-artery stenosis.
        N Engl J Med. 2016; 374: 1021-1031
      2. MRC European Carotid Surgery Trial: interim results for symptomatic patients with severe (70-99%) or with mild (0-29%) carotid stenosis. European Carotid Surgery Trialists' Collaborative Group.
        Lancet. 1991; 337: 1235-1243
        • Gasecki A.P.
        • Ferguson G.G.
        • Eliasziw M.
        • et al.
        Early endarterectomy for severe carotid artery stenosis after a nondisabling stroke: results from the North American Symptomatic Carotid Endarterectomy Trial.
        J Vasc Surg. 1994; 20: 288-295
        • Brott T.G.
        • Hobson 2nd, R.W.
        • Howard G.
        • et al.
        Stenting versus endarterectomy for treatment of carotid-artery stenosis.
        N Engl J Med. 2010; 363: 11-23
        • Baker R.N.
        • Ramseyer J.C.
        • Schwartz W.S.
        Prognosis in patients with transient cerebral ischemic attacks.
        Neurology. 1968; 18: 1157-1165
        • Baker R.N.
        • Schwartz W.S.
        • Ramseyer J.C.
        Prognosis among survivors of ischemic stroke.
        Neurology. 1968; 18: 933-941
        • Schwartz W.S.
        • Ramseyer J.C.
        • Baker R.N.
        Management of transient cerebral ischemic attacks.
        Calif Med. 1967; 107: 471-480
        • Ferrero E.
        • Ferri M.
        • Viazzo A.
        • et al.
        Early carotid surgery in patients after acute ischemic stroke: is it safe? A retrospective analysis in a single center between early and delayed/deferred carotid surgery on 285 patients.
        Ann Vasc Surg. 2010; 24: 890-899
        • Ferrero E.
        • Ferri M.
        • Viazzo A.
        • et al.
        A retrospective study on early carotid endarterectomy within 48 hours after transient ischemic attack and stroke in evolution.
        Ann Vasc Surg. 2014; 28: 227-238
        • Rerkasem K.
        • Rothwell P.M.
        Systematic review of the operative risks of carotid endarterectomy for recently symptomatic stenosis in relation to the timing of surgery.
        Stroke. 2009; 40: e564-e572
        • Blaisdell W.F.
        • Clauss R.H.
        • Galbraith J.G.
        • et al.
        Joint study of extracranial arterial occlusion. IV. A review of surgical considerations.
        JAMA. 1969; 209: 1889-1895
        • Brinjikji W.
        • Rabinstein A.A.
        • Meyer F.B.
        • et al.
        Risk of early carotid endarterectomy for symptomatic carotid stenosis.
        Stroke. 2010; 41: 2186-2190
        • Kulkarni S.R.
        • Gohel M.S.
        • Bulbulia R.A.
        • et al.
        The importance of early carotid endarterectomy in symptomatic patients.
        Ann R Coll Surg Engl. 2009; 91: 210-213
        • Rantner B.
        • Kollerits B.
        • Schmidauer C.
        • et al.
        Carotid endarterectomy within seven days after the neurological index event is safe and effective in stroke prevention.
        Eur J Vasc Endovasc Surg. 2011; 42: 732-739
        • Rantner B.
        • Pavelka M.
        • Posch L.
        • et al.
        Carotid endarterectomy after ischemic stroke--is there a justification for delayed surgery?.
        Eur J Vasc Endovasc Surg. 2005; 30: 36-40
        • Rantner B.
        • Schmidauer C.
        • Knoflach M.
        • et al.
        Very urgent carotid endarterectomy does not increase the procedural risk.
        Eur J Vasc Endovasc Surg. 2015; 49: 129-136
        • Rothwell P.M.
        • Eliasziw M.
        • Gutnikov S.A.
        • et al.
        Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery.
        Lancet. 2004; 363: 915-924
        • Liapis C.D.
        • Bell P.R.
        • Mikhailidis D.
        • et al.
        • ESVS Guidelines
        Invasive treatment for carotid stenosis: indications, techniques.
        Eur J Vasc Endovasc Surg. 2009; 37: 1-19
        • Meschia J.F.
        • Hopkins L.N.
        • Altafullah I.
        • et al.
        Time from symptoms to carotid endarterectomy or stenting and perioperative risk.
        Stroke. 2015; 46: 3540-3542
        • Stromberg S.
        • Gelin J.
        • Osterberg T.
        • et al.
        Very urgent carotid endarterectomy confers increased procedural risk.
        Stroke. 2012; 43: 1331-1335
        • Tsantilas P.
        • Kuhnl A.
        • Kallmayer M.
        • et al.
        A short time interval between the neurologic index event and carotid endarterectomy is not a risk factor for carotid surgery.
        J Vasc Surg. 2017; 65: 12-20.e1
        • Karkos C.D.
        • Hernandez-Lahoz I.
        • Naylor A.R.
        Urgent carotid surgery in patients with crescendo transient ischaemic attacks and stroke-in-evolution: a systematic review.
        Eur J Vasc Endovasc Surg. 2009; 37: 279-288
        • Karkos C.D.
        • McMahon G.
        • McCarthy M.J.
        • et al.
        The value of urgent carotid surgery for crescendo transient ischemic attacks.
        J Vasc Surg. 2007; 45: 1148-1154
        • Loftus I.M.
        • Paraskevas K.I.
        • Naylor A.R.
        Urgent carotid endarterectomy does not increase risk and will prevent more strokes.
        Angiology. 2017; 68: 469-471
        • Naylor A.R.
        Letter by Naylor regarding article, “Urgent best medical therapy may obviate the need for urgent surgery in patients with symptomatic carotid stenosis”.
        Stroke. 2013; 44: e156
        • Naylor R.
        Letter by Naylor regarding article, “very urgent carotid endarterectomy confers increased procedural risk”.
        Stroke. 2012; 43 (author reply e5): e94
        • Samson R.H.
        • Cline J.L.
        • Showalter D.P.
        • et al.
        Contralateral carotid artery occlusion is not a contraindication to carotid endarterectomy even if shunts are not routinely used.
        J Vasc Surg. 2013; 58: 935-940
        • van Alphen H.A.
        • Polman C.H.
        The value of continuous intra-operative EEG monitoring during carotid endarterectomy.
        Acta Neurochir (Wien). 1988; 91: 95-99
        • Waltz A.G.
        • Sundt Jr., T.M.
        • Michenfelder J.D.
        Cerebral blood flow during carotid endarterectomy.
        Circulation. 1972; 45: 1091-1096
        • Ospel J.M.
        • Menon B.K.
        • Qiu W.
        • et al.
        A detailed analysis of infarct patterns and volumes at 24-hour noncontrast CT and diffusion-weighted MRI in acute ischemic stroke due to large vessel occlusion: results from the ESCAPE-NA1 trial.
        Radiology. 2021; 300: 152-159
        • Reinhard M.
        • Rutsch S.
        • Lambeck J.
        • et al.
        Dynamic cerebral autoregulation associates with infarct size and outcome after ischemic stroke.
        Acta Neurol Scand. 2012; 125: 156-162