Carotid Endarterectomy within 2 weeks of minor ischemic stroke: A prospective study

Ballotta, Enzo; Meneghetti, Giorgio; Giau, Giuseppe Da; Manara, Renzo; Saladini, Marina; Baracchini, Claudio

doi:10.1016/j.jvs.2008.04.044

Cited by 44 publications

(29 citation statements)

References 34 publications

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“…Our median time (73 days) between symptom onset and CEA in our cohort of patients referred to vascular surgery from a neurologist was larger than the median time (26 days) in a group of all patients referred in a previously studied cohort 8 . We also determined the specific delays for each event in the evaluation process.…”

Section: Discussioncontrasting

confidence: 63%

“…These times were shortened in hospitalized inpatients and in those receiving care via the emergency room, but the time to surgery still exceeded the two weeks recommended by guidelines 8 . Other surveys have found similar or longer waiting times 10,11 , and noted that delays to surgery were associated with an increase in the number of cerebrovascular events prior to intervention, many of which are disabling or fatal 9,12 .…”

Section: Original Articlementioning

confidence: 91%

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mentioning

confidence: 99%

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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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Section: Discussioncontrasting

confidence: 63%

Section: Original Articlementioning

confidence: 91%

“…

…”

mentioning

confidence: 99%

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Delays in Carotid Endarterectomy: The Process is the Problem

Blacquiere

Sharma²,

Jetty³

2013

Can. J. Neurol. Sci.

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“…Delay before surgery for patients who suffered a TIA due to internal carotid stenosis is established and surgery should be performed precociously [5][6][7][8]. This is why we excluded all patients presenting with TIA, in order to focus on stroke outcomes.…”

Section: Discussionmentioning

confidence: 99%

“…Many randomized trials have shown the bene it of early carotid revascularization for symptomatic carotid stenosis in stable patients [4]. According to recent literature, carotid revascularization (CR) should be performed within the irst two weeks following transient ischemic attack (TIA) or minor stroke, [5][6][7][8] and to some extend in the hyperacute period, within 48 hours [9,10]. In contrast, regarding major strokes or ongoing strokes, major studies recommend that surgery should be delayed four to six weeks after the irst neurological symptoms when clinical and radiological lesions have stabilized [11,12].…”

Section: Introductionmentioning

confidence: 99%

Analysis of early Versus Delayed Carotid Surgery after Acute Ischemic Stroke

Perou

2017

J Neurosci Neurol Disord

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Objective: We evaluated the 30-day outcomes of early (≤ 14 days) or delayed (15 days to three months) carotid revascularization (CR) performed in patients who presented acute brain infarction secondary to internal carotid artery (ICA) stenosis. Methods:We included all patients with a recent cerebral infarction from July 2010 to June 2014 who underwent CR in our center within three months after the onset of symptoms for ICA stenosis. Data were retrospectively collected. Two groups were identifi ed: Group A included patients who underwent early CR within the fi rst fourteen days after symptom onset, and Group B, patients who underwent delayed CR, from the fi fteenth day up to the third month after symptom onset. Death, stroke and major adverse cardiac events (MACE) were analyzed.Results: Seventy-one patients underwent CR (73.2% men, with a median age of 71). Nineteen patients underwent early CR and 52 underwent delayed CR. The mean interval from initial examination to surgery was 9.5 days (range, 3-14 days) in Group A and 42 days (range, 15-92 days) in Group B. No complication occurred in Group A within the 30 postoperative days. In Group B, no MACE or death was observed and two patients presented with post-operative stroke (3.8%). Conclusion:This retrospective study confi rmed the satisfactory outcomes of early CR after acute brain infarct. Accurate clinical and radiological selection of patients prevents early neurological complications.

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