Outcomes of urgent carotid endarterectomy for stable and unstable acute neurologic deficits

Barbetta, Iacopo; Carmo, Michele; Mercandalli, Giulio; Lattuada, P.; Mazzaccaro, Daniela; Settembrini, Alberto M.; Dallatana, Raffaello; Settembrini, Piergiorgio

doi:10.1016/j.jvs.2013.08.035

Cited by 49 publications

(26 citation statements)

References 28 publications

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“…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%

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: 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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“…This surgery is considered to be at high risk. Nevertheless, several small monocentric studies reported favourable outcomes, including patients with major strokes during acute phase [15,17,18]. Lesèche et al 2012; reported no death or postoperative stroke for 27 patients who underwent CR during the acute phase of stroke with a median delay of six days from symptom onset to surgery [13].…”

Section: Discussionmentioning

confidence: 99%

“…Their results should be interpreted taking into account the postoperative risks related to the severity of the initial lesion. For example, for Barbetta et al 2014; the 30-day outcomes of early CR in 90 patients were considered as satisfactory despite four deaths and six postoperative strokes. In their series, half of the complications occurred in 11 patients who presented with severe stroke in evolution [15].Nevertheless, in many series, results suggest that early CR after brain infarct is safe.…”

Section: Discussionmentioning

confidence: 99%

“…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]. However, some recent series with excellent outcomes after early revascularization during the acute phase of major stroke have questioned revascularization delay [13][14][15]. The main objective of our study was to evaluate the 30-day outcomes of early or delayed CR performed in our department in patients who presented acute brain infarction secondary to internal carotid artery (ICA) stenosis.…”

Section: Introductionmentioning

confidence: 99%

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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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“…A recent study found that 25% of strokes are preceded by a TIA, and 45% of the TIAs occur the week prior 71. Interestingly, carotid intervention for patients with a stroke-in-evolution (worsening symptoms over the course of hours to days) is unclear,72,73 with poor outcomes for patients with stroke-in-evolution, regardless of medical or surgical management 72…”

Section: Carotid Endarterectomy In Symptomatic Patientsmentioning

confidence: 99%

Carotid revascularization: risks and benefits

O'Brien¹,

Chandra²

2014

VHRM

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Despite a decline during the recent decades in stroke-related death, the incidence of stroke has remained unchanged or slightly increased, and extracranial carotid artery stenosis is implicated in 20%–30% of all strokes. Medical therapy and risk factor modification are first-line therapies for all patients with carotid occlusive disease. Evidence for the treatment of patients with symptomatic carotid stenosis greater than 70% with either carotid artery stenting (CAS) or carotid endarterectomy (CEA) is compelling, and several trials have demonstrated a benefit to carotid revascularization in the symptomatic patient population. Asymptomatic carotid stenosis is more controversial, with the largest trials only demonstrating a 1% per year risk stroke reduction with CEA. Although there are sufficient data to advocate for aggressive medical therapy as the primary mode of treatment for asymptomatic carotid stenosis, there are also data to suggest that certain patient populations will benefit from a stroke risk reduction with carotid revascularization. In the United States, consensus and practice guidelines dictate that CEA is reasonable in patients with high-grade asymptomatic stenosis, a reasonable life expectancy, and perioperative risk of less than 3%. Regarding CAS versus CEA, the best-available evidence demonstrates no difference between the two procedures in early perioperative stroke, myocardial infarction, or death, and no difference in 4-year ipsilateral stroke risk. However, because of the higher perioperative risks of stroke in patients undergoing CAS, particularly in symptomatic, female, or elderly patients, it is difficult to recommend CAS over CEA except in populations with prohibitive cardiac risk, previous carotid surgery, or prior neck radiation. Current treatment paradigms are based on identifying the magnitude of perioperative risk in patient subsets and on using predictive factors to stratify patients with high-risk asymptomatic stenosis.

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Outcomes of urgent carotid endarterectomy for stable and unstable acute neurologic deficits

Cited by 49 publications

References 28 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

Analysis of early Versus Delayed Carotid Surgery after Acute Ischemic Stroke

Carotid revascularization: risks and benefits

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