Safety of Carotid Endarterectomy After Intravenous Thrombolysis for Acute Ischaemic Stroke: A Case-Controlled Multicentre Registry Study

Abstract

Objective: Few studies have been published on the safety of carotid endarterectomy (CEA) after intravenous thrombolysis (IVT). Registry reports have been recommended in order to gather large study groups.Design: A retrospective, registry based, case controlled study on prospectively gathered data from Sweden, the capital region of Finland, and from Denmark, including 30 days of follow up.Methods: The study group was a consecutive series of 5526 patients who had CEA for symptomatic carotid artery stenosis during a 4.5 year period. Among these, 202 (4%) had IVT prior to surgery, including 117 having CEA within 14 days, and 59 within 7 days of thrombolysis. IVT as well as CEA were performed following established guidelines. The median time from index symptom to CEA was 12 days (range 0e130, IQR 7e21).Results: The 30 day combined stroke and death rate was 3.5% (95% CI 1.69e6.99) for those having IVT + CEA, 4.1% (95% CI 3.46e4.39) for those having CEA without previous IVT (odds ratio 0.84 [95% CI 0.39e1.81]), 3.4% (95% CI 1.33e8.39) for those having IVT + CEA within 14 days, and 5.1% (95% CI 1.74e13.91) for those having IVT + CEA within 7 days.Conclusion: Data on the time from symptoms to CEA in patients not having IVT, Rankin score, degree of stenosis, and cerebral imaging were not available. Despite its weaknesses, this study reasserts that CEA can be performed within the recommended 2 weeks of the onset of symptoms and IVT without increasing the risk of peri-operative stroke or death. Centres and vascular registries are recommended to continue monitoring changes in patient characteristics, lead times, and major complications after CEA in general, with a special focus on those who have undergone a prior thrombolysis.

Analysis of early Versus Delayed Carotid Surgery after Acute Ischemic Stroke

“…Yet, with the increasing number of stroke units, the question of a rapid revascularization of residual ICA stenosis after thrombolysis has emerged. Recent studies reported reassuring results but they were small population studies [25][26][27][28].Among the two neurological complications in our study, one was a postoperative stroke after thrombolysis and delayed CR. We believe early CR after thrombolysis should be considered, but larger series of patients are required to con irm the safety of such management.…”

Emergent Carotid Thromboendarterectomy for Acute Symptomatic Occlusion of the Extracranial Internal Carotid Artery

“…However, this recommendation is supported by low- or very-low-quality evidence. 10 -15 Even though the half-life of the thrombolytic agent is only 3 to 5 minutes, IVT has been shown to induce a widespread response of the coagulation system persisting for up to 72 hours. Additionally, rt-PA may contribute to a hyperperfusion injury by influencing blood–brain barrier permeability and activating several inflammatory mediators and metalloproteinases, which all last considerably longer than the half-life of the thrombolytic agent.…”

“…At present, the results of available studies support the indication that CEA can be performed safely within the recommended 2 weeks after onset of symptoms and IVT. 10 -15 However, studies focusing on emergency carotid artery thromboendarterectomy for severe acute ischemic stroke performed immediately after failed IVT with the aim to achieve neurological improvement by reperfusion of the ischemic penumbra are almost nonexistent.…”

Editor's Choice – Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)

“…248 The largest published series (202 cases) reported 30-day death/stroke rates of 3.4% among patients who underwent CEA <14 days of IVT, compared with 5.1% in those undergoing CEA <7 days. 249 It is essential, however, that CEA patients who undergo treatment within a few days of completing IVT are monitored carefully and treated actively for post-CEA hypertension (Section 2.6.1. 3.3).…”