The Efficacy of Carotid Surgery by Subgroups: The Concept of Stroke Prevention Potential

Abstract

WHAT THIS PAPER ADDS Patient selection should be a key component of carotid surgery reports. A calculator was created where the presence and recentness of symptoms, sex, increasing stenosis severity, and complication rates could all be combined into a single figure. The calculator was tested on real life material and some theoretical inclusion scenarios. Single hospital treatment development over time and benchmarking between hospitals can be monitored when registered data includes these parameters, ultimately leading to improved patient selection. Objective: Considering carotid endarterectomy (CEA), reporting treatment delay, symptom status, and surgical complication rates separately gives an incomplete picture of efficacy; therefore, the aim was to combine these factors and develop a reporting standard that better describes the number of potentially prevented strokes. With a real life cohort and theoretical inclusion scenarios, the aim was to explore the stroke prevention potential of different carotid practices. Methods: Landmark studies for symptomatic and asymptomatic patients were revisited. By using published estimates of treatment effect, a simplified calculator was designed to assess the five year stroke prevention rate per 1000 CEAs (stroke prevention potential [SPP], range 0e478), including the presence and recentness of symptoms, sex, increasing stenosis severity, and complication rates. Patients operated on for carotid stenosis at Helsinki University Hospital (HUH) between 2008 and 2016 were collected from a vascular registry (HUSVASC) and categorised according to the model. The local annual complication rate was re-evaluated and added to the model. The HUH patient cohort was incorporated into the SPP model, and changes over time analysed. Finally, theoretical changes in patient selection were compared in order to explore the theoretical impact of patient selection and shortening of the delay. Results: Fifteen hundred and five symptomatic and 356 asymptomatic carotid stenoses were operated on with stroke plus death rates of 3.6% and 0.3%, respectively. The proportion of CEAs performed within two weeks of the index event increased over the follow up period, being 77% in 2016. The SPP increased from 123 in 2008 to 229 in 2016. Theoretically, 350 ischaemic strokes were prevented in the period 2008e16, with 1861 CEAs. Conclusions: National and international comparison of different CEA series is irrelevant if the inclusion criteria are not considered. A calculator that is easy to apply to large scale high quality registered data was developed and tested. SPP was found to increase over time, which is a probable sign of improved patient selection and an increased number of strokes prevented by the CEAs performed.

Carotid Stenosis and Stroke: Medicines, Stents, Surgery—“Wait-and-See” or Protect?

“…20 Patients in at-risk population categories deserve comprehensive information in reaching treatment decisions about therapies designed to prevent stroke. 20 112 113 114 115 116 117 Patients in at-risk categories deserve comprehensive information to assist in treatment decisions regarding therapies designed to prevent stroke. 20 Patient preference typically and overwhelmingly is to receive preventive treatment for stroke which is effective in both short and long term and delivered with a low procedural risk and with least invasiveness.…”

“…reactive and should be safe and effective, including the long term 56,65 . Recent evidence indicates that less 20 unselected patients with a significant carotid stenosis need to be revascularized (NNR) to prevent 1 stroke 71 . NNR is likely to be significantly lower in patients with increased lesion-level and/or clinical risk features 14,7,22,31,[33][34][35][36]41 .…”

“Stroke-Stop” Formula: A Tool for Risk Index Determination in Development of Acute Cerebrovascular Disease in Patients with Asymptomatic Internal Carotid Artery Stenosis

“…It was established that the carotid endarterectomy is the effective treatment to reduce the risk of subsequent stroke in symptomatic patients with carotid stenosis [6]. Moreover, the risk-bene t ratio prefers surgery for about 70% symptomatic stenosis.…”

“…At the same time, the risk of developing postoperative complications is from 2 to 5% [4,5]. It indicates the fact that performing carotid endarterectomy in patients with symptomatic ICA stenosis allows reducing the risk of stroke development by approximately 9-10 times, while in patients with asymptomatic ICA stenosis -by 1.5-2 times only [6]. Therefore, the criteria for selecting patients for surgical prevention of acute cerebrovascular disease among patients with asymptomatic ICA stenosis are broadly discussed nowadays [7,8].…”

Carotid Stenting versus Endarterectomy: The Evidence is Evident. Or is it?

“…2,3 Regarding symptoms, some refuse to intervene when the patient is asymptomatic, whereas some encourage their asymptomatic patients to be treated and end up in a situation where most of their patients have a limited theoretical benefit from the procedure. 4 Until relatively recently, the durability of CAS has been questioned. Today, and once more underlined by the authors, it seems accepted that if the patient does not get a peri-procedural complication, CAS is a durable procedure despite some restenosis, until at least 10 years, which is long enough for many of our patients.…”