Very Urgent Carotid Endarterectomy Confers Increased Procedural Risk

Abstract

More than 100 years ago, Trousseau reported migratory thrombophlebitis in cancer patients (Trosseau A, Lectures on Clinical Medicine, delivered at the Hotel-Dieu, Paris, London: New Sydenham Society; 1872; p 281-95). Subsequently, patients with DVT or pulmonary embolism (PE) have been shown to have up to a fourfold increased risk of cancer in the first year after the venous thromboembolic (VTE) event (Baron JA et al, Br J Cancer 2004;91:92-5). However, only one previous study has investigated the relationship between SVT and cancer risk (van Doormaal FF et al, Ann Fam Med 2010;8:47-50). In an effort to understand the broader cancer risk associated with all types of venous thrombosis, the authors used populationbased registries in Denmark to investigate associations of cancer with SVT, DVT, and PE. They identified all patients in Denmark from 1994 to 2009 with a diagnosis of SVT, DVT in the legs, or PE. The occurrence of cancer in each of the venous cohorts was compared with expected numbers of cases using national incidence rates to compute standardized incidence ratios (SIRs). The authors identified 763 patients with SVT, 45,252 with DVT, and 24,332 with PE. Very similar proportions of patients in the three cohorts in the first year of follow-up were diagnosed with cancer. The SIRs (95% confidence intervals) were 2.46 (2.10-2.86) for SVT, 2.75 (2.6-2.9) for DVT, and 3.27 (3.03-3.52) for PE, and declined after 1 year to 1.05 (0.96-1.16), 1.11 (1.07-1.16), and 1.15 (1.09-1.22), respectively. Venous thrombotic cohorts showed strong associations for particular cancers (liver, lung, ovaries, pancreas, and non-Hodgkin lymphoma).Comment:The key point here is that all forms of lower extremity venous thrombosis, SVT, DVT, and potential sequelae, such as PE, are markers for a clearly higher occurrence rate of cancer, particularly during the first year after diagnosis. Practical implications for screening for cancer in patients with VTE are unclear. If someone has cancer and a VTE event within 1 year of diagnosis, the prognosis is poor, with only a 12% survival (Sorensen HT et al, N Engl J Med 2000;343:1846-50). However, the implications for screening derived from this particular study are also unclear. The authors point out 45,981 individuals with VTE would have to be investigated to find 304 excess cancers during the first year of follow-up. That is a lot of investigation for not many cancers, especially when it is unclear that an early cancer diagnosis stemming from evaluation of a VTE event would ultimately prolong the life of a VTE patient with underlying cancer.

The True Risk of Early Recurrent Stroke: Importance of Cohort Composition and Index Event Definition

“…Strömberg et al 2 recommend against performing CEA within the first 48 hours, because of the high risk of procedural stroke observed in an earlier national audit. However, the current study did not assess procedural risk and the methodology was insufficient to draw any conclusions regarding the risks of early surgery.…”

Optimization of the timing of carotid endarterectomy

“…Multivariate ana lysis showed that time to intervention was the strongest determinant of risk of stroke or death, with an odds ratio of 4.24 (95% CI 2.07-8.70, P <0.001) for surgery within 2 days of the ischaemic event compared with surgery on days 3-7. 1 The increased risk was not attrib utable to a difference between centres, nor to variation in qualify ing events (TIA, minor stroke or major stroke) in those under going CEA at early or late time points. How ever, amaurosis fugax (transient monocular blindness) as the qualifying event was inde pendently associated with a lower risk of surgery complications.…”

“…The recent publication by Stromberg et al 1 provides convincing data to settle the ques tion of timing of surgery. The conclusion of their study involving 2,596 patients was that very early CEA, performed within 2 days of an ischaemic event (that is, on the day of symptoms or on either of the follow ing 2 days), has a detrimental effect on outcome.…”

Neues in der Primär- und Sekundärprävention des Schlaganfalls

“…Eine interessante und für den klinischen Alltag relevante Auswertung bezüglich der Komplikationsrate einer Karotis-Thrombendarterektomie (Karotis-TEA) in Abhängigkeit vom Operationszeitraum wurde aus schwedischen Registerdaten veröffentlicht [25]. Insgesamt wurde das Outcome nach Karotis-TEA bei 2596 Patienten untersucht, von denen 2000 prospektiv in die Datenbank eingeschlossen worden waren.…”