Early carotid endarterectomy after stroke (original) (raw)
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Early carotid endarterectomy after acute stroke
Journal of Vascular Surgery, 2004
Purpose: Carotid endarterectomy (CEA) after acute stroke is generally delayed 6 to 8 weeks because of fear of stroke progression. This delay can result in an interval stroke rate of 9% to 15%. We analyzed our results with CEA performed within 1 to 4 weeks of stroke. Methods: Records for all patients undergoing CEA after stroke between 1980 and 2001 were analyzed. Perioperative evaluation included carotid duplex scanning or angiography, and head computed tomography or magnetic resonance imaging. All patients with nonworsening neurologic status, additional brain territory at risk for recurrent stroke, and severe ipsilateral carotid stenosis underwent CEA. Patients were grouped according to time of CEA after stroke: group 1, first week; group 2, second week; group 3, third week; group 4, fourth week. Statistical analysis was performed with the 2 test, logistic regression, and analysis of variance. Results: Two hundred twenty-eight patients underwent CEA within 1 to 4 weeks of stroke. Perioperative permanent neurologic deficits occurred in 2.8% of patients in group 1 (72 procedures), 3.4% of patients in group 2 (59 procedures), 3.4% of patients in group 3 (29 procedures), and 2.6% of patients in group 4 (78 procedures). There was no relationship between location or size of preoperative infarct and time of surgery. Only preoperative infarct size correlated with probability of neurologic deficit after CEA (P < .05).
Carotid Endarterectomy After Recent Cerebral Infarction
European Journal of Vascular and Endovascular Surgery, 1999
Objectives: whether timing of carotid endarterectomy (CEA) was significant in terms of morbidity and mortality for significant carotid stenosis. Design/materials: comparison was made of patients requiring CEA performed in less than 6 weeks or more than 6 weeks after their stroke. To enable quantification in terms of clinical presentation, aetiology and handicap, standardised scales were incorporated into the registry protocol. A postoperative event was considered to have occurred if a stroke or death from any cause took place within one month of surgery. Results: patients with CEA (n=1005) and stroke numbered 232. Comparison was made of the early (n=86) and late surgery groups (n=121) in terms of demography, risk factors, clinical findings, quantitative neurological deficit, handicap and degree of carotid stenosis with no significant differences found except for race. There was no difference in morbidity and mortality (M+M) between the early and late surgery group. The relative risk (RR) of >6 week group was 1.90 with an odds ratio of ). There is, therefore, a trend of a two-fold risk of MM in the >6 week group. Conclusion: we propose that the historical 6-week wait period for CEA post stroke is outdated.
Timing of carotid endarterectomy in patients with recent stroke
Surgery, 1997
Background. Thme is little oblective data to support the conventional wisdom of waiting 4 to 6 weeks after stroke to improve surgr'cal outcome of subsequent carotid endarterectomy (CEA). I4'P have aggressively pursued CEA in patients after recent stroke; in this study we report our results. Methods. TG performed 215 CEA /J >ocedures in 200 patients who presented with an indication of stroke within 6 months of C&L Cervical block anesthesia was used 193 cases. The rest woe @e$ormed with the patient under general anesthesza. Results. Perioperative stroke rate was 1.4 %I (3/215), and operatrve mortality was 2 % (g/ZOO) (stroke mortality = 3.4 70 j. There were four early occlusions. Shunts were used in 13.970, patch closure in 8.4 %, and eversion endarterectomy in 48 % of cases. There was no correlation between timi)~,g of surgery, extent of izfar-ct on computed tomopaphy/magnetic resonence imap'ng, and postoperative neurologic complications with the occurrence of postoperative stroke ($ = NS). During the same period, 1,922 patients underwent CE4 for indications other th,an stroke, with a pnioperatzve stroke rate and mortality rate of 1.1 7~. Conclusions. Selected patients Presenting with a history of stroke and sign#cant carotid artery disease can safely undergo early GEL4 with a mortality and ,morbidity comparable to patients rtndergoi,ng CEA for other5ndications.
Journal of Vascular Surgery, 2002
Objective: The purpose of this study was to examine the safety of carotid endarterectomy (CEA) wtihin 6 weeks after a nondisabling carotid-related ischemic stroke. Endpoints were the perioperative stroke or mortality rate and the incidence rate of cerebral bleedings. Methods: This prospective observational multicenter trial was performed in community and university centers. One hundred sixty-four hospitalized patients with nondisabling carotid-related ischemic stroke were included. The patients were identified clinically with the modified Rankin scale (initial neurologic deficit grade > 2, n ؍ 160). Four patients with evidence of ischemic territorial infarction on cerebral computed tomographic (CT) scan but no persisting functional deficit were also included. CEA was performed within 6 weeks after stroke. Neurologic examinations were performed initially, before surgery, 3 days after surgery, and 6 weeks after CEA. Worsening of more than 1 grade on the Rankin scale was considered as a new stroke or stroke extension. Unenhanced CT scans of the brain were performed before and after surgery. CT scans were evaluated blind to clinical patient data. Statistical analysis included univariate and multivariate analysis. Results: The combined stroke or mortality rate within 30 days after CEA was 6.7%. Ten patients had a new ipsilateral stroke or stroke extension, and one patient died after surgery of a myocardial infarction. One patient (0.6%) had parenchymatous cerebral bleeding, and in 10 patients, hemorrhagic transformation within the preexisting ischemic infarction was detected but no infarct extension was observed. In the multivariate analysis, American Society of Anesthesiology (ASA) grades III and IV and decreasing age were significant predictors for an increased perioperative risk. Patients with a higher risk profile (ASA classification grades III and IV) had a high perioperative risk when CEA was performed within the first 3 weeks (14.6% versus 4.8% beyond 3 weeks). Patients without severe concomitant diseases (ASA grades I/II) had a low perioperative risk of 3.4% if CEA was performed within the first 3 weeks. Conclusion: Early CEA within 6 weeks after a carotid-related ischemic stroke can be performed with a perioperative stroke or mortality rate comparable with the results reported in the European Carotid Surgery Trial and the North American Symptomatic Carotid Endarterectomy Trial. The risk of parenchymatous bleeding is low. ASA grades III and IV and decreasing age were predictive of an increased perioperative risk, especially if CEA was performed within the first 3 weeks. Patients at low risk can undergo operation safely within the first 3 weeks. Individual patient selection in an interdisciplinary approach between neurologists, anesthesiologists, and vascular surgeons remains mandatory in these patients. (J Vasc Surg 2002;36:997-1004.)
Carotid Endarterectomy within 2 weeks of minor ischemic stroke: A prospective study
Journal of Vascular Surgery, 2008
Objective: Data from multicenter symptomatic trials have shown that benefit from carotid endarterectomy (CEA) was greatest in patients with carotid disease operated within 2 weeks of their last ischemic event. We prospectively analyzed the safety and benefit of CEA performed within 2 weeks of a stroke. Methods: The study involved patients with acute minor stroke admitted to two stroke units who underwent CEA within 2 weeks of their last ischemic event, once they were considered neurologically stable. Preoperative workup included scoring ischemia-related symptoms according to a modified ranking scale (mRS), carotid duplex scan, transcranial Doppler ultrasound, and head computed tomography or magnetic resonance imaging. All patients underwent neurological assessment on admission, 1 day before and 2 days after CEA, and at discharge. A complete neurological and ultrasound follow-up was performed at 1, 6, and 12 months after CEA, then yearly. All procedures were eversion CEA under deep general anesthesia, with selective shunting. Endpoints were perioperative (30-day) stroke/mortality rate or cerebral bleeding and long-term stroke recurrence or cerebral hemorrhage. Results: Between 2000 and 2005, 102 patients with a mRS < 2 underwent CEA within a median 8 days of acute ischemic stroke. Shunting and contralateral carotid occlusion were found significantly correlated. There were no perioperative strokes or deaths, or cerebral hemorrhage. All patients were followed up for a mean 34 months (range 1-66) with no recurrent stroke or cerebral bleeding. Conclusions: CEA can be performed within 2 weeks of carotid-related ischemic stroke with no perioperative stroke or cerebral bleeding, preventing the risk of stroke recurrence. ( J Vasc Surg 2008;48:595-600.)
Timing of carotid endarterectomy and clinical outcomes
Annals of Translational Medicine
The timing of carotid endarterectomy (CEA) for symptomatic ipsilateral carotid artery stenosis has evolved in practice over time. Key landmark trials outlined the benefit of performing CEA in the recently symptomatic carotid artery stenosis, defined as revascularisation within 6 months of the index neurological event. Further evidence and sub-analysis demonstrate that performing CEA within 2 weeks of symptoms has the maximal benefit in reducing stroke free survival and is associated with a safe perioperative complication profile. This has translated into guideline recommendations and widespread clinical practice. The case for performing urgent CEA (within 48 hours of index neurological event) over early CEA (within 2 weeks) has been put forward and studied. Data examining perioperative complications for urgent CEA are mostly derived from retrospective single series studies. A moderate balance exists in the literature for the safety and risk of urgent CEA. Although many studies present acceptable perioperative stroke and mortality rates associated with urgent CEA, evidence still exists that the perioperative complications may not be insignificant. This is particularly the case if the presenting neurology is a stroke, rather than a transient ischaemic attack (TIA) or amaurosis fugax. This should be contextualised in the practice of modern aggressive medical therapy with dual antiplatelets and statins, with evidence suggesting a reduction in recurrent ischaemic events prior to surgical intervention. Careful patient selection, presenting neurology and medical therapy is likely to be a key feature in considering urgent CEA versus early CEA.
European Journal of Vascular and Endovascular Surgery, 2012
This study demonstrates how it is possible to shorten the delay to carotid endarterectomy among patients with symptomatic carotid stenosis with quite simple changes made in the surgical and the neurological unit. However, affecting only the in-hospital delay, optimal results are still not achieved, as our study corroborates. At the same time, our study points out the areas where we could and should still focus more carefully in order to minimise the delay and maximise the expected benefit in stroke prevention.
European Journal of Neurology, 2018
Background and purposeInternational recommendations advocate that carotid endarterectomy (CEA) should be performed within 2 weeks from the index event in symptomatic carotid artery stenosis (sCAS) patients. However, there are controversial data regarding the safety of CEA performed during the first 2 days of ictus. The aim of this international, multicenter study was to prospectively evaluate the safety of urgent (0–2 days) in comparison to early (3–14 days) CEA in patients with sCAS.MethodsConsecutive patients with non‐disabling (modified Rankin Scale scores ≤2) acute ischaemic stroke or transient ischaemic attack due to sCAS (≥70%) underwent urgent or early CEA at five tertiary‐care stroke centers during a 6‐year period. The primary outcome events included stroke, myocardial infarction or death during the 30‐day follow‐up period.ResultsA total of 311 patients with sCAS underwent urgent (n = 63) or early (n = 248) CEA. The two groups did not differ in baseline characteristics with ...