Prior Intravenous Stroke Thrombolysis Does not Increase Complications of Carotid Endarterectomy (original) (raw)
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Urgent Carotid Surgery and Stenting May Be Safe After Systemic Thrombolysis for Stroke
Stroke, 2014
The literature on the safety of carotid endarterectomy (CEA) after intravenous thrombolysis (IVT) consists of relatively small series. This study presents the first very large registry based case controlled study on a consecutive series of patients having CEA with or without previous IVT for acute stroke. Equally low procedure related stroke and death rates were found in the two groups. Despite weaknesses in this study, including lack of data on the interval from symptoms to CEA in the control group, the results support the indication that CEA can also be performed within the recommended 2 weeks in patients having had IVT.
Very Early Carotid Endarterectomy After Intravenous Thrombolysis
European Journal of Vascular and Endovascular Surgery, 2016
The timing of carotid endarterectomy (CEA) after intravenous thrombolysis is a controversial issue. Some reports indicate that the surgery soon after thrombolytic therapy is safe. This case series suggests that CEA could be performed very early after thrombolysis, to reduce the risk of recurrence and to save the ischaemic penumbra and improve clinical outcome. Objective/Background: The timing of carotid endarterectomy (CEA) after thrombolysis is still a matter of debate. The aim of this study was to analyse a cohort of patients undergoing urgent endarterectomy after intravenous thrombolysis for acute ischaemic stroke. Methods: This was an observational study. Prospective databases were reviewed and matched to identify patients who underwent CEA early after intravenous thrombolysis (2009e14). The focus was carotid surgery performed within 12 hours of stroke onset in patients with a high grade (!70%) symptomatic carotid stenosis, associated with vulnerable plaques or stroke in evolution, and evidence of a significant salvageable ischaemic penumbra on perfusion computed tomography scan. Demographic and clinical information, as well as data on relevant outcomes were extracted. Results: Thirty four consecutive stroke patients who underwent CEA within 2 weeks of thrombolysis for acute ischaemic stroke and ipsilateral high grade carotid stenosis were identified. In 11 patients the surgical procedure was performed within 12 hours of the onset of symptoms. All patients showed a clinical improvement after combined treatment. The 3 month outcome was favourable (modified Rankin Scale 2) in 10 patients. No haemorrhagic complications were registered. There was neither peri-operative stroke nor stroke within 3 months of surgery. One patient died from acute myocardial infarction 3 days after intervention. Conclusion: This experience suggests that very early CEA after thrombolysis, aimed at removing the source of potential embolisation and restoring blood flow, may be safe and can lead to a favourable outcome.
European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery, 2014
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. 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. 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 0-130, IQR 7-21). The 30 day combined stroke and death rate was 3.5% (95% CI 1.69-6.99) for those having IVT + CEA, 4.1% (95% CI 3.46-4.39) for those having CEA without previous IVT (odds ratio 0.84 [95% CI 0.39-1.81]), 3.4% (95% C...
Stroke From Carotid Endarterectomy: When and How to Reduce Perioperative Stroke Rate?
European Journal of Vascular and Endovascular Surgery, 2001
Objectives: to analyse four years of CEA with respect to the underlying mechanisms of perioperative stroke and the role of intraoperative monitoring in the prevention of stroke. Patients and Methods: from January 1996 through December 1999, 599 CEAs were performed in 404 men and 195 women (mean age: 65 years, range: 39-88). All operations were performed under general anaesthesia using computerised electroencephalography (EEG) and transcranial Doppler (TCD). Any new or any extension of an existing focal cerebral deficit, as well as stroke-related death were registered. Perioperative strokes were classified by time of onset (intraoperative or postoperative), outcome (minor or major stroke), and side (ipsilateral or contralateral). Stroke aetiology was assessed intraoperatively by means of EEG, TCD, completion arteriography or immediate re-exploration, and postoperatively by duplex sonography, computerised tomography (CT) or magnetic resonance imaging (MRI) of the head. , and contralateral ischaemia due to prolonged clamping (1). In three procedures the cause was unknown. Conclusions: in our experience most strokes from CEA developed after a symptom-free interval and mainly due to thromboembolism of the operated artery. We suggest the introduction of additional TCD monitoring during the immediate postoperative phase.
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.
Annals of Vascular Surgery, 2020
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Annals of Vascular Surgery, 2010
Background: The early risk of stroke after transient ischemic attack (TIA)/stroke is of the order of 5-10% at 1 week and 10-20% at 3 months. Even if carotid endarterectomy (CEA) is the treatment of choice in symptomatic internal carotid artery stenosis, the timing of carotid intervention after acute stroke is not yet codified. The authors want to determinate whether early CEA is safely carried out in the first few hours (<48 hours) successive to the nondebilitating neurological event and whether the outcome (TIA/stroke/death) in these cases is comparable with the results of those treated by delayed/deferred surgery (range, 48 hours-24 weeks). Methods: In 4 years, the authors performed 1,184 CEA (285 symptomatic). Five groups were formed from 285 symptomatic patients, according to interval between TIA/stroke onset and performance of CEA: G1, less than 48 hours; G2, 48 hours-2 weeks; G3, 2-4 weeks; G4, 4-8 weeks; G5, 8-24 weeks. Surgery was never performed on patients with disabling neurological deficit (modified Rankin Scale, 5) at the time of admittance, cerebral lesions greater than 3 cm at magnetic resonance/computed tomography scan, presence or suspect of parenchymal hemorrhage associated with ischemic damage, condition considered unfit for surgery (American Society of Anesthesiology classification grade V), and occlusion of the cerebral middle artery. Neurological and diagnostic examinations (duplex-scanning and computed tomography/magnetic resonance scan) were used in determining the selection for early CEA. Results: Cumulative TIA/stroke/death rate after CEA was 3.8% (11/285) and at 30 days was 2.8% (8/285). The cumulative TIA rate after CEA and at 30 days was 0% (0/285). The cumulative stroke rate after CEA was 3.5% (10/285) and at 30 days was 2.4% (7/285). The cumulative death rate after CEA and at 30 days was 0.3% (1/285). Stroke rate after CEA in each group was: G1 4.2% (3/70); G2 3.2% (2/61); G3 0% (0/22); G4 3.4% (1/29); G5 3.8% (4/ 103). Any statistically significant difference between G1 and the other four groups was not detected with regard to postoperative stroke: G1 (4.2%) versus G2 (3.2%), p ¼ 0.7641; G1 (4.2%) versus G3 (0%), p ¼ 0.7648; G1 (4.2%) versus G4 (3.4%), p ¼ 0.8473; G1 (4.2%) versus G5 (3.8%), p ¼ 0.8952. No hemorrhagic stroke was detected after early CEA. The 890 type of anesthesia and the use of a shunt didn't show any significant difference between the five groups. Conclusions: The analysis of these records suggests that early CEA in the acute post stroke phase, for patients clinically selected, does not result in greater complications than when performed delayed or deferred . Furthermore, the advantage of early CEA is the reduction of recurrent strokes, as untreated patients present a higher incidence of neurological events.
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).
European Journal of Vascular and Endovascular Surgery, 2022
Intracranial endovascular thrombectomy (EVT) has revolutionised the care of patients with large vessel acute ischaemic stroke, reducing long term disability, but little is known about how to treat residual concomitant extracranial carotid stenosis. The present study is the first relatively large cohort study on patients treated with carotid endarterectomy (CEA) after successful EVT. Although the results are preliminary, and pending larger studies, and ideally a randomised controlled trial comparing CEA with stenting, it seems safe. Except in cases of large cerebral infarction, CEA can be performed early after EVT, without increased risk of post-operative stroke or death. Objective: Recent randomised controlled trials demonstrated the benefit of intracranial endovascular thrombectomy (EVT) in acute ischaemic stroke.There is no consensus, however, on how to treat concomitant extracranial carotid artery stenosis after EVT. The aim of this study was to evaluate the outcome in patients treated with carotid endarterectomy (CEA) after EVT, comparing complication rates among patients undergoing CEA for stroke without previous EVT. Methods: This was a registry study of all patients (n ¼ 3 780) treated with CEA after stroke in Sweden and the capital Helsinki region, Finland, from January 2011 to September 2020. Sixty three patients (1.7%; 0.5% 2011, 4.3% 2019) underwent EVT prior to CEA. The primary outcome was 30 day stroke and death rate. Results: The EVTþCEA group had major stroke as the qualifying neurological event (QNE) in 79%, but just 5.9% had this in the CEA only group (p < .001). Intravenous thrombolysis was administered before EVT in 54% of patients in the EVTþCEA group, but in just 12% in those receiving CEA only (p < .001). The combined stroke and death rate at 30 days for EVTþCEA was 0.0% (95% confidence interval [CI] 0.0 e 5.7). One patient had a post-operative TIA, none had post-operative intracerebral or surgical site haemorrhage. CEA was performed within a median of seven days (interquartile range 4, 15) after QNE, and 75% had CEA 14 days from QNE. The main reason to postpone CEA was an infarct larger than one third of the middle cerebral artery territory. The stroke and death rate in patients treated with CEA only was 3.7% (95% CI 3.2 e 4.4), CEA was performed a median of eight days after QNE, and in 79.7% in 14 days. The three year survival after EVTþCEA was 93% (95% CI 85 e 100), compared with 87% (95% CI 86 e 88) after CEA only. Cox regression analysis adjusting for age showed no increased all cause mortality after EVTþCEA (HR 1.3, 95% CI 0.6 e 2.7, p ¼ .52). Conclusion: These results indicate that CEA is safe to perform after previous successful EVT for acute ischaemic stroke. Results were comparable with those undergoing CEA only, despite the EVTþCEA patients having more severe stroke symptoms prior to surgery, and timing was similar.