Timing of carotid endarterectomy in patients with recent 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).
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.
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.)
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.)
Prior Intravenous Stroke Thrombolysis Does not Increase Complications of Carotid Endarterectomy
Journal of Vascular Surgery, 2018
Background and Purpose-Carotid endarterectomy (CEA) is recommended within 14 days after carotid artery stroke to prevent recurrence. However, the optimal timing of CEA after intravenous thrombolysis (IVT) remains unclear. We studied the safety of CEA after IVT while taking into account both stroke recurrence and CEA-related complications. Methods-Patients who underwent IVT followed by CEA in Helsinki University Hospital 2005 to 2016 were withdrawn from prospectively collected registers. The incidence of stroke recurrence during the time between IVT and CEA, peri/ postoperative stroke, hyperperfusion syndrome or drug-resistant high blood pressure, and 3-month outcome measured by modified Rankin Scale was recorded. Stroke patients treated with CEA without preceding IVT were used as controls. Results-Altogether 128 CEAs with preceding IVT and 777 CEAs for stroke without IVT were identified. The median time from IVT to CEA was 9 days (range, 0-349 days; interquartile range, 16). Seven patients (5.5%) underwent CEA within 24 hours, 20 (15.6%) within 48 hours and 87 (68.0%) within 2 weeks from IVT. Stroke recurrence in IVT-CEA patients was 5.5% at median 4 days after IVT (range, 0-8 days). Outcome from CEAs performed within 48 hours from IVT did not differ from CEAs performed later with respect to peri/postoperative ischemic strokes (5.0% and 3.7%), hemorrhagic strokes (5.0% and 1.9%), neck hematomas (5.0% and 8.3%), myocardial infarctions (0.0% and 0.9%), or 3-month modified Rankin Scale. There was a tendency toward higher incidence of hyperperfusion syndrome in the patients operated within 48 hours from IVT (20.0% versus 6.5%; P=0.070). The CEA-related stroke rate was similar to that of the operation without thrombolysis. Only smoking was significantly associated with peri/postoperative stroke (odds ratio, 21.82; 95% confidence interval, 1.08-439.58). Conclusions-Time between IVT and CEA was not associated with CEA-related complications. The high rate of stroke recurrence during the waiting time for CEA underscores the importance of shortening surgery delays.
Early carotid endarterectomy after stroke
Cardiovascular Surgery, 2000
The authors sought to determine if patients with stroke and a high-grade carotid stenosis benefited from a delay before carotid endarterectomy. A retrospective study of 45 patients undergoing carotid endarterectomy after stroke is presented. The patients were divided into two groups: group I (early group, n ϭ 20), composed of patients who had carotid endarterectomy less than 6 weeks after stroke, and group II (late group, n ϭ 25), comprised of patients who had carotid endarterectomy more than 6 weeks after stroke. As assessed by cerebral angiography, 100% of patients in group I and 64% of patients in group II had carotid artery stenoses > 76% (P Ͻ 0.001). The median interval from stroke to carotid endarterectomy was 14 days in group I and 129 days in group II. There was no mortality in either group. No patients in either group demonstrated any neurological deterioration. The authors conclude that, in select patients, carotid endarterectomy may be done safely less than 6 weeks after stroke in order to avoid new events or carotid occlusion while awaiting surgery.
Carotid Endarterectomy for Stroke Prevention
Introduction: Several randomized trials now have established guidelines regarding patient selection for zarotid endarterectomy (CEA) that have been widely accepted but have little relevance unless they are considered in the context ofperioperative risk. The Purpose of this study was to demonstrate the feasibility of zarly outcome assessment for stroke prevention. Material and methods: Since 1993 demographic information and in hospital results for all C.E.A performed by pur department have been entered into a prospective registry for the purpose of this report, we have analyzed the stroke and mortality rates for 369 consecutive CEAs (358 patients) including 355 that were oerformed as isolated operations and 14 that were combined with simultaneous coronary artery bypass grafting 'CABG). Minor complications like, transient nerve injuries which recovered completely, wound hematoma v .hat did not require evacuation or blood transfusion and wound infection which did not require any intervention uere not included in this study. Conclusions: Prospective outcome assessment is essential to reconcile the indications for CEA with its actual ••esults and it may lead incidentally to important observations concerning patient care. (J. Vase Surg 1997; 26: 1-10). To conclude, CEA is a safe procedure with a beneficial role in stroke prevention but strict selection -.riteria and precise and safe operative details must be adhered to, to prevent the procedure from going into iisrepute. It has a learning curve, which is evident from our experience.__________________________
Journal of Vascular Surgery, 2012
This study documented with independent neurologic assessment the 30-day and 90-day outcomes in selected patients with severe internal carotid artery (ICA) stenosis who underwent carotid endarterectomy (CEA) in the acute phase of stroke-in-evolution (SIE). From January 2003 to December 2010, data from patients who had surgery ≤2 weeks of an SIE with high-grade carotid stenosis were extracted from two prospectively collected databases. Clinical assessment was by the vascular neurologist using the National Institute of Health Stroke Scale (NIHSS) and the modified Rankin Scale score. All patients had computed tomography or magnetic resonance brain imaging ≤3 hours of stroke onset. Those eligible received thrombolysis. Duplex ultrasound imaging was initially used for the diagnosis of severe (≥60%) ICA stenosis, and further assessment was by magnetic resonance or computed tomography angiography, or both. Perioperative medical treatment and operative techniques were standardized. Stroke, death, major cardiac events, and functional outcome were analyzed. Twenty-seven patients underwent carotid revascularization in the acute phase of SIE. Fluctuating or progressive neurologic deficit was the presenting pattern in 20 patients and occurred after otherwise successful thrombolytic therapy in the remaining 7 (26%). Median NIHSS score at admission was 8. Median delay to surgery from the index event was 6 days. The mean degree of ICA stenosis was 87%. All patients received antiplatelet and statin therapy during the intervening period. Procedures were conventional CEA with patch angioplasty (polytetrafluoroethylene) in 26 patients (96.3%) and redo interposition bypass grafting in 1 patient. CEA was done under local anesthesia in 23 patients (85.2%), with selective shunting in 3 (13.0%), and under general anesthesia, with systematic shunting in 4. At discharge and at 1 and 3 months, no recurrent stroke or death, and one nonfatal myocardial infarction occurred in this series, with a 100% complete follow-up. At 3 months, all patients had a favorable functional outcome defined as a modified Rankin Scale score of ≤2. This short series demonstrates that CEA in the acute phase of SIE with strict selection criteria and close blood pressure monitoring is safe, even after recent thrombolytic therapy, and is effective in functional outcome at 3 months. Larger series of patients are required to confirm the safety and efficacy of this management.