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Very urgent carotid endarterectomy does not increase the procedural risk
B Rantner1, C Schmidauer2, M Knoflach2
1Department of Vascular Surgery, Innsbruck Medical University, Innsbruck, Austria.
Insights
Urgent carotid endarterectomy (CEA) for symptomatic internal carotid artery stenosis does not increase procedural risk. Prompt surgery offers the greatest benefit for stroke prevention in patients with neurological symptoms.
Area of Science:
- Vascular Surgery
- Neurology
- Cardiovascular Medicine
Background:
- The optimal timing for carotid endarterectomy (CEA) in symptomatic internal carotid artery (ICA) stenosis is debated.
- Registry data suggest increased risks in the hyperacute phase post-symptom onset.
- This study investigates CEA outcomes in the hyperacute phase.
Purpose of the Study:
- To evaluate the safety and efficacy of CEA performed in the hyperacute phase for symptomatic ICA stenosis.
- To determine if early surgical intervention impacts peri-operative stroke and death rates.
Main Methods:
- Retrospective analysis of 761 patients undergoing CEA for symptomatic ICA stenosis (2004-2013).
- Patients categorized into four surgical timing groups: 0-2 days, 3-7 days, 8-14 days, and >14 days post-symptom onset.
- Assessed 30-day peri-operative stroke and death rates.
Main Results:
- Overall peri-operative stroke and death rate was 3.3%.
- No significant difference in stroke/death rates observed across timing groups (4.4% for 0-2 days vs. 1.8% for 3-7 days, etc.; p=0.25).
- Multivariate analysis confirmed timing did not influence peri-operative outcome (OR 0.93, p=0.71).
Conclusions:
- Carotid endarterectomy in the hyperacute phase for symptomatic ICA stenosis can be performed safely.
- Early intervention is recommended to maximize stroke prevention benefits.
- Prompt treatment of ruptured plaques causing neurological symptoms is crucial.
Objectives:
The timing of CEA for symptomatic internal carotid artery (ICA) stenosis remains a matter of controversy. Recent registry data showed a significantly increased risk, especially in the very early days after the onset of symptoms. In this study the outcome of CEA in the hyperacute phase has been investigated.
Methods:
The outcome of CEA for symptomatic ICA stenosis between January 2004 and December 2013 has been retrospectively analyzed. Patients were divided into four timing groups: surgery within 0 and 2 days, between 3 and 7 days, 8 and 14 days, and thereafter. The post-operative 30 day stroke and death rates were assessed.
Results:
A total of 761 symptomatic patients (40.1% with transient ischemic attack [TIA], 21.3% with amaurosis fugax, and 38.6% with ischemic stroke) were included, with an overall peri-operative stroke and death rate of 3.3%. A stroke and death rate of 4.4% (9/206) for surgery within 0 and 2 days, 1.8% (4/219) between 3 and 7 days, 4.4% (6/136) between 8 and 14 days, and 2.5% (5/200) in the period thereafter (p = .25 for the difference between the groups) was observed. The timing of surgery did not influence the peri-operative outcome in a multivariate regression analysis (OR 0.93 [0.63-1.36], p = .71).
Conclusions:
These data show that very urgent surgery in symptomatic patients can be performed without increased procedural risk. Given the fact that ruptured plaques with neurological symptoms carry the highest risk of a recurrent ischemic event in the first 2 days, treating patients as soon as possible to offer the highest benefit in stroke prevention is recommended.
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