Thrombolysis and expedited carotid revascularization

Area of Science:

• Vascular Surgery
• Neurology
• Interventional Cardiology

Background:

• Expedited carotid endarterectomy (CEA) is increasingly considered for patients with transient ischemic attack/minor stroke.
• Intravenous thrombolysis is now standard for acute ischemic stroke within 3 hours.
• This creates a need to determine optimal timing for CEA after thrombolysis in patients with significant internal carotid artery stenosis.

Purpose of the Study:

• To evaluate the safety and optimal timing of carotid endarterectomy (CEA) following intravenous thrombolysis.
• To assess the perioperative risks, including intracranial hemorrhage (ICH) and further embolization, associated with early CEA after thrombolysis.

Main Methods:

• Systematic review of 13 series including 361 patients who underwent CEA after thrombolysis.
• Analysis of 30-day death/stroke rates and prevalence of ICH.
• Comparison of outcomes for CEA performed at different intervals post-thrombolysis.

Main Results:

• Most CEAs were performed within 14 days of thrombolysis, with a small proportion (<5%) expedited.
• The overall 30-day death/stroke rate was 3.6% (13/361), and ICH prevalence was 2.5% (4/159).
• Most studies found no increased procedural risk with early CEA, but one noted higher ICH risk if performed <72 hours.

Conclusions:

• Carotid endarterectomy (CEA) appears safe when performed within 14 days of thrombolysis.
• The safety of CEA performed within 72 hours of thrombolysis remains uncertain due to potential increased ICH risk.
• Aggressive management of post-CEA hypertension is crucial for surgical outcomes.