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Editor's Choice - Delays to Surgery and Procedural Risks Following Carotid Endarterectomy in the UK National Vascular
I M Loftus1, K I Paraskevas1, A Johal2
1St. George's Vascular Institute, St. George's Healthcare NHS Trust, London, UK.
Insights
The time for carotid endarterectomy (CEA) after transient ischaemic attack (TIA) or stroke has decreased, but 42% of patients still face delays. Rapid intervention within 48 hours may slightly increase stroke risk.
Area of Science:
- Vascular surgery
- Neurology
- Public health
Background:
- Guidelines recommend carotid endarterectomy (CEA) within 14 days for transient ischaemic attack (TIA) or stroke patients with carotid artery stenosis.
- This study evaluated UK vascular unit adherence to this guideline and the impact of rapid intervention on procedural risks.
Discussion:
- While the median time to CEA decreased significantly between 2009 and 2014, 42% of patients still exceeded the 14-day recommendation.
- Improvements were observed across the entire care pathway, from symptom onset to surgical intervention.
- Hospital volume did not significantly impact the improvement in treatment times.
Key Insights:
- The proportion of patients treated within 14 days increased from 37% to 58% over the study period.
- Performing CEA within 48 hours of symptom onset was associated with a small increase in 30-day stroke and death rates (3.1% vs. 2.0%).
Outlook:
- Further efforts are needed to ensure all patients receive timely CEA within the recommended 14-day window.
- The findings suggest a potential trade-off between speed and safety for very early interventions (within 48 hours).
- Continued monitoring of outcomes and adherence to guidelines is crucial for optimizing patient care in cerebrovascular disease.
Objective:
Guidelines recommend that patients suffering an ischaemic transient ischaemic attack (TIA) or stroke caused by carotid artery stenosis should undergo carotid endarterectomy (CEA) within 14 days.
Method:
The degree to which UK vascular units met this standard was examined and whether rapid interventions were associated with procedural risks. The study analysed patients undergoing CEA between January 2009 and December 2014 from 100 UK NHS hospitals. Data were collected on patient characteristics, intervals of time from symptoms to surgery, and 30-day postoperative outcomes. The relationship between outcomes and time from symptom to surgery was evaluated using multilevel multivariable logistic regression.
Results:
In 23,235 patients, the median time from TIA/stroke to CEA decreased over time, from 22 days (IQR 10-56) in 2009 to 12 days (IQR 7-26) in 2014. The proportion of patients treated within 14 days increased from 37% to 58%. This improvement was produced by shorter times across the care pathway: symptoms to referral, from medical review to being seen by a vascular surgeon, and then to surgery. The spread of the median time from symptom to surgery among NHS hospitals shrank between 2009 and 2013 but then grew slightly. Low-, medium-, and high-volume NHS hospitals all improved their performance similarly. Performing CEA within 48 h of symptom onset was associated with a small increase in the 30-day stroke and death rate: 3.1% (0-2 days) compared with 2.0% (3-7 days); adjusted odds ratio 1.64 (95% CI 1.04-2.59) but not with longer delays.
Conclusions:
The delay from symptom to CEA in symptomatic patients with ipsilateral 50-99% carotid stenoses has reduced substantially, although 42% of patients underwent CEA after the recommended 14 days. The risk of stroke after CEA was low, but there may be a small increase in risk during the first 48 h after symptoms.
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