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Editor's Choice - Very Urgent Carotid Endarterectomy is Associated with an Increased Procedural Risk: The Carotid
A Nordanstig1, L Rosengren1, S Strömberg2
1Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden; Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden.
Insights
Carotid endarterectomy (CEA) within 48 hours of a stroke carries a higher risk of complications. Surgery between 48 hours and 14 days post-event is associated with better outcomes for patients with carotid stenosis.
Area of Science:
- Vascular Surgery
- Neurology
- Clinical Outcomes Research
Background:
- Carotid endarterectomy (CEA) is a procedure to prevent stroke in patients with symptomatic carotid stenosis.
- The optimal timing for CEA following a cerebrovascular ischemic event is debated.
- Early intervention aims to reduce recurrent ischemic events, but may increase procedural risk.
Purpose of the Study:
- To compare the procedural risk of CEA performed within 48 hours versus 48 hours to 14 days after an ischemic event.
- To evaluate the composite endpoint of death and/or stroke within 30 days of CEA.
- To identify factors associated with increased risk in CEA procedures.
Main Methods:
- Prospective recruitment of consecutive patients with symptomatic carotid stenosis undergoing CEA.
- Calculation of time from the most recent ischemic event to surgery.
- Neurological examination pre- and post-CEA.
- Primary endpoint: composite of death and/or any stroke within 30 days.
Main Results:
- The study included 418 patients; 75 underwent CEA within 48 hours.
- CEA within 48 hours was associated with a higher risk of the primary endpoint (8.0% vs. 2.9%).
- Independent risk factors for complications included CEA within 48 hours, out-of-office-hours surgery, and shunt use.
Conclusions:
- CEA performed within 48 hours of an ischemic event is linked to increased complication risk.
- Delayed CEA (48 hours to 14 days) appears safer for patients with carotid stenosis.
- Surgical timing and perioperative factors significantly influence CEA outcomes.
Objective/Background:
The aim of the Carotid Alarm Study was to compare the procedural risk of carotid endarterectomy (CEA) performed within 48 hours with that after 48 hours to 14 days following an ipsilateral cerebrovascular ischaemic event.
Methods:
Consecutive patients with symptomatic carotid stenosis undergoing CEA were prospectively recruited. Time to surgery was calculated as time from the most recent ischaemic event preceding surgery. A neurologist examined patients before and, after CEA. The primary endpoint was the composite endpoint of death and/or any stroke within 30 days of the surgical procedure. The study was designed to include 600 patients, with 150 operated on within 48 hours.
Results:
From October 2010 to December 2015, 418 patients were included, of whom 75 were operated within 48 hours of an ischaemic event. The study was prematurely terminated owing to the slow recruitment rate in the group operated on within 48 hours. Patients undergoing CEA within 48 hours had a higher risk of reaching the primary endpoint than those operated on later (8.0% vs. 2.9%). Multivariate logistic regression analyses showed that CEA performed within 48 h (odds ratio [OR] 3.07; 95% confidence interval [CI] 1.04-9.09), CEA performed out of office hours (OR 3.65; 95% CI 1.14-11.67), and use of shunt (OR 4.02; 95% CI 1.36-11.93) were all independently associated with an increased risk of reaching the primary endpoint.
Conclusion:
CEA performed within 48 hours was associated with a higher risk of complications compared with surgery performed 48 hours-14 days after the most recent ischaemic event.
