Timing of procedural stroke and death in asymptomatic patients undergoing carotid endarterectomy: individual patient
M H F Poorthuis1,2,3, R Bulbulia1,2, D R Morris1,2
1Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK.
Insights
Carotid endarterectomy (CEA) complications, including stroke, occur frequently on surgery day and after discharge. Understanding complication timing is crucial for stroke prevention and safe patient discharge after CEA.
Area of Science:
- Vascular Surgery
- Neurology
- Public Health
Background:
- Carotid endarterectomy (CEA) is vital for stroke prevention.
- Low procedural risk is essential for CEA effectiveness.
- Assessing CEA complication frequency and timing aids in understanding mechanisms and informing discharge policies.
Purpose of the Study:
- To evaluate the frequency and timing of procedural complications following CEA.
- To provide data that can inform safe discharge protocols after CEA.
- To clarify mechanisms underlying CEA-related complications.
Main Methods:
- Analysis of individual patient data from four major carotid intervention trials (VACS, ACAS, ACST-1, GALA).
- Inclusion of patients undergoing CEA for asymptomatic carotid artery stenosis.
- Categorization of procedural death and stroke timing: intraoperative day 0, postoperative day 0, days 1-3, and days 4-30.
Main Results:
- 2.8% of 3694 patients experienced serious procedural complications.
- 68 non-fatal strokes and 18 fatal strokes occurred, with 78% ipsilateral to the treated artery.
- Half of all serious complications occurred on day 0, with 35% occurring between days 4-30.
Conclusions:
- Half of procedural strokes were ischemic and ipsilateral.
- Significant complications occur post-discharge (days 4-30), impacting patient safety.
- Findings emphasize the need for careful monitoring and tailored discharge planning post-CEA.
Background:
The effectiveness of carotid endarterectomy (CEA) for stroke prevention depends on low procedural risks. The aim of this study was to assess the frequency and timing of procedural complications after CEA, which may clarify underlying mechanisms and help inform safe discharge policies.
Methods:
Individual-patient data were obtained from four large carotid intervention trials (VACS, ACAS, ACST-1 and GALA; 1983-2007). Patients undergoing CEA for asymptomatic carotid artery stenosis directly after randomization were used for the present analysis. Timing of procedural death and stroke was divided into intraoperative day 0, postoperative day 0, days 1-3 and days 4-30.
Results:
Some 3694 patients were included in the analysis. A total of 103 patients (2·8 per cent) had serious procedural complications (18 fatal strokes, 68 non-fatal strokes, 11 fatal myocardial infarctions and 6 deaths from other causes) [Correction added on 20 April, after first online publication: the percentage value has been corrected to 2·8]. Of the 86 strokes, 67 (78 per cent) were ipsilateral, 17 (20 per cent) were contralateral and two (2 per cent) were vertebrobasilar. Forty-five strokes (52 per cent) were ischaemic, nine (10 per cent) haemorrhagic, and stroke subtype was not determined in 32 patients (37 per cent). Half of the strokes happened on the day of CEA. Of all serious complications recorded, 44 (42·7 per cent) occurred on day 0 (20 intraoperative, 17 postoperative, 7 with unclear timing), 23 (22·3 per cent) on days 1-3 and 36 (35·0 per cent) on days 4-30.
Conclusion:
At least half of the procedural strokes in this study were ischaemic and ipsilateral to the treated artery. Half of all procedural complications occurred on the day of surgery, but one-third after day 3 when many patients had been discharged.
