Timing of carotid endarterectomy and clinical outcomes

The timing of carotid endarterectomy (CEA) for symptomatic ipsilateral carotid artery stenosis has evolved in practice over time. Key landmark trials outlined the benefit of performing CEA in the recently symptomatic carotid artery stenosis, defined as revascularisation within 6 months of the index neurological event. Further evidence and sub-analysis demonstrate that performing CEA within 2 weeks of symptoms has the maximal benefit in reducing stroke free survival and is associated with a safe perioperative complication profile. This has translated into guideline recommendations and widespread clinical practice. The case for performing urgent CEA (within 48 hours of index neurological event) over early CEA (within 2 weeks) has been put forward and studied. Data examining perioperative complications for urgent CEA are mostly derived from retrospective single series studies. A moderate balance exists in the literature for the safety and risk of urgent CEA. Although many studies present acceptable perioperative stroke and mortality rates associated with urgent CEA, evidence still exists that the perioperative complications may not be insignificant. This is particularly the case if the presenting neurology is a stroke, rather than a transient ischaemic attack (TIA) or amaurosis fugax. This should be contextualised in the practice of modern aggressive medical therapy with dual antiplatelets and statins, with evidence suggesting a reduction in recurrent ischaemic events prior to surgical intervention. Careful patient selection, presenting neurology and medical therapy is likely to be a key feature in considering urgent CEA versus early CEA.