A Systematic Review and Meta-analysis of Peri-Procedural Outcomes in Patients Undergoing Carotid Interventions
Stavros K Kakkos1, Melina Vega de Ceniga2, Ross Naylor3
1Department of Vascular Surgery, University Hospital of Patras, Patras, Greece.
Insights
Thrombolytic therapy (TT) increases risks for stroke, death, and intracranial hemorrhage (ICH) after carotid artery stenting (CAS) or endarterectomy (CEA). Deferring CEA for six to seven days after TT may reduce these peri-procedural risks.
Area of Science:
- Vascular Surgery
- Neurology
- Interventional Cardiology
Background:
- Thrombolytic therapy (TT) is crucial for acute ischemic stroke but may increase risks for subsequent cerebrovascular procedures.
- Carotid artery stenting (CAS) and carotid endarterectomy (CEA) are common interventions for carotid artery stenosis.
- The safety of performing CAS or CEA after TT requires careful evaluation.
Purpose of the Study:
- To assess the safety of carotid artery stenting (CAS) and carotid endarterectomy (CEA) in patients who have received thrombolytic therapy (TT).
- To compare peri-procedural risks, including stroke, death, and intracranial hemorrhage (ICH), between CAS and CEA following TT.
- To investigate the impact of the time interval between TT and intervention on procedural outcomes.
Main Methods:
- Systematic review and meta-analysis of studies indexed in Medline, Scopus, and Cochrane databases.
- Inclusion of 25 studies with a total of 147,810 patients undergoing CEA or CAS after TT.
- Comparative analysis of outcomes between patients receiving TT versus those not receiving TT, and meta-regression to assess timing effects.
Main Results:
- Higher pooled peri-procedural stroke/death rates (14.9%) and ICH (5.5%) were observed after CAS compared to CEA (stroke/death 5.2%, ICH 3.4%) following TT.
- Patients undergoing CEA after TT showed significantly higher rates of ICH (2.2% vs. 0.12%) and local hematoma compared to those without TT.
- CAS after TT was associated with significantly higher peri-procedural stroke/death (5.2% vs. 1.5%) and ICH (5.4% vs. 0.7%).
- Meta-regression revealed an inverse association between time from TT to CEA and stroke/death risk, with risks decreasing significantly after six to seven days.
Conclusions:
- Peri-procedural intracranial hemorrhage and local hematoma are more frequent after CEA in patients who received TT.
- Carotid artery stenting after TT is associated with significantly higher peri-procedural stroke/death and ICH rates.
- Deferring CEA for six to seven days after TT is recommended to mitigate peri-procedural stroke/death risks.
Objective:
To evaluate the safety of carotid artery stenting (CAS) and carotid endarterectomy (CEA) after thrombolytic therapy (TT).
Data Sources:
Medline, Scopus, and Cochrane databases.
Review Methods:
Systematic review and meta-analysis of studies involving patients who underwent CEA/CAS after TT.
Results:
In 25 studies (n = 147 810 patients), 2 557 underwent CEA (n = 2 076) or CAS (n = 481) following TT. After CEA, the pooled peri-procedural stroke/death rate was 5.2% (95% confidence interval [CI] 3.3 - 7.5) and intracranial haemorrhage (ICH) was 3.4% (95% CI 1.7 - 5.6). After CAS, the pooled peri-procedural stroke/death rate was 14.9% (95% CI 11.9 - 18.2) and ICH was 5.5% (95% CI 3.7 - 7.7). In case control studies comparing CEA outcomes in patients receiving TT vs. no TT, peri-procedural death/stroke was non-significantly higher after TT (4.3% vs. 1.5%; odds ratio [OR] 2.34, 95% CI 0.74 - 7.47), but ICH was significantly higher after TT (2.2% vs. 0.12%; OR 7.82, 95% CI 4.07 - 15.02), as was local haematoma formation (3.6% vs. 2.26%; OR 1.17, 95% CI 1.17 - 2.33). In case control studies comparing CAS outcomes in patients receiving TT vs. no TT, peri-procedural stroke/death was significantly higher after TT (5.2% vs. 1.5%; OR 8.49, 95% CI 2.12 - 33.95) as was ICH (5.4% vs. 0.7%; OR 7.48, 95% CI 4.69 - 11.92). Meta-regression analysis demonstrated an inverse association between the time interval from intravenous (IV) TT to undergoing CEA and the risk of peri-procedural stroke/death (p = .032). Peri-operative stroke/death was 13.0% when CEA was performed three days after TT and 10.6% when performed four days after TT, with the risk reducing to within the currently accepted 6% threshold after six-seven days had elapsed.
Conclusion:
Peri-procedural ICH and local haematoma were significantly more frequent in patients undergoing CEA after TT (vs. no TT), although there were no randomised comparisons. Peri-procedural hazards were also significantly higher for CAS after TT. The inverse relationship between timing to CEA and peri-procedural stroke/death mandates careful patient selection and suggests that it may be safer to defer CEA for six-seven days after TT.
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