Outcomes of Preferential Early Carotid Endarterectomy following Recent Stroke

With the risk of recurrent ischemic stroke being highest in the first week following transient ischemic attack or stroke, the current guidelines of "early" endarterectomy within 2 weeks still leave potential vulnerability for patients with a significant bifurcation lesion and a new stroke. The intent of this analysis is to determine the safety of carotid endarterectomy even earlier than the current guidelines, based on a single surgeon experience of more than 12 years.

Although there has been a progressive movement toward earlier intervention following acute ischemic stroke in the presence of a culprit bifurcation lesion, most of the recommendations still are for performance of endarterectomy within two weeks following the event. This compression is welcome but given that the risk of recurrent stroke is highest within the first week following stroke, there is a reason to evaluate an earlier time frame for carotid endarterectomy (CEA).

A retrospective review of all CEA performed by a single surgeon over a 12-year period was performed. Patient demographics, Modified Rankin score (mRS) whenever documented, degree of internal carotid artery (ICA) stenosis, and preoperative neurologic symptoms were recorded. The 30-day outcomes including stroke, transient ischemic attack, death, and other major complications were tabulated.

A total of 444 patients (mean age 74 ± 10.1) underwent a total of 465 CEAs. Two hundred and twenty-eight (49%) CEAs were for a symptomatic disease: of these, 194 had a documented stroke. One hundred and eighty-one stroke patients (93%) underwent CEA within 72 hr and the remaining 13 patients within 5 days. Of the stroke cohort, for whom the mRS was available, the mean preCEA mRS was 3.4. One patient in the stroke cohort had a postoperative stroke (0.5%, 1/194). In the total CEA cohort, there were 3 total postoperative strokes (0.6%, 3/465). There was one death in the total cohort (0.2%). The mean operative time was 45 min ± 4 min.

Early CEA for recurrent stroke prevention can be performed safely, at an earlier time frame than current recommendations. Given the safety of early CEA and the risk of recurrent stroke, CEA for stroke is best done early with no additional increase in morbidity or mortality.