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Urgent Carotid Artery Revascularization Fraught with Higher Rates of Neurovascular Events in Symptomatic Carotid
Camilo Polania-Sandoval1, James F Meschia2, Josephine Huang2
1Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL.
Insights
Urgent carotid revascularization (<48 hours) increases perioperative stroke risk compared to early or delayed procedures. However, mid-term outcomes and stroke rates are similar, though restenosis is higher in urgent/delayed groups.
Area of Science:
- Vascular Surgery
- Neurology
- Interventional Cardiology
Background:
- Symptomatic carotid artery stenosis poses a significant risk of recurrent stroke.
- Optimal timing for carotid revascularization remains a critical clinical question.
- Timely intervention is crucial to mitigate stroke risk.
Purpose of the Study:
- To evaluate the outcomes of carotid revascularization based on intervention timing: urgent (<48 hours), early (3-14 days), and delayed (>14 days).
- To compare perioperative complications and long-term results across different intervention timeframes.
Main Methods:
- Retrospective cohort study of 186 symptomatic patients undergoing carotid revascularization.
- Patients categorized into urgent (n=47), early (n=90), and delayed (n=49) intervention groups.
- Analysis of baseline characteristics, procedural details, and outcomes including stroke, TIA, MI, and mortality at 30 days and follow-up.
Main Results:
- The urgent group showed a significantly higher 30-day composite of stroke, TIA, MI, or death (8.5% vs. 1.1% early, 0.0% delayed; P=0.02).
- Ipsilateral stroke/TIA rates at 30 days were higher in the urgent group (6.4% vs. 0% early/delayed; P=0.02).
- Restenosis and reintervention rates were significantly higher in urgent (10.6%) and delayed (14.3%) groups compared to the early group (2.2%; P=0.01).
Conclusions:
- Urgent carotid revascularization is linked to increased perioperative stroke/TIA risk.
- Mid-term stroke and mortality outcomes were comparable across all intervention timing groups.
- Early intervention (3-14 days) may be associated with lower rates of restenosis and reintervention.
Background:
Symptomatic carotid artery stenosis requires timely intervention to reduce risk of recurrent stroke. However, the optimal timing of revascularization remains debated. This study evaluates outcomes in patients undergoing urgent (<48 hr), early (3-14 days), or delayed (>14 days) carotid artery revascularization.
Methods:
This retrospective cohort study included 186 interventions in symptomatic patients categorized by timing of intervention defined as urgent (<48 hr from symptom onset, n = 47), early (3-14 days, n = 90), and delayed (>14 days, n = 49). Baseline characteristics, procedural details, and outcomes were analyzed. Outcome measures included perioperative stroke, transient ischemic attack (TIA), myocardial infarction, and mortality at 30 days and on follow-up.
Results:
The cohort's mean age was 71.3 ± 9.6 years, with no difference among groups, and with a balanced sex distribution (P = 0.75). Comorbidities included hypertension, hyperlipidemia, and chronic kidney disease, which were similar across groups (P > 0.05). National Institutes of Health stroke scale on admission was significantly different between groups (urgent: 4.7 ± 4.6; early: 8.2 ± 8.1; delayed: 4.0 ± 5.2; P = 0.01). The level of disability measured through the modified Rankin scale at discharge demonstrated no significant difference between groups (urgent: 0.9 ± 1.3; early: 1.1 ± 1.3; delayed: 0.5 ± 1.0; P = 0.09). At 30 days, ipsilateral strokes/TIA occurred in 3 (6.4%) patients in the urgent group, and none in either the early group or delayed group (P = 0.02). Thirty-day mortality was observed in 2 (4.3%) patients in the urgent group and 1 (1.1%) in the early group (P = 0.23). The 30-day composite of stroke, TIA, myocardial infarction, or death was significantly higher in the urgent group (urgent: 8.5%, early: 1.1%, delayed: 0.0%; P = 0.02). At a mean follow-up of 14.6 ± 16.9 months, ipsilateral stroke rates were similar across groups (urgent: 4.3%, early: 5.6%, delayed: 4.1%; P = 1.00). All-cause mortality at follow-up occurred in 21.3% of urgent, 10.0% of early, and 10.2% of delayed patients (P = 0.17). Restenosis and reintervention rates at follow-up were significantly higher in the urgent (10.6%) and delayed (14.3%) groups than the early group (2.2%; P = 0.01).
Conclusion:
Urgent carotid revascularization is associated with higher perioperative stroke/TIA rate than early and delayed interventions. Mid-term outcomes were comparable across groups. Restenosis and reintervention rates were higher in the urgent and delayed groups than the early intervention group.
