When to Intervene a Symptomatic Carotid Stenosis?

Guidelines recommend that carotid endarterectomy be performed within two weeks of stroke in patients with symptomatic carotid stenosis.

Because a Swedish registry study showed patients treated within the first days after a transient ischemic attack or stroke are at increased risk of death and perioperatory stroke, this study aims at verifying this risk in another series of patients in Germany.

It included 56,336 elective carotid endarterectomies performed in patients with symptomatic stenosis between 2009 and 2014. The overall population was divided in four cohorts according to time interval between index event and surgery.

Cohort 1: 0 to 2 days.

Cohort 2: 3 to 7 days.

Cohort 3: 8 to 14 days.

Cohort 4: 14 to 180 days.

Primary end point was stroke or inhospital death. A multilevel multivariable regression model was used for risk adjusted analyzis, given the differences between cohorts.

With a mean age of 71.1±9.6 years and 67.5% men, the overall rate of any stroke or death was 2.5% (n=1.434).

Risk of any inhospital stroke or death was:

• 3% for the group intervened within 48 hours of index event
• 2.5% for the group intervened between days 3 and 7
• 2.6% for the group intervened between days 7 and 14
• 2.3% for those intervened between days 14 and 180

At multivariable analyzis, the study showed the time of intervention was not significantly associated to events.

Even though this study does not assess recurrent events in patients awaiting intervention, but only inhospital events post procedure, we are well aware patients are a high risk of events and, therefore, early intervention is recommended.

Historically, early intervention has been resisted by surgeons, because of the supposedly high periprocedural events rate. Mostly, they have tried to “cool the case down”.

Conclusion

A shorter time interval between index event and carotid endarterectomy was not associated with an increased risk of peri-procedural events such as death or stroke in patients with symptomatic carotid stenosis.

Original Title: Short Time Interval Between Neurologic Event and Carotid Surgery Is Not Associated With an Increased Procedural Risk.

Reference: Pavlos Tsantilas et al. Stroke. 2016 Oct 13. Epub ahead of print.

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