Carotid Revascularization After Stroke: When Should It Be Performed?

In 2006, the American Heart Association guidelines recommended that carotid revascularization be performed within 2 weeks of stroke based on data from 2 randomized trials on carotid endarterectomy.

This study aimed to determine whether the time between the event and revascularization has decreased after these guidelines were issued, and the proportion of patients receiving some sort of revascularization (endarterectomy or angioplasty) within 14 days.

Researchers identified all patients admitted with ischemic stroke who underwent carotid endarterectomy or angioplasty within 90 days of a stroke from 2005 to 2013.

The primary objective of this study was the number of days between stroke and angioplasty or endarterectomy, and the proportion of patients undergoing revascularization within the 14-day period recommended by the guidelines.

We identified 16,298 patients with ischemic stroke who underwent angioplasty or surgery within 90 days.

The time between stroke and revascularization (through any of both strategies) decreased from 25 days (range, 5-48 days) in 2005 to only 6 days (range, 3-17 days) in 2013 (p <0.001).

The proportion of patients who underwent angioplasty or endarterectomy within 14 days of the event increased from 40% in 2005 to 73% in 2013 (p <0.001).

These temporal changes remained significant after adjustment for patient demographics and comorbidities.

Conclusion

Since 2005, carotid revascularization through angioplasty or endarterectomy has been performed progressively sooner after ischemic stroke.

Editorial

Performing a carotid angioplasty or endarterectomy within 14 days of stroke carries a risk of peri-procedural events of about 10%, i.e. twice or thrice the risk presented by an asymptomatic patient. Consequently, both surgeons and specialists in hemodynamics often choose to wait for at least a month. However, this is a risk that should be ran: every 1000 treated patients, 150 new spontaneous strokes are prevented (strokes that would otherwise take place during the wait).

The moment to intervene after stroke seems to be clear; however, there is still no definitive answer on what the revascularization strategy should be. Surgeons feel that they can perform the procedure with a lower risk of stroke, and that peri-procedural myocardial infarction is not a real problem. Specialists in hemodynamics believe that angioplasty is as safe as surgery and that, eventually, stroke excess is due to minor strokes only.

Finally, many neurologists believe that both strategies are extremely risky, and consider waiting and prescribing medication as the best approach.

Original title: Timing of Carotid Revascularization Procedures After Ischemic Stroke.

Reference: Michael Reznik et al. Stroke. 2016 Dec 6. Epub ahead of print.

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