Abstract 53: Development of Standardized Approach in Symptomatic Carotid Stenosis for Early Intervention

Abstract

Listen

Translate article

Background: Despite current guidelines recommend performing carotid endarterectomy (CEA) within the first 7-14 days from symptoms onset, this is not the routine approach for symptomatic carotid stenosis in most countries because of logistic difficulties and concerns regarding perioperative risk of “urgent CEA”. The aim of this study was to implement a multi-service in-hospital protocol to standardize the approach and reduce recurrence risk in acute symptomatic carotid stenosis without radical logistic reorganizations. Methods: All patients referred to the Emergency Room (ER) for acute cerebrovascular events will be seen within 24hours by the neurovascular specialist on call who rapidly triages patients (ABCD2 score), starts optimum medical therapy and performs carotid duplex ultrasound in the ER where immediate cerebral imaging will be also done by the neuroradiologist on call. Patients with 50-99% stenosis are discussed with the vascular surgeon on call and treatment decided (CEA vs stenting vs medical therapy) according to patients’ comorbidities, neurological status and carotid plaque morphology. Decision for intervention implies immediate transferal to the Vascular Surgery Unit where treatment is guaranteed within 2-48 hours in a hybrid operating room. The neurovascular specialist follows all postoperative courses (eventual transferal to Stroke Unit can be decided). Results: Before the application of the standardized protocol, over 2002 consecutive carotid interventions, 684 were performed for symptomatic stenosis with perioperative stroke/death risk of 3.5%, similar in Stenting and CEA. The stroke risk at 5 years after the procedure was 8.7% after CEA vs. 4.9% after stenting (p =0.7). However, there was extreme variability in symptoms-to-treatment delay. Conclusion: Multidisciplinary team collaboration among traditional 24h availability local services would standardize the approach to carotid stenosis in symptomatic patients without substantially changes in hospital services and relevant logistic reorganization. The efficacy of stenting in early treatment will be verified. Increased prevalence of symptomatic interventions and improved stroke prevention rates are expected with the new protocol.