Delay Prior to Expedited Carotid Endarterectomy: A Prospective Audit of Practice

Abstract

To identify reasons for delay before carotid endarterectomy (CEA) in a reconfigured "fast-track" system where patients were admitted from the TIA (transient ischaemic attack) Clinic for urgent CEA. Prospective audit in 89 recently symptomatic patients. Ten patients (11%) suffered recurrent symptoms between admission and surgery. Two strokes were sufficiently severe that CEA was cancelled. The median delay from index symptom to CEA was 8 days. 74/87 (85%) underwent CEA <14 days from the index symptom; 39/87 (45%) within 7 days. Forty-five (51%) were ready for CEA <24 hours of admission; 74 (83%) <72 hours. The most common reasons for delay to CEA were logistical, especially a failure to plan for access to weekend operating. Two-thirds of the Tuesday/Friday theatre lists that were reserved for urgent CEAs were actually used for CEA; 27 (33%) were not used for CEA but were utilized for another vascular procedure, and five (4%) were cancelled the day before and went unused. The vast majority of patients (85%) underwent CEA <14 days from the index symptom, but 11% still suffered recurrent symptoms prior to surgery. Transferring patients directly from the TIA Clinic reduced overall delays, but Vascular Units adopting such an approach might then be vulnerable to criticisms regarding prolonged lengths of pre-operative in-patient stay while patients were worked up for theatre. Protected theatre lists both optimized (and delayed) access to CEA, but the most important cause of delay was that we had not planned for weekend operating using specialist anaesthetic and theatre staff.