Invited commentary

Abstract

The North American Symptomatic Carotid Endarterectomy Trial (NASCET) concluded that carotid surgery for symptomatic stenosis is better than medical therapy, and the conferred benefit of surgery is proportional to the degree of stenosis.1North American Symptomatic Endarterectomy Trial CollaboratorsBeneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis.N Engl J Med. 1991; 325: 445-453Crossref PubMed Scopus (7865) Google Scholar The European Carotid Surgery Trial (ECST) came to a similar conclusion and that “on average, the immediate risk of surgery was worth trading off against the long-term risk of stroke without surgery when the stenosis was greater than 80% diameter.”2European Carotid Surgery Trialists Collaborative GroupRandomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST).Lancet. 1998; 351: 1379-1387Abstract Full Text Full Text PDF PubMed Scopus (2966) Google Scholar The preceding and other studies leave little room for doubt that endarterectomy is beneficial to symptomatic patients; what is still being debated is the exact timing of surgery. Most clinicians agree that patients presenting with crescendo transient ischemic attacks or a mobile plaque on imaging deserve to be considered for an emergent endarterectomy to prevent a severe stroke. What is not clear is what type of patient ought to have an urgent (ie, during the same hospitalization and as promptly as possible) carotid endarterectomy. Avgerinos et al attempt to answer the question, When is it optimal to perform endarterectomy for symptomatic patients? They queried the Vascular Study Group of New England database of 14,864 carotid endarterectomies and identified 4076 performed for symptomatic stenosis. Of the latter cases, 989 carotid endarterectomies were performed within a month of symptom onset. They analyzed outcomes based on timing of surgery: same day, <48 hours, 2-5 days, and >6 days. They found that the postoperative stroke rate was highest if surgery was performed <48 hours after presenting stroke or transient ischemic attack, whereas postoperative stroke rates were similar in the other time frames. In a similar analysis from a single center and spanning the same time period, Tsantilas et al found a combined stroke and mortality rate for symptomatic patients of 2.5% and no significant difference in stroke rates in the various time periods of 48 hours, 3-7 days, 8-14 days, and 15-180 days.3Tsantilas P. Kuhnl A. Kallmeyer M. Pelisek J. Poppert H. Schmid S. et al.A short time interval between the neurologic index event and carotid endarterectomy is not a risk factor for carotid surgery.J Vasc Surg. 2017; 65: 12-20Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar Other authors have strongly emphasized the need for prompt carotid endarterectomy, provided symptoms are stable, to prevent a recurrent stroke.4Bond R. Rerkasem K. Rothwell P.M. Systematic review of the risks of carotid endarterectomy in relation to the clinical indication for and timing of surgery.Stroke. 2003; 34: 2290-2303Crossref PubMed Scopus (246) Google Scholar In performing an urgent carotid endarterectomy, there are many factors that need to be taken into consideration. By the time the surgeon sees the consult, proper imaging is obtained, and the patient is prepared for surgery, several hours would have passed. Adding to the complexity, a patient admitted on a Friday or Saturday may experience longer delays. This paper concludes that there is no major penalty in waiting a few days. Until we have more sophisticated imaging capabilities to detect which plaques are likely to disintegrate and cause recurrent symptoms, it is a guessing game.5Rothwell P.M. Prediction and prevention of stroke in patients with symptomatic carotid stenosis: the high-risk period and the high-risk patient.Eur J Vasc Endovasc Surg. 2008; 35: 255-263Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar The prudent approach, though, is to avoid delays in removing the offending plaque. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Early carotid endarterectomy performed 2 to 5 days after the onset of neurologic symptoms leads to comparable results to carotid endarterectomy performed at later time pointsJournal of Vascular SurgeryVol. 66Issue 6PreviewTiming of carotid endarterectomy (CEA) after onset of neurologic symptoms remains controversial. We assessed the association of CEA timing with postoperative outcomes. Full-Text PDF Open Archive