Risk of Early Carotid Endarterectomy for Symptomatic Carotid Stenosis

Abstract

Conclusion: Carotid endarterectomy (CEA) can be performed with slightly increased, but acceptable, risk in symptomatic patients within two weeks of stroke or transient ischemic attack. Summary: Current guidelines from the American Academy of Neurology and the American Heart Association indicate patients with symptomatic carotid stenosis should preferentially undergo CEA within 2 weeks of the symptomatic event (Chaturvedi S, et al. Neurology 2005;65:794-801, and Sacco RL, et al. Stroke 2006;37:577-617). However many patients are not operated within 2 weeks. In addition, traditional “surgical wisdom” has shied away from acute operation especially in stroke patients for fear of a higher incidence of complications (Naylor AR. Surgeon 2007;5:23-30). The authors examined their institutional experience with CEA with particular analysis of symptomatic patients operated within 2 weeks of symptoms. Symptomatic patients were not considered for early CEA if they had an infarct involving more than one third of the middle cerebral artery territory or if a patient had a fixed disabling deficit or an unstable medical condition. When those conditions were not present patients were operated soon after evaluation irrespective of the interval from the symptomatic event. The authors felt delays were usually related to delayed referral after symptom onset. The patients analyzed were those operated between January 2004 and May 2009. Patients were divided into three groups. Group 1 were asymptomatic, group 2 were symptomatic patients operated >2 weeks after their symptom, and group 3 were symptomatic patients operated on <2 weeks after their symptom (transient ischemic attack or stroke). Primary outcome was any myocardial infarction, stroke, or death within 30 days of the operation. A secondary endpoint was transient ischemic attack within 30 days postoperatively. There were 532 carotid endarterectomies performed in 507 patients. There were 500 patients with 525 CEA's who had 30 day follow up. There were 278 in group 1, 105 in group 2, and 142 in group 3. The primary outcome occurred in 5 patients in group 1 (1.8%); 1 patient in group 2 (1.0%); and 6 patients in group 3 (4.2%). There were no significant differences in the rate of primary outcome among the three groups (P = .17). There was also no significant difference comparing group 2 to group 3 (P = .24). Comment: This study has all the limitations of a single institution retrospective review. The biggest problem is insuring patients in group 2 and group 3 did in fact only differ primarily by referral pattern and not by other more pertinent medical conditions. The percentage of patients with stroke in group 2 and group 3 was similar (36.2% versus 35.2%), but we really don't know whether the severity of the strokes were the same and whether perioperative management and other co-morbidities were the same. Nevertheless, this study lends further support to a policy of performance of CEA in selected patients shortly after the onset of a neurologic symptom.