Very Early CEA Without Shunting for Stroke—The Preferred Therapy

Abstract

There has been an evolution toward early carotid endarterectomy (CEA) after stroke, but there remains a reluctance to perform CEA earlier than 2 weeks. There has also historically been a bias toward shunting for previous stroke. This study analyzed the results of early CEA (<2 weeks) for stroke patients without shunting over a 12-year period to determine whether CEA earlier than 2 weeks after stroke was safe and whether a strategy of no shunting absent neuromonitoring changes was justified. A retrospective review of all CEA performed by a single surgeon over a 12-year period was performed. All patients with stroke were included except modified Rankin scale 6. The decision to shunt was based only on defined changes in continuous electroencephalography/somatosensory evoked potentials dynamics reflecting ischemia intraoperatively. Patient demographics, including age, degree of internal carotid artery (ICA) stenosis, preoperative neurologic symptoms, and medications were reviewed. Thirty-day outcomes were tabulated, including stroke, transient ischemic attack, death, and other major complications. A total of 432 patients (100 men [62.5%]) with a mean age of 69.4 years (range, 44-91 years) underwent 451 CEAs. There were 220 CEAs (49%) for symptomatic disease; of these, 183 had a documented stroke. CEA was performed within 72 hours in 162 stroke patients (88%) and within 5 days in the remaining 21 patients. Of the stroke cohort, mean pre-CEA modified Rankin scale was 3.8. One patient of this cohort had a new stroke (contralateral). The 72-hour perioperative stroke rate for the whole CEA group was 0.66% (3 of 451). The 30-day stroke, transient ischemic attack, and death rates were 5 (1.1%), 0 (0%), and 5 (1.1%), respectively. There was one intraoperative stroke, and the remainder of the four strokes occurred within 30 days. Early CEA for stroke (ie, <72 hours) can be performed safely without the need for shunting and does not increase postoperative stroke, morbidity, or mortality. Electroencephalography and somatosensory evoked potentials monitoring dramatically reduces the need to place a shunt during CEA. Recent stroke, contralateral ICA occlusion, or contralateral high-grade ICA stenosis are not an indication for intraoperative shunting. CEA for stroke is best done early, with no additional increase in perioperative stroke, thus shielding the patient from the early risk of recurrent stroke.