Document Detail

Early carotid endarterectomy in symptomatic patients is associated with poorer perioperative outcomes.
MedLine Citation:
PMID:  16844338     Owner:  NLM     Status:  MEDLINE    
OBJECTIVE: The optimal timing of carotid endarterectomy (CEA) after ipsilateral hemispheric stroke is controversial. Although early studies suggested that an interval of about 6 weeks after a completed stroke was preferred, more recent data have suggested that delaying CEA for this period of time is not necessary. With these issues in mind, we reviewed our experience to examine perioperative outcome with respect to the timing of CEA in previously symptomatic patients.
METHODS: A retrospective review of a prospectively maintained database of all CEAs performed at our institution from 1992 to 2003 showed that 2537 CEA were performed, of which 1,158 (45.6%) were in symptomatic patients. Patients who were operated on emergently <or=48 hours of symptoms for crescendo transient ischemic attacks (TIAs) or stroke-in-evolution were excluded from analysis (n = 25). CEA was considered "early" if performed <or=4 weeks of symptoms, and "delayed" if performed after a minimum of a 4-week interval following the most recent symptom.
RESULTS: Of nonurgent CEAs in symptomatic patients, in 87 instances the exact time interval from symptoms to surgery could not be precisely determined secondary to the remoteness of the symptoms (>18 months), and these were excluded from further analysis. Of the remaining 1,046 cases, 62.7% had TIAs and 37.3% had completed strokes as their indication for surgery. Among the entire cohort, patients who underwent early CEA were significantly more likely to experience a perioperative stroke than patients who underwent delayed CEA (5.1% vs 1.6%, P = .002). Patients with TIAs alone were more likely to be operated on early rather than in a delayed fashion (64.3% vs 46.7%, P < .0001), likely reflecting institutional bias in selecting delayed CEA for stroke patients. However, even when examined as two separate groups, both TIA patients (n = 656) and CVA patients (n = 390) were significantly more likely to experience a perioperative stroke when operated upon early rather than in a delayed fashion (TIA patients, 3.3% vs 0.9%, P = .05; CVA patients, 9.4% vs 2.4%, P = .003). There were no significant differences in demographics or other meaningful variables between patients who underwent early CEA and those who underwent delayed CEA.
CONCLUSIONS: In a large institutional experience, patients who underwent CEA <or=4 weeks of ipsilateral TIA or stroke experienced a significantly increased rate of perioperative stroke compared with patients who underwent CEA in a more delayed fashion. This was true for both TIA and stroke patients, although the results were more impressive among stroke patients. On the basis of these results, we continue to recommend that waiting period of 4 weeks be considered in stroke patients who are candidates for CEA.
Caron B Rockman; Thomas S Maldonado; Glenn R Jacobowitz; Neal S Cayne; Paul J Gagne; Thomas S Riles
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Publication Detail:
Type:  Journal Article     Date:  2006-07-14
Journal Detail:
Title:  Journal of vascular surgery     Volume:  44     ISSN:  0741-5214     ISO Abbreviation:  J. Vasc. Surg.     Publication Date:  2006 Sep 
Date Detail:
Created Date:  2006-09-04     Completed Date:  2006-10-24     Revised Date:  2012-10-03    
Medline Journal Info:
Nlm Unique ID:  8407742     Medline TA:  J Vasc Surg     Country:  United States    
Other Details:
Languages:  eng     Pagination:  480-7     Citation Subset:  IM    
Division of Vascular Surgery, New York University Medical Center, 530 First Avenue, Suite 6F, New York, NY 10016, USA.
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MeSH Terms
Brain Ischemia / etiology
Carotid Stenosis / complications,  surgery*
Endarterectomy, Carotid*
Intraoperative Complications / epidemiology
Postoperative Complications / epidemiology
Stroke / etiology,  physiopathology
Time Factors
Treatment Outcome
Comment In:
J Vasc Surg. 2007 Sep;46(3):616-7; author reply 617   [PMID:  17826262 ]
J Vasc Surg. 2007 Mar;45(3):641; author reply 641   [PMID:  17321357 ]

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