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December 23, 2005
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Caron Rockman, MD, Thomas Maldonado, MD, Glenn Jacobowitz, MD, Neal Cayne, MD, Mark Adelman, MD, Paul Gagne, MD, Matthew Nalbandian, MD, Patrick Lamparello, MD, Thomas Riles, MD.
New York University, New York, NY, USA.
Objective: The optimal timing of carotid endarterectomy (CEA) following ipsilateral hemispheric transient ischemic attack (TIA) or stroke (CVA) is controversial. While early studies suggested that an interval period of approximately six weeks following a completed stroke was preferred, more recent data has suggested that delaying CEA for this period of time is not necessary. With these issues in mind, the objective of this study was to review 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 CEA performed at our institution from 1992 - 2003 was performed. A total of 2537 CEA were performed, of which 1158 (45.6%) were in symptomatic patients. Patients who were operated on emergently within 48 hours of symptoms for crescendo TIA’s or stroke-in-evolution were excluded from analysis (n=26). CEA was considered “early” if performed within 4 weeks of symptoms, and “delayed” if performed after a minimum of a 4 week interval following the most recent symptom.
Results: Of 1158 CEA’s in symptomatic patients, 62.7% had TIA’s 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 TIA’s 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=726) and CVA patients (n=432) 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=0.05; CVA patients: 9.4% vs. 2.4%, p=0.003). 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 within 4 weeks of ipsilateral TIA or stroke experienced a significantly increased rate of perioperative stroke when compared to 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. Based on our results, we continue to recommend a waiting period of 4 weeks in symptomatic patients who are candidates for carotid endarterectomy, particularly in those who have experience a completed stroke.
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Early carotid endarterectomy in symptomatic patients is associated with poorer perioperative outcomes
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Caron Rockman, MD, Thomas Maldonado, MD, Glenn Jacobowitz, MD, Neal Cayne, MD, Mark Adelman, MD, Paul Gagne, MD, Matthew Nalbandian, MD, Patrick Lamparello, MD, Thomas Riles, MD.
New York University, New York, NY, USA.
Objective: The optimal timing of carotid endarterectomy (CEA) following ipsilateral hemispheric transient ischemic attack (TIA) or stroke (CVA) is controversial. While early studies suggested that an interval period of approximately six weeks following a completed stroke was preferred, more recent data has suggested that delaying CEA for this period of time is not necessary. With these issues in mind, the objective of this study was to review 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 CEA performed at our institution from 1992 - 2003 was performed. A total of 2537 CEA were performed, of which 1158 (45.6%) were in symptomatic patients. Patients who were operated on emergently within 48 hours of symptoms for crescendo TIA’s or stroke-in-evolution were excluded from analysis (n=26). CEA was considered “early” if performed within 4 weeks of symptoms, and “delayed” if performed after a minimum of a 4 week interval following the most recent symptom.
Results: Of 1158 CEA’s in symptomatic patients, 62.7% had TIA’s 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 TIA’s 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=726) and CVA patients (n=432) 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=0.05; CVA patients: 9.4% vs. 2.4%, p=0.003). 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 within 4 weeks of ipsilateral TIA or stroke experienced a significantly increased rate of perioperative stroke when compared to 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. Based on our results, we continue to recommend a waiting period of 4 weeks in symptomatic patients who are candidates for carotid endarterectomy, particularly in those who have experience a completed stroke.
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