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Kirchhoff F, Knappich C, Kallmayer M, Bohmann B, Lohe V, Tsantilas P, Naher S, Eckstein HH, Kühnl A. Determinants of prehospital and in-hospital delay in patients with symptomatic carotid stenosis and their influence on the outcome after elective carotid endarterectomy. Stroke Vasc Neurol 2024:svn-2024-003098. [PMID: 38969509 DOI: 10.1136/svn-2024-003098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/13/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND This study analyses the determinants of prehospital (index event to admission) and in-hospital delay (admission to carotid endarterectomy (CEA)). In addition, the analysis addresses the association between prehospital or in-hospital delay and outcomes after CEA for symptomatic patients in German hospitals. MATERIALS AND METHODS This retrospective analysis is based on the nationwide German statutory quality assurance database. 55 437 patients were included in the analysis. Prehospital delay was grouped as follows: 180-15, 14-8, 7-3, 2-0 days or 'in-hospital index event'. In-hospital delay was divided into: 0-1, 2-3 and >3 days. The primary outcome event (POE) was in-hospital stroke or death. Univariate and multivariable regression analyses were performed for statistical analysis. The slope of the linear regression line is given as the β-value, and the rate parameter of the logistic regression is given as the adjusted OR (aOR). RESULTS Prehospital delay was 0-2 days in 34.9%, 3-14 days in 29.5% and >14 days in 18.6%. Higher age (β=-1.08, p<0.001) and a more severe index event (transitory ischaemic attack: β=-4.41, p<0.001; stroke: β=-6.05, p<0.001, Ref: amaurosis fugax) were determinants of shorter prehospital delay. Higher age (β=0.28, p<0.001) and female sex (β=0.09, p=0.014) were associated with a longer in-hospital delay. Index event after admission (aOR 1.23, 95% CI: 1.04 to 1.47) and an intermediate in-hospital delay of 2-3 days (aOR 1.15, 95% CI: 1.00 to 1.33) were associated with an increased POE risk. CONCLUSIONS This study revealed that older age, higher American Society of Anesthesiology (ASA) stage, increasing severity of symptoms and ipsilateral moderate stenosis were associated with shorter prehospital delay. Non-specific symptoms were associated with a longer prehospital delay. Regarding in-hospital delay, older age, higher ASA stage, contralateral occlusion, preprocedural examination by a neurologist and admission on Fridays or Saturdays were associated with lagged treatment. A very short (<2 days) prehospital and intermediate in-hospital delay (2-3 days) were associated with increased risk of perioperative stroke or death.
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Affiliation(s)
- Felix Kirchhoff
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christoph Knappich
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kallmayer
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bianca Bohmann
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Vanessa Lohe
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | - Shamsun Naher
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas Kühnl
- Clinic and Policlinic for Vascular and Endovascular Surgery, Hospital Rechts der Isar, Technical University of Munich, Munich, Germany
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 218] [Impact Index Per Article: 218.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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Saxhaug LM, Graven T, Olsen Ø, Kleinau JO, Skjetne K, Ellekjær H, Dalen H. Reliability and agreement of point-of-care carotid artery examinations by experts using hand-held ultrasound devices in patients with ischaemic stroke or transitory ischaemic attack. Open Heart 2022; 9:openhrt-2021-001917. [PMID: 35105719 PMCID: PMC8808450 DOI: 10.1136/openhrt-2021-001917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 01/09/2022] [Indexed: 12/23/2022] Open
Abstract
Objectives To investigate the reliability and agreement of hand-held ultrasound devices (HUDs) compared with conventional duplex ultrasound (HIGH) in examination for carotid stenosis in patients with suspected transitory ischaemic attack (TIA) or ischaemic stroke. Methods Cardiologists, experienced in carotid ultrasound, examined patients admitted to a community hospital with suspected stroke or TIA. Patients were first examined by an HUD and second by HIGH as per usual care. Different operators performed HUD and HIGH blinded to each other. On clinical discretion, CT angiography (CTA) was performed, and analysed by a radiologist blinded to the results from the ultrasound. Results Of 80 patients included, 9 (11%) were found to have >50% internal carotid artery (ICA) stenosis on reference examination. Agreement for classification of the degree of ICA stenosis was good for HUD versus HIGH (weighted Kappa 0.76) and HUD versus CTA (weighted Kappa 0.66). Agreement between HUD and HIGH examinations was excellent when ICA was classified as <50% diameter stenosis by HUD (99% agreement), but significantly lower when ICA diameter stenosis was classified as >50% by HUD (OR 0.15, 95% CI 0.06 to 0.42). Overall, HUD tended to overestimate the degree of carotid stenoses rather than underestimate (p=0.048). Conclusion Hand-held carotid ultrasound performed by experts demonstrated good agreement with conventional duplex ultrasound. The use of HUDs was reliable for ruling out significant carotid artery disease, but less reliable for ruling in significant disease.
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Affiliation(s)
- Lars Mølgaard Saxhaug
- Department of Internal Medicine, Levanger Hospital, Levanger, Norway .,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Torbjorn Graven
- Department of Internal Medicine, Levanger Hospital, Levanger, Norway
| | - Øystein Olsen
- Department of Radiology, Levanger Hospital, Levanger, Norway
| | - Jens Olaf Kleinau
- Department of Internal Medicine, Levanger Hospital, Levanger, Norway
| | - Kyrre Skjetne
- Department of Internal Medicine, Levanger Hospital, Levanger, Norway
| | - Hanne Ellekjær
- Department of Neuromedicine and Movement Science, Norwegian University of Science and Technology Faculty of Medicine and Health Sciences, Trondheim, Norway.,Stroke Unit, Department of Medicine, St Olavs Hospital University Hospital in Trondheim, Trondheim, Norway
| | - Havard Dalen
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway.,Clinic of Cardiology, St Olavs Hospital University Hospital in Trondheim, Trondheim, Norway
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Coelho A, Peixoto J, Mansilha A, Naylor AR, de Borst GJ. Timing of Carotid Intervention in Symptomatic Carotid Artery Stenosis: A Systematic Review and Meta-Analysis. Eur J Vasc Endovasc Surg 2021; 63:3-23. [PMID: 34953681 DOI: 10.1016/j.ejvs.2021.08.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 07/05/2021] [Accepted: 08/13/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVE This review aimed to analyse the timing of carotid endarterectomy (CEA) and carotid artery stenting (CAS) after the index event as well as 30 day outcomes at varying time periods within 14 days of symptom onset. METHODS A systematic review was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis statement, comprising an online search of the Medline and Cochrane databases. Methodical quality assessment of the included studies was performed. Endpoints included procedural stroke and/or death stratified by delay from the index event and surgical technique (CEA/CAS). RESULTS Seventy-one studies with 232 952 symptomatic patients were included. Overall, 34 retrospective analyses of prospective databases, nine prospective, three RCT, three case control, and 22 retrospective studies were included. Compared with CEA, CAS was associated with higher 30 day stroke (OR 0.70; 95% CI 0.58 - 0.85) and mortality rates (OR 0.41; 95% CI 0.31 - 0.53) when performed ≤ 2 days of symptom onset. Patients undergoing CEA/CAS were analysed in different time frames (≤ 2 vs. 3 - 14 and ≤ 7 vs. 8 - 14 days). Expedited CEA (vs. 3 - 14 days) presented a sampled 30 day stroke rate of 1.4%; 95% CI 0.9 - 1.8 vs. 1.8%; 95% CI 1.8 - 2.0, with no statistically significant difference. Expedited CAS (vs. 3 - 14 days) was associated with no difference in stroke rate but statistically significantly higher mortality rate (OR 2.76; 95% CI 1.39 - 5.50). CONCLUSION At present, CEA is safer than transfemoral CAS within 2/7 days of symptom onset. Also, considering absolute rates, expedited CEA complies with the accepted thresholds in international guidelines. The ideal timing for performing CAS (when indicated against CEA) is not yet defined. Additional granular data and standard reporting of timing of intervention will facilitate future monitoring.
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Affiliation(s)
- Andreia Coelho
- Department of Angiology and Vascular Surgery, Centro Hospitalar Universitário do Porto, Portugal; Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal
| | - João Peixoto
- Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal; Department of Angiology and Vascular Surgery, Centro Hospitalar Vila Nova de Gaia/Espinho, Portugal
| | - Armando Mansilha
- Department of Surgery and Physiology, Faculdade Medicina da Universidade do Porto, Portugal
| | | | - Gert J de Borst
- Department of Vascular Surgery, University Medical Centre Utrecht, the Netherlands.
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Feasibility and Clinical Impact of Point-of-Care Carotid Artery Examinations by Experts using Hand-Held Ultrasound Devices in Patients with Ischemic Stroke or Transitory Ischemic Attack. J Stroke Cerebrovasc Dis 2021; 30:106086. [PMID: 34537688 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 07/05/2021] [Accepted: 08/29/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND AND PURPOSE To evaluate the feasibility and clinical influence of carotid artery examinations in patients admitted with stroke or TIA with hand-held ultrasound by experts, to identify individuals not in need of further carotid artery diagnostics. MATERIALS AND METHODS Cardiologists experienced in carotid ultrasound examined 80 patients admitted to a stroke unit with suspected stroke or TIA with hand-held ultrasound devices (HUD). Grey scale and color Doppler images were stored using a GE Vscan with dual probe (phased array and linear transducer). High-end triplex ultrasound performed by a cardiologist, blinded to the details of the HUD study, was performed in all patients and used as reference. Computer tomography angiography was performed when clinically indicated. RESULTS Stroke or TIA was diagnosed in 62 (78%) patients. Age was median (range) 72 (23-93) years. A significant stenosis (> 50% diameter reduction) was ruled out in 61 (76%) of patients by the HUD examinations. Sensitivity and specificity for diagnosing a significant stenosis was 92% and 93%, respectively. One of 12 significant stenoses was missed by HUD. All four patients in need of surgery were identified by the HUD examination. Sensitivity and specificity to identify a significant stenosis by HUD was 87% and 83%, respectively, compared to CT angiography. CONCLUSION HUD examinations of the carotid arteries by experts, using hand-held ultrasound devices, were feasible and may reduce the need for high-end diagnostic imaging of the carotid vessels in patients with stroke and TIA. Thus, HUD may improve diagnostic workflow in stroke units in the future.
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Lawaetz M, Sandholt B, Eilersen EN, Petersen C, Tørslev K, Shilenok D, Houlind KC, Sillesen H, Shahidi S, Rathenborg LK, Eiberg J. Low Risk of Neurological Recurrence while Awaiting Carotid Endarterectomy: Results From a Danish Multicentre Study. Eur J Vasc Endovasc Surg 2021; 62:160-166. [PMID: 34127375 DOI: 10.1016/j.ejvs.2021.04.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 04/07/2021] [Accepted: 04/17/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The risk of ipsilateral neurological recurrence (NR) was assessed in patients awaiting carotid endarterectomy (CEA) due to symptomatic carotid artery stenosis and whether current national guidelines of performing CEA within 14 days are adequate in present day practice. METHODS This was a retrospective multicentre observational cohort study. Patients scheduled for CEA due to symptomatic carotid artery stenosis in a five year period, 1 January 2014 to 31 December 2018, from four centres were included. Data from the Danish Vascular Registry (www.karbase.dk), operative managing systems, and electronic medical records were reviewed. RESULTS In total, 1 125 patients scheduled for CEA were included and 1 095 (97%) underwent the planned surgery. During a median delay from index event to CEA of 11 days (interquartile range 8-16 days), 40 patients (3.6%; 95% confidence interval [CI] 2.5%-5%) experienced a NR. One third were minor strokes (n = 12, 30%); half were transient ischaemic attacks (TIA) (n = 22, 55%); and amaurosis fugax accounted for 15% (n = 6). Twenty-six (2%) CEA procedures was cancelled, of which one was due to a disabling recurrent ischaemic event (aphasia). There were no deaths or major strokes in the waiting time for CEA. Best medical treatment (BMT) with platelet inhibitory or anticoagulation drugs and a statin was initiated in nearly all patients (98%) at first assessment. The overall 30 day risk of a post-operative major event (death or stroke) was (Kaplan-Meier [KM] estimate) 2.7% (95% CI 1.8-3.8), and not significantly correlated with the timing of surgery. Most (69%) occurred within the first three days. One, two, and three year mortality rate for CEA patients was (KM estimate) 4.8%, 7.8%, and 11.5% respectively. CONCLUSION In symptomatic carotid artery stenosis patients awaiting CEA, very few NRs occurred within 14 days. Institution of immediate BMT in specialised TIA/stroke units followed by early, but not necessarily urgent, CEA is a reasonable course of action in patients with high grade symptomatic carotid artery stenosis.
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Affiliation(s)
- Martin Lawaetz
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Vascular Surgery, Zealand University Hospital, Roskilde, Denmark.
| | | | - Emilie N Eilersen
- Department of Vascular Surgery, Zealand University Hospital, Roskilde, Denmark
| | - Christian Petersen
- Department of Vascular Surgery, Aalborg University Hospital, Aalborg, Denmark
| | - Katrine Tørslev
- Department of Vascular Surgery, Aalborg University Hospital, Aalborg, Denmark
| | | | - Kim C Houlind
- Department of Vascular Surgery, Kolding Hospital, Denmark; Dept. of Regional Health Research, University of Southern Denmark, Denmark
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Saeid Shahidi
- Department of Vascular Surgery, Zealand University Hospital, Roskilde, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | | | - Jonas Eiberg
- Department of Vascular Surgery, Rigshospitalet, Copenhagen, Denmark; Copenhagen Academy for Medical Education and Simulation (CAMES), Capital Region of Denmark, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Chen X, Su J, Wang G, Zhao H, Zhang S, Liu T, Su X, Zhou N. Safety and Efficacy of Early Carotid Endarterectomy in Patients with Symptomatic Carotid Artery Stenosis: A Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2021; 2021:6623426. [PMID: 33506024 PMCID: PMC7811422 DOI: 10.1155/2021/6623426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 12/09/2020] [Accepted: 12/24/2020] [Indexed: 11/17/2022]
Abstract
DESIGN A systematic document retrieval of studies published in the past 10 years reporting periprocedural stroke/mortality/MI after carotid endarterectomy (CEA) related to the time between CEA and qualifying neurological symptoms. The application database has "PubMed, EMbase and Cochrane databases." RevMan5.3 software provided by the Cochrane collaboration was used for meta-analysis. RESULTS A systematic literature search was conducted in databases. A total of 10 articles were included in this study. They were divided into early CEA and delayed CEA with operation within 48 h, 1 w, or 2 w after onset of neurological symptoms. Incidence of the postoperative stroke in patients undergoing delayed CEA (≥48 h) was significantly higher than patients with delayed CEA (<48 h) (OR = 2.14, 95% CI: 1.43-3.21, P = 0.0002). The postoperative mortality of patients after delayed CEA (≥48 h) was significantly higher than patients after early CEA (<48 h) (OR = 1.35, 95% CI: 1.06-1.71, P = 0.02). The risk of postoperative mortality of patients treated with delayed CEA (≥7 d) was significantly higher than patients after the early CEA group (<7 d) (OR = 1.69, 95% CI: 1.21-2.32, P = 0.001). CONCLUSION Early CEA is safe and effective for a part of patients with symptomatic carotid stenosis, but a comprehensive preoperative evaluation of patients with carotid stenosis must be performed.
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Affiliation(s)
- Xiao Chen
- Shandong First Medical University (Shandong Academy of Medical Sciences), Jinan City, Shandong Province, China
| | - Jing Su
- Shandong Taian City Central Hospital, Taian City, Shandong Province, China
| | - Guojun Wang
- Shandong Taian City Central Hospital, Taian City, Shandong Province, China
| | - Han Zhao
- Shandong Taian City Central Hospital, Taian City, Shandong Province, China
| | - Shizhong Zhang
- Shandong Taian City Central Hospital, Taian City, Shandong Province, China
| | - Tao Liu
- Shandong Taian City Central Hospital, Taian City, Shandong Province, China
| | - Xindi Su
- Jinzhou Medical University, Jinzhou City, Liaoning Province, China
| | - Ning Zhou
- Shandong Taian City Central Hospital Branch, Taian City, Shandong Province, China
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Cui CL, Dakour-Aridi H, Eldrup-Jorgensen J, Schermerhorn ML, Siracuse JJ, Malas MB. Effects of timing on in-hospital and one-year outcomes after transcarotid artery revascularization. J Vasc Surg 2020; 73:1649-1657.e1. [PMID: 33038481 DOI: 10.1016/j.jvs.2020.08.148] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 08/27/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The current recommendations are to perform carotid endarterectomy within 2 weeks of symptoms for maximum long-term stroke prevention, although urgent carotid endarterectomy within 48 hours has been associated with increased perioperative stroke. With the development and rapid adoption of transcarotid artery revascularization (TCAR), we decided to study the effect of timing on the outcomes after TCAR. METHODS The Vascular Quality Initiative database was searched for symptomatic patients who had undergone TCAR from September 2016 to November 2019. These patients were stratified by the interval to TCAR after symptom onset: urgent, within 48 hours; early, 3 to 14 days; and late, >14 days. The primary outcome was the in-hospital rate of combined stroke and death (stroke/death), evaluated using logistic regression analysis. The secondary outcome was the 1-year rate of recurrent ipsilateral stroke and mortality, evaluated using Kaplan-Meier survival analysis. RESULTS A total of 2608 symptomatic patients who had undergone TCAR were included. The timing was urgent for 144 patients (5.52%), early for 928 patients (35.58%), and late for 1536 patients (58.90%). Patients undergoing urgent intervention had an increased risk of in-hospital stroke/death, which was driven primarily by an increased risk of stroke. No differences were seen for in-hospital death. On adjusted analysis, urgent intervention resulted in a threefold increased risk of stroke (odds ratio [OR], 2.8; 95% confidence interval [CI], 1.3-6.2; P = .01) and a threefold increased risk of stroke/death (OR, 2.9; 95% CI, 1.3-6.4; P = .01) compared with late intervention. Patients undergoing early intervention had comparable risks of stroke (OR, 1.3; 95% CI, 0.7-2.3; P = .40) and stroke/death (OR, 1.2; 95% CI, 0.7-2.1; P = .48) compared with late intervention. On subset analysis, the type of presenting symptoms was an effect modifier. Patients presenting with stroke and those presenting with transient ischemic attack or amaurosis fugax both had an increased risk of stroke/death when undergoing urgent compared with late TCAR (OR, 2.7; 95% CI, 1.1-6.6; P = .04; and OR, 4.1; 95% CI, 1.1-15.0; P = .03, respectively). However only patients presenting with transient ischemic attack or amaurosis fugax had experienced an increased risk of stroke with urgent compared with late TCAR (OR, 5.0; 95% CI, 1.4-17.5; P < .01). At 1 year of follow-up, no differences were seen in the incidence of recurrent ipsilateral stroke (urgent, 0.7%; early, 0.2%; late, 0.1%; P = .13) or postdischarge mortality (urgent, 0.7%; early, 1.6%; late, 1.8%; P = .71). CONCLUSIONS We found that TCAR had a reduced incidence of stroke when performed 48 hours after symptom onset. Urgent TCAR within 48 hours of the onset of stroke was associated with a threefold increased risk of in-hospital stroke/death, with no added benefit for ≤1 year after intervention. Further studies are needed on long-term outcomes of TCAR stratified by the timing of the procedure.
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Affiliation(s)
- Christina L Cui
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif
| | - Hanaa Dakour-Aridi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif
| | - Jens Eldrup-Jorgensen
- Division of Vascular and Endovascular Therapy, Department of Surgery, Maine Medical Center, Portland, Me
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Department of Surgery, Boston University, Boston Medical Center, Boston, Mass
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla, Calif.
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Brinster CJ, Sternbergh WC. Safety of urgent carotid endarterectomy following thrombolysis. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:149-158. [PMID: 32225134 DOI: 10.23736/s0021-9509.20.11179-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Acute ischemic stroke is a leading cause of morbidity and mortality worldwide, and the incidence of ischemic stroke is predicted to increase in coming years. Carotid atherosclerotic occlusive disease accounts for up to 20% of all ischemic strokes, and mounting evidence suggests that, in the setting of an acute ischemic stroke due to carotid disease, earlier treatment with carotid intervention results in better outcomes. In patients with acute ischemic stroke, systemic or intravenous thrombolysis (IVT) has revolutionized ischemic stroke therapy, and intravenous tissue plasminogen activator (tPA) has become the principal treatment for acute ischemic stroke when administered within 3 to 4.5 hours of neurologic symptom onset. Given these trends in acute ischemic stroke therapy, vascular specialists are increasingly asked to perform carotid intervention following IVT, but reports in the literature examining outcomes in this circumstance are scarce, and the data regarding the appropriate interval from IVT to carotid endarterectomy (CEA) remains controversial. EVIDENCE ACQUISITION Literature searches were performed in PubMed (MEDLINE) and Ovid examining journal articles published between January 1st, 1998 and September 30th, 2019. The search terms used were: "urgent carotid endarterectomy," "carotid endarterectomy" AND "thrombolysis," "acute stroke and thrombolysis," "timing of carotid endarterectomy," and various combinations of these terms. EVIDENCE SYTNHESIS A total of 21 published reports detailing outcomes in 1165 patients have been published to date, with an average interval from IVT to CEA of 7.1 days, a cumulative 30-day stroke and death rate of 4.1% (0-18%) and a mean frequency of intracranial hemorrhage of 2.6% (0-18%). The aggregate data from the 21 reported series suggest that CEA can be performed safely within the first 14 days after the onset of neurologic symptoms in patients receiving antecedent IVT, however, data regarding the safety of urgent CEA within 48 to 72 hours of thrombolysis is conflicting, with some series reporting excellent results and others showing an increased risk of ICH, stroke, and/or death in these select patients. CONCLUSIONS Given the trend toward expedited treatment of acute ischemic stroke with subsequent transfer to regional referral centers, vascular specialists will be confronted with an increasing number of patients who may require urgent CEA after antecedent IVT. Further study is warranted to clearly delineate the appropriate interval from IVT to CEA and, specifically, to establish the safety of CEA with 72 hours of tPA administration.
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Affiliation(s)
- Clayton J Brinster
- Section of Vascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA, USA -
| | - W Charles Sternbergh
- Section of Vascular Surgery, Department of Surgery, Ochsner Clinic Foundation, New Orleans, LA, USA
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Lim ETA, Laws PE, Beresford TP, Khanafer AMA, Roake JA. Timeliness and outcomes of carotid endarterectomy for symptomatic carotid artery stenosis: a single centre audit. ANZ J Surg 2020; 90:345-349. [PMID: 32080950 DOI: 10.1111/ans.15757] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 01/14/2020] [Accepted: 01/21/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND For patients presenting with symptomatic internal carotid artery stenosis, carotid endarterectomy (CEA) surgery is recommended to be performed generally within a 48-hr to 14-day window. This study aimed to assess timeliness of delivery, and outcomes, of CEA surgery in a tertiary vascular centre. METHOD Patients with symptomatic internal carotid artery stenosis who underwent CEA between 1 June 2014 and 31 June 2017 were identified and data were obtained from hospital records. The timeline of their journey from presentation to surgery was then mapped together with their outcomes. RESULTS One hundred and seventy-two cases were included in the study. Overall, the median time from development of presenting symptoms to surgery was 9 days and 119 (69%) cases were operated on within 14 days. The median time from development of presenting symptoms to ultrasound imaging was 2 days and the median time from symptoms to vascular referral was also 2 days. There were no deaths, strokes or transient ischaemic attacks within 30 days of CEA. At 1 year, survival was 100% but 15 (8.7%) had experienced at least one transient ischaemic attack or stroke. In the 53 cases operated upon beyond 14 days the dominant cause of delay in 32 (60%) was accessing surgery after review by the vascular service. CONCLUSION The aim of delivering CEA within 14 days of developing relevant symptoms was achieved in most cases with good outcomes. Nevertheless, points of delay in the patient journey that could be targeted for future quality improvement were identified.
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Affiliation(s)
- Eric T A Lim
- Department of Vascular, Endovascular and Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Peter E Laws
- Department of Vascular, Endovascular and Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Timothy P Beresford
- Department of Vascular, Endovascular and Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Adib M A Khanafer
- Department of Vascular, Endovascular and Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Justin A Roake
- Department of Vascular, Endovascular and Transplant Surgery, Christchurch Hospital, Christchurch, New Zealand
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Kakkos SK. Are Delays to Perform Carotid Endarterectomy in Symptomatic Stenosis Inevitable for Some Patients? Eur J Vasc Endovasc Surg 2019; 58:502. [DOI: 10.1016/j.ejvs.2019.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 06/13/2019] [Indexed: 11/25/2022]
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12
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Factors Associated with Hospital Dependent Delay to Carotid Endarterectomy in the Dutch Audit for Carotid Interventions. Eur J Vasc Endovasc Surg 2019; 58:495-501. [DOI: 10.1016/j.ejvs.2019.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 05/16/2019] [Accepted: 05/18/2019] [Indexed: 11/23/2022]
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13
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Johal AS, Loftus IM, Boyle JR, Naylor AR, Waton S, Heikkila K, Cromwell DA. Changing Patterns of Carotid Endarterectomy Between 2011 and 2017 in England. Stroke 2019; 50:2461-2468. [DOI: 10.1161/strokeaha.119.025231] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Carotid endarterectomy (CEA) reduces the risk of stroke in recently symptomatic patients and less so in asymptomatic patients. Recent evidence suggests that the number of CEAs may be declining. The aim of this study was to investigate annual patterns of CEA in asymptomatic and symptomatic patients in England from 2011 to 2017.
Methods—
Data from the National Vascular Registry were used to describe (1) the number of CEA procedures in England and its 9 geographic regions from 2011 to 2017, (2) the characteristics of patients undergoing CEA, and (3) whether rates of CEA correlated with the number of vascular arterial units within each region. Annual stroke incidence for each region was derived from official population figures and the number of index stroke admissions per year.
Results—
The overall number of CEAs performed in England fell from 4992 in 2011 to 3482 in 2017, a 30% decline. Among symptomatic patients, there was a 25% decline, the number of CEAs falling from 4270 to 3217. In asymptomatic patients, there were 722 CEAs performed in 2011 and 265 in 2017, a 63% decline. CEAs per 100 000 adults within all regions declined over time but the size of change varied across the regions (range, 1.7–5.5 per 100 000). The regional numbers of CEAs per year were associated with changes in the regional stroke incidence, the proportion of CEAs performed in asymptomatic patients, and the number of hospitals performing CEA.
Conclusions—
This population-based study revealed a 63% decline in CEAs among asymptomatic patients between 2011 and 2017, possibly because of changing attitudes in the role of CEA. Reasons for the 25% decline in CEAs among symptomatic patients are unclear as UK guidelines on CEA have not changed for these patients. Whether the proportion of symptomatic patients with 50% to 99% ipsilateral stenosis has changed requires investigation.
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Affiliation(s)
- Amundeep S. Johal
- From the Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (A.S.J., S.W., K.H., D.A.C.)
| | - Ian M. Loftus
- St George’s University Hospitals NHS Foundation Trust, London, United Kingdom (I.M.L.)
| | - Jonathan R. Boyle
- Division of Vascular and Endovascular Surgery, Addenbrooke’s Hospital, Cambridge University Hospital Trust, United Kingdom (J.R.B.)
| | - A. Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, United Kingdom (A.R.N.)
| | - Sam Waton
- From the Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (A.S.J., S.W., K.H., D.A.C.)
| | - Katriina Heikkila
- From the Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (A.S.J., S.W., K.H., D.A.C.)
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine (K.H., D.A.C.)
| | - David A. Cromwell
- From the Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom (A.S.J., S.W., K.H., D.A.C.)
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine (K.H., D.A.C.)
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14
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Aro E, Ijäs P, Vikatmaa L, Soinne L, Sund R, Venermo M, Vikatmaa P. The Efficacy of Carotid Surgery by Subgroups: The Concept of Stroke Prevention Potential. Eur J Vasc Endovasc Surg 2019; 58:5-12. [PMID: 31182335 DOI: 10.1016/j.ejvs.2019.04.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 03/27/2019] [Accepted: 04/07/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Considering carotid endarterectomy (CEA), reporting treatment delay, symptom status, and surgical complication rates separately gives an incomplete picture of efficacy; therefore, the aim was to combine these factors and develop a reporting standard that better describes the number of potentially prevented strokes. With a real life cohort and theoretical inclusion scenarios, the aim was to explore the stroke prevention potential of different carotid practices. METHODS Landmark studies for symptomatic and asymptomatic patients were revisited. By using published estimates of treatment effect, a simplified calculator was designed to assess the five year stroke prevention rate per 1000 CEAs (stroke prevention potential [SPP], range 0-478), including the presence and recentness of symptoms, sex, increasing stenosis severity, and complication rates. Patients operated on for carotid stenosis at Helsinki University Hospital (HUH) between 2008 and 2016 were collected from a vascular registry (HUSVASC) and categorised according to the model. The local annual complication rate was re-evaluated and added to the model. The HUH patient cohort was incorporated into the SPP model, and changes over time analysed. Finally, theoretical changes in patient selection were compared in order to explore the theoretical impact of patient selection and shortening of the delay. RESULTS Fifteen hundred and five symptomatic and 356 asymptomatic carotid stenoses were operated on with stroke plus death rates of 3.6% and 0.3%, respectively. The proportion of CEAs performed within two weeks of the index event increased over the follow up period, being 77% in 2016. The SPP increased from 123 in 2008 to 229 in 2016. Theoretically, 350 ischaemic strokes were prevented in the period 2008-16, with 1861 CEAs. CONCLUSIONS National and international comparison of different CEA series is irrelevant if the inclusion criteria are not considered. A calculator that is easy to apply to large scale high quality registered data was developed and tested. SPP was found to increase over time, which is a probable sign of improved patient selection and an increased number of strokes prevented by the CEAs performed.
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Affiliation(s)
- Ellinoora Aro
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Petra Ijäs
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Neurosciences, University of Helsinki, Helsinki, Finland
| | - Leena Vikatmaa
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Lauri Soinne
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Neurosciences, University of Helsinki, Helsinki, Finland
| | - Reijo Sund
- Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland; Centre for Research Methods, Faculty of Social Sciences, University of Helsinki, Helsinki, Finland
| | - Maarit Venermo
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pirkka Vikatmaa
- Department of Vascular Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
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15
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Savardekar AR, Narayan V, Patra DP, Spetzler RF, Sun H. Timing of Carotid Endarterectomy for Symptomatic Carotid Stenosis: A Snapshot of Current Trends and Systematic Review of Literature on Changing Paradigm towards Early Surgery. Neurosurgery 2019; 85:E214-E225. [DOI: 10.1093/neuros/nyy557] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 01/31/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Carotid revascularization has been recommended as the maximally beneficial treatment for stroke prevention in patients with recently symptomatic carotid stenosis (SCS). The appropriate timing for performing carotid endarterectomy (CEA) within the first 14 d after the occurrence of the index event remains controversial. We aim to provide a snapshot of the pertinent current literature related to the timing of CEA for patients with SCS. A systematic review of literature was conducted to study the timing of CEA for SCS. The guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) were followed. A total of 63 articles were identified as relevant to this topic. A summary of 15 articles favoring urgent CEA (within 48 h) for SCS within 48 h of index event and 9 articles not favoring urgent CEA is presented. A consensus is still to be achieved on the ideal timing of CEA for SCS within the 14-d window presently prescribed. The current literature suggests that patients who undergo urgent CEA (within 48 h) after nondisabling stroke as the index event have an increased periprocedural risk as compared to those who had transient ischemic attack (TIA) as the index event. Further prospective studies and clinical trials studying this question with separate groups classified as per the index event are required to shed more light on the subject. The current literature points to a changing paradigm towards early carotid surgery, specifically targeted within 48 h if the index event is TIA, and within 7 d if the index event is stroke.
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Affiliation(s)
- Amey R Savardekar
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Vinayak Narayan
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Devi P Patra
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Robert F Spetzler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Hai Sun
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana
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16
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Calderon VJ, Kasturiarachi BM, Lin E, Bansal V, Zaidat OO. Review of the Mobile Stroke Unit Experience Worldwide. INTERVENTIONAL NEUROLOGY 2018; 7:347-358. [PMID: 30410512 DOI: 10.1159/000487334] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 01/31/2018] [Indexed: 11/19/2022]
Abstract
Background The treatment of stroke is dependent on a narrow therapeutic time window that requires interventions to be emergently pursued. Despite recent "FAST" initiatives that have underscored "time is brain," many patients still fail to present within the narrow time window to receive maximum treatment benefit from advanced stroke therapies, including recombinant tissue plasminogen activator (tPA) and mechanical thrombectomy. The convergence of emergency medical services, telemedicine, and mobile technology, including transportable computed tomography scanners, has presented a unique opportunity to advance patient stroke care in the prehospital field by shortening time to hyperacute stroke treatment with a mobile stroke unit (MSU). Summary In this review, we provide a look at the evolution of the MSU into its current status as well as future directions. Our summary statement includes historical and implementation information, economic cost, and published clinical outcome and time metrics, including the utilization rate of thrombolysis. Key Messages Initially hypothesized in 2003, the first MSUs were launched in Germany and adopted worldwide in acute, prehospital stroke management. These specialized ambulances have made the diagnosis and treatment of many neurological emergencies, in addition to ischemic and hemorrhagic stroke, possible at the emergency site. Providing treatment as early as possible, including within the prehospital phase of stroke management, improves patient outcomes. As MSUs continue to collect data and improve their methods, shortened time metrics are expected, resulting in more patients who will benefit from faster treatment of their acute neurological emergencies in the prehospital field.
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Affiliation(s)
| | | | - Eugene Lin
- Mercy Health-St. Vincent Medical Center, Toledo, Ohio, USA
| | - Vibhav Bansal
- Mercy Health-St. Rita Medical Center, Lima, Ohio, USA
| | - Osama O Zaidat
- Mercy Health-St. Vincent Medical Center, Toledo, Ohio, USA
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17
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Naylor AR, Vega de Ceniga M. Something Old, Something New, Something Borrowed, and Something Blue. Eur J Vasc Endovasc Surg 2017; 54:413-414. [PMID: 28888385 DOI: 10.1016/j.ejvs.2017.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 08/01/2017] [Indexed: 11/17/2022]
Affiliation(s)
- A R Naylor
- Department of Vascular Surgery at Leicester Royal Infirmary, Leicester, UK.
| | - M Vega de Ceniga
- Department of Vascular Surgery Hospital de Galdakao-Usansolo, Galdakao, Bizkaia, Spain
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