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Bellomo TR, DeCarlo C, Lella SK, Jessula S, Feldman Z, Romero JM, Eagleton MJ, Dua A, Zacharias N. Complications of Carotid Interventions for Symptomatic Lesions after Systemic Thrombolysis. Ann Vasc Surg 2024; 106:377-385. [PMID: 38821470 DOI: 10.1016/j.avsg.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/21/2024] [Accepted: 04/01/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Series detailing complications after carotid endarterectomy (CEA) and transfemoral carotid stenting (tfCAS) for patients presenting with neurologic symptoms that are treated with systemic thrombolysis (ST) are sparse. We sought to determine if treatment with ST was associated with a higher rate of post-carotid intervention complications. METHODS A multispecialty, institutional, prospectively maintained database was queried for symptomatic patients treated with CEA or tfCAS from 2007 to 2019. The primary outcomes of interest were bleeding complications (access/wound complications, hematuria, intracranial hemorrhage) or need for reintervention, stroke, and death. We compared rates of these outcomes between patients who were and were not treated with ST. To adjust for preoperative patient factors and confounding variables, propensity scores for assignment to ST and non-ST were calculated. RESULTS There were 1,139 patients included (949 [82%] CEA and 190 [17%] tfCAS. All treated lesions were symptomatic (550 [48%] stroke, 603 [52%] transient ischemic attack). Fifty-six patients (5%) were treated with ST. Fifteen of 56 patients also underwent catheter-based intervention for stroke. ST was administered 0 to 1 day preoperatively in 21 (38%) patients, 2 to 6 days preoperatively in 27 (48%) patients, and greater than 6 days preoperatively in 8 (14%) patients. ST patients were more likely to present with stroke (93% vs. 45%; P < 0.001) and have higher preoperative Rankin scores. Unadjusted rate of bleeding/return to operating room was 3% for ST group and 3% for non-ST group (P = 0.60). Unadjusted rate of stroke was 4% for ST group and 3% for the non-ST group (P = 0.91), while perioperative mortality was 5% for ST group and 1% for non-ST group (P = 0.009). After adjusting for patient factors, preoperative antiplatelet/anticoagulation, and operative factors, ST was not associated with an increased odds of perioperative bleeding/return to the operating room (odds ratio 0.37; 95% confidence interval: 0.02-1.63; P = 0.309) or stroke (odds ratio 0.62; 95% confidence interval: 0.16-2.40; P = 0.493). CONCLUSIONS ST does not convey a higher risk of complications after CEA or tfCAS. After controlling for other factors, patients that received ST had similar rates of local complications and stroke when compared to non-ST patients. Early carotid intervention is safe in patients that have received ST, and delays should be avoided in symptomatic patients given the high risk of recurrent stroke.
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Affiliation(s)
- Tiffany R Bellomo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA.
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Srihari K Lella
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Samuel Jessula
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Zachary Feldman
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Javier M Romero
- Division of Neuroradiology, Massachusetts General Hospital, Boston, MA
| | - Matthew J Eagleton
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - Nikolaos Zacharias
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
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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: 184] [Impact Index Per Article: 184.0] [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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Elder TA, Verhey LH, Schultz H, Smith ES, Adel JG. Cervical carotid occlusion in acute ischemic stroke: Should we give tPA? Surg Neurol Int 2022; 13:177. [PMID: 35509556 PMCID: PMC9063023 DOI: 10.25259/sni_176_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/12/2022] [Indexed: 12/03/2022] Open
Abstract
Background: Acute ischemic stroke (AIS) due to cervical internal carotid artery (cICA) occlusion is challenging to treat, with the lower revascularization rates, higher risk for complications, and poor response to thrombolytic therapy compared to isolated intracranial occlusions. While emergent revascularization through mechanical thrombectomy (MT) improves outcomes, the impact of tissue plasminogen activator (tPA) on outcomes in this subgroup of patients remains unclear. The objective of this study is to report our preliminary experience in treating AIS with cICA occlusions secondary to severe atherosclerotic stenosis and to establish the need for further clinical studies to determine the optimal intervention strategy for these lesions. Methods: Data were collected on patients who presented with acute cICA occlusion who underwent MT and either acute or staged carotid angioplasty and stenting. We compare patients who received tPA to those who did not, analyzing revascularization times, outcomes, and complications between the two populations, and discuss how this influenced our preferred treatment approach. Results: Twenty-one patients met inclusion criteria, seven of who received tPA and 14 did not receive tPA before surgical intervention. Procedural and functional outcomes were similar between the two populations. TPA administration correlated with a higher rate of vessel reocclusion in staged procedures and trended toward higher rates of symptomatic ICH and 90-day mortality. Conclusion: Emergent revascularization with acute cICA stenting carries advantages, but its safety is precluded by tPA administration. We suggest a trial which randomizes patients with cICA occlusions to receiving either tPA or dual antiplatelet therapy before surgical intervention, aiming to ultimately improved outcomes in these patients.
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Affiliation(s)
- Theresa A. Elder
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio,
| | - Leonard H. Verhey
- Department of Clinical Neurosciences, Spectrum Health, Michigan State University College of Human Medicine, Grand Rapids,
| | - Haritha Schultz
- Department of Internal Medicine, Central Michigan University College of Medicine,
| | - Eleanor S. Smith
- Department of Neurosurgery, Central Michigan University College of Medicine,
| | - Joseph G. Adel
- Department of Neuroscience, Ascension St Mary’s Hospital, Saginaw, Michigan, United States
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Mastrorilli D, Mezzetto L, D'Oria M, Fiorini R, Lepidi S, Scorsone L, Veraldi E, Veraldi GF. NIHSS score at admission can predict functional outcomes in patients with ischemic stroke undergoing carotid endarterectomy. J Vasc Surg 2021; 75:1661-1669.e2. [PMID: 34954269 DOI: 10.1016/j.jvs.2021.11.079] [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: 09/17/2021] [Accepted: 11/29/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The aim of present study was to evaluate the prognostic impact of National Institutes of Health Stroke Scale (NIHSS) score in patients undergoing acute CEA, and to assess clinical and morphological factors that could predict worse outcomes. METHODS The data of 183 consecutive patients who have undergone CEA after ischemic stroke was analyzed from January 2015 to January 2021. Patients were divided into two groups using the NIHSS cut off point of 4. Functional dependence was assessed on hospital discharge and 90 days after. RESULTS In total, 102 patients (55.7%) had a minor stroke (Group A: NIHSS ≤ 4), whereas 81 patients (44.3%) had a moderate-major stroke (Group B: NIHSS > 4). Group A and group B showed significant differences in their intracranial anatomic features: presence of incomplete Circle of Willis (7.8% vs 17.3%; p=.05), volume of Cerebral ischemic lesion volume ≥4000 mm3 (5.9 % vs 24.7%; p=<.001), and high ASPECTS of 8 to 10 (75.5% vs 44.4%; p=<.001). The overall rate of combined perioperative stroke/myocardial infarction/death was 1.1%, with no strokes recorded during the waiting time to carotid endarterectomy (CEA). Patients in group A had a lower rate of functional dependence at discharge (4.9% vs. 35.8%; p = <.001) and at 90 days after index stroke event (2.5% vs. 19.6%; p = <.001) versus those in group B. Using multivariate binary logistic regression, admission NIHSS>4 was significantly associated with higher odds of functional dependence at discharge (OR= 7.9, 95%CI= 2.7-18.5, p = <.001) and at 90 days (OR= 10.4, 95%CI= 2.7-19.3, p = .002). CONCLUSIONS NIHSS>4 at admission will increase the risk of having higher mRS scores both at hospital discharge and at 90 days after index stroke event. acute CEA was safe and feasible in patients with ischemic stroke, even if they had previously undergone intravenous thrombolysis.
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Affiliation(s)
- Davide Mastrorilli
- Department of Vascular Surgery, University Hospital of Verona, University of Verona-School of Medicine, Verona, Italy.
| | - Luca Mezzetto
- Department of Vascular Surgery, University Hospital of Verona, University of Verona-School of Medicine, Verona, Italy
| | - Mario D'Oria
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Roberta Fiorini
- Department of Vascular Surgery, University Hospital of Verona, University of Verona-School of Medicine, Verona, Italy
| | - Sandro Lepidi
- Division of Vascular and Endovascular Surgery, Cardiovascular Department, Cattinara University Hospital ASUGI, Trieste, Italy
| | - Lorenzo Scorsone
- Department of Vascular Surgery, University Hospital of Verona, University of Verona-School of Medicine, Verona, Italy
| | - Edoardo Veraldi
- Department of Vascular Surgery, University Hospital of Verona, University of Verona-School of Medicine, Verona, Italy
| | - Gian Franco Veraldi
- Department of Vascular Surgery, University Hospital of Verona, University of Verona-School of Medicine, Verona, Italy
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Jonsson M, Aro E, Björses K, Holmin S, Ijäs P, Martinez-Majander N, Vikatmaa P, Wahlgren CM, Venermo M, Björck M. Carotid Endarterectomy After Intracranial Endovascular Thrombectomy for Acute Ischaemic Stroke in Patients with Carotid Artery Stenosis. Eur J Vasc Endovasc Surg 2021; 63:371-378. [PMID: 34887207 DOI: 10.1016/j.ejvs.2021.10.034] [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: 04/23/2021] [Revised: 09/29/2021] [Accepted: 10/10/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Recent randomised controlled trials demonstrated the benefit of intracranial endovascular thrombectomy (EVT) in acute ischaemic stroke. There is no consensus, however, on how to treat concomitant extracranial carotid artery stenosis after EVT. The aim of this study was to evaluate the outcome in patients treated with carotid endarterectomy (CEA) after EVT, comparing complication rates among patients undergoing CEA for stroke without previous EVT. METHODS This was a registry study of all patients (n = 3 780) treated with CEA after stroke in Sweden and the capital Helsinki region, Finland, from January 2011 to September 2020. Sixty three patients (1.7%; 0.5% 2011, 4.3% 2019) underwent EVT prior to CEA. The primary outcome was 30 day stroke and death rate. RESULTS The EVT+CEA group had major stroke as the qualifying neurological event (QNE) in 79%, but just 5.9% had this in the CEA only group (p < .001). Intravenous thrombolysis was administered before EVT in 54% of patients in the EVT+CEA group, but in just 12% in those receiving CEA only (p < .001). The combined stroke and death rate at 30 days for EVT+CEA was 0.0% (95% confidence interval [CI] 0.0 - 5.7). One patient had a post-operative TIA, none had post-operative intracerebral or surgical site haemorrhage. CEA was performed within a median of seven days (interquartile range 4, 15) after QNE, and 75% had CEA ≤14 days from QNE. The main reason to postpone CEA was an infarct larger than one third of the middle cerebral artery territory. The stroke and death rate in patients treated with CEA only was 3.7% (95% CI 3.2 - 4.4), CEA was performed a median of eight days after QNE, and in 79.7% in ≤14 days. The three year survival after EVT+CEA was 93% (95% CI 85 - 100), compared with 87% (95% CI 86 - 88) after CEA only. Cox regression analysis adjusting for age showed no increased all cause mortality after EVT+CEA (HR 1.3, 95% CI 0.6 - 2.7, p = .52). CONCLUSION These results indicate that CEA is safe to perform after previous successful EVT for acute ischaemic stroke. Results were comparable with those undergoing CEA only, despite the EVT+CEA patients having more severe stroke symptoms prior to surgery, and timing was similar.
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Affiliation(s)
- Magnus Jonsson
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Ellinoora Aro
- Vascular Surgery, Helsinki University Hospital and University of Helsinki, Finland
| | | | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institute and Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Petra Ijäs
- Neurology, Helsinki University Hospital and University of Helsinki, Finland
| | | | - Pirkka Vikatmaa
- Vascular Surgery, Helsinki University Hospital and University of Helsinki, Finland
| | - Carl-Magnus Wahlgren
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden; Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Maarit Venermo
- Vascular Surgery, Helsinki University Hospital and University of Helsinki, Finland
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University, Sweden
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Kakkos SK, Vega de Ceniga M, Naylor R. A Systematic Review and Meta-analysis of Peri-Procedural Outcomes in Patients Undergoing Carotid Interventions Following Thrombolysis. Eur J Vasc Endovasc Surg 2021; 62:340-349. [PMID: 34266765 DOI: 10.1016/j.ejvs.2021.06.003] [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: 03/02/2021] [Revised: 06/01/2021] [Accepted: 06/03/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate the safety of carotid artery stenting (CAS) and carotid endarterectomy (CEA) after thrombolytic therapy (TT). DATA SOURCES Medline, Scopus, and Cochrane databases. REVIEW METHODS Systematic review and meta-analysis of studies involving patients who underwent CEA/CAS after TT. RESULTS In 25 studies (n = 147 810 patients), 2 557 underwent CEA (n = 2 076) or CAS (n = 481) following TT. After CEA, the pooled peri-procedural stroke/death rate was 5.2% (95% confidence interval [CI] 3.3 - 7.5) and intracranial haemorrhage (ICH) was 3.4% (95% CI 1.7 - 5.6). After CAS, the pooled peri-procedural stroke/death rate was 14.9% (95% CI 11.9 - 18.2) and ICH was 5.5% (95% CI 3.7 - 7.7). In case control studies comparing CEA outcomes in patients receiving TT vs. no TT, peri-procedural death/stroke was non-significantly higher after TT (4.3% vs. 1.5%; odds ratio [OR] 2.34, 95% CI 0.74 - 7.47), but ICH was significantly higher after TT (2.2% vs. 0.12%; OR 7.82, 95% CI 4.07 - 15.02), as was local haematoma formation (3.6% vs. 2.26%; OR 1.17, 95% CI 1.17 - 2.33). In case control studies comparing CAS outcomes in patients receiving TT vs. no TT, peri-procedural stroke/death was significantly higher after TT (5.2% vs. 1.5%; OR 8.49, 95% CI 2.12 - 33.95) as was ICH (5.4% vs. 0.7%; OR 7.48, 95% CI 4.69 - 11.92). Meta-regression analysis demonstrated an inverse association between the time interval from intravenous (IV) TT to undergoing CEA and the risk of peri-procedural stroke/death (p = .032). Peri-operative stroke/death was 13.0% when CEA was performed three days after TT and 10.6% when performed four days after TT, with the risk reducing to within the currently accepted 6% threshold after six-seven days had elapsed. CONCLUSION Peri-procedural ICH and local haematoma were significantly more frequent in patients undergoing CEA after TT (vs. no TT), although there were no randomised comparisons. Peri-procedural hazards were also significantly higher for CAS after TT. The inverse relationship between timing to CEA and peri-procedural stroke/death mandates careful patient selection and suggests that it may be safer to defer CEA for six-seven days after TT.
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Affiliation(s)
- Stavros K Kakkos
- Department of Vascular Surgery, University Hospital of Patras, Patras, Greece.
| | - Melina Vega de Ceniga
- Department of Angiology and Vascular Surgery, Hospital de Galdakao-Usansolo, Galdakao and Biocruces Bizkaia Health Research Institute, Barakaldo, Spain
| | - Ross Naylor
- Leicester Vascular Institute, Glenfield Hospital, Leicester, UK
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Johal AS, Naylor AR, Pherwani AD, Li Q, Birmpili P, Waton S, O'Neill R, Boyle JR, Cromwell DA. Carotid Endarterectomy Following Intravenous Thrombolysis in the UK. Eur J Vasc Endovasc Surg 2021; 62:9-15. [PMID: 34088616 DOI: 10.1016/j.ejvs.2021.03.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/24/2021] [Accepted: 03/30/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the effect of pre-operative intravenous thrombolytic therapy (ivTT) on short term outcomes after carotid endarterectomy (CEA) among patients who presented with ischaemic stroke. METHODS A retrospective study using a large population based dataset from the National Vascular Registry in the United Kingdom (UK-NVR). The cohort included adult patients who underwent CEA for ischaemic stroke between 1 January 2014 and 31 December 2019. NVR records provided information on patient demographics, Rankin score, medication, time from onset of symptoms to surgery and whether the patient received ivTT prior to surgery. Logistic regression was used to evaluate the relationship between ivTT and rates of any stroke at 30 days after CEA and in hospital complication rates for neck haematoma. Secondary outcomes included in hospital cardiac and respiratory complications, and cranial nerve injury. RESULTS Between 2014 and 2019, 9 030 patients presented with a stroke and underwent CEA, of whom 1 055 (11.7%) had received pre-operative ivTT. Those receiving ivTT were younger (mean 70.6 vs. 72.0 years, p < .001). The median (IQR) time from symptom to CEA was 10 days (6 - 17) for ivTT patients and 11 days (7 - 20) for CEA patients not receiving ivTT. Post-operative rates of 30 day stroke were similar between the no ivTT (2.1%) and ivTT (1.8%) cohorts (p = .48). In hospital neck haematomas were statistically significantly more common in CEA patients receiving ivTT (3.7%) vs. no ivTT (2.3%) (p = .006). There was no statistically significant association between 30 day stroke and neck haematoma complications when stratified for delays from symptom onset to CEA, but the overall cohort contained few adverse events for analysis during the very early time period. CONCLUSION The use of ivTT before CEA in stroke patients was not associated with an increased risk of 30 day stroke, but there was an increase in the risk of neck haematoma.
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Affiliation(s)
- Amundeep S Johal
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK.
| | - A Ross Naylor
- The Leicester Vascular Institute, Glenfield Hospital, Leicester, UK
| | - Arun D Pherwani
- Royal Stoke Vascular Unit, Royal Stoke University Hospital, Stoke-On-Trent, UK
| | - Qiuju Li
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Panagiota Birmpili
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Sam Waton
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK
| | - Richard O'Neill
- Interventional Radiology Department, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jonathan R Boyle
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Trust & Department of Surgery, University of Cambridge, Cambridge, UK
| | - David A Cromwell
- The Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, UK; Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
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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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Fortin W, Chaput M, Elkouri S, Beaudoin N, Blair JF. Carotid endarterectomy after systemic thrombolysis in a stroke population. J Vasc Surg 2019; 71:1254-1259. [PMID: 31526691 DOI: 10.1016/j.jvs.2019.05.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/25/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Vascular specialists are increasingly being requested to perform carotid endarterectomy (CEA) after intravenous thrombolysis (IVT) for stroke patients, raising concerns about hemorrhagic complications. Few case series and registry reports have assessed the question, and even fewer studies have included a control group. The aim of this study was to evaluate the overall outcome of patients undergoing CEA after IVT and to compare them with contemporary patients with CEA after simple stroke (non-IVT group). It also aimed to evaluate the differences in outcomes of stroke patients requiring CEA between nonvascular and vascular centers. METHODS The data of 169 consecutive patients who have undergone CEA after stroke in a single center was analyzed from January 2011 to December 2016, 27 of them (16%) having undergone previous IVT. A comparative analysis between the non-IVT and the IVT groups was performed. The time between stroke diagnosis and referral to a vascular specialist was also studied. RESULTS Age, sex, and cardiovascular comorbidities were similar in both groups. Median time between stroke and CEA was 13 days (Q1-Q3, 8-23 days), with 16 of the 27 patients (59%) in the IVT group undergoing CEA less than 14 days after the initial event. There were three intracranial hemorrhages (2.1%) in the non-IVT group versus one (3.7%) in the IVT group (P = NS). The overall 30-day combined stroke and death rate was 7.1% (6.3% in the non-IVT group vs 11.1% in the IVT group; P = .70). The incidence of postoperative cervical hematoma requiring reoperation was similar in both groups (2.1% vs 3.7%; P = NS). The median time between diagnosis of stroke and referral to a vascular specialist was higher for patients in nonvascular centers compared with vascular centers (3.5 days vs 1.0 day; P < .001), which translated to fewer patients referred from nonvascular centers undergoing surgery in the 14-day window period (38% vs 67%; P < .001). CONCLUSIONS In this retrospective analysis, CEA after IVT showed similar outcomes when compared with the overall CEA after stroke population. Stroke patients diagnosed in nonvascular centers were referred later than those in vascular centers and, although postoperative outcomes were similar, that was correlated with fewer patients undergoing surgery in a timely fashion.
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Affiliation(s)
- William Fortin
- Division of Vascular Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada; Division of Vascular Surgery, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Miguel Chaput
- Division of Vascular Surgery, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Stephane Elkouri
- Division of Vascular Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Nathalie Beaudoin
- Division of Vascular Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada
| | - Jean-François Blair
- Division of Vascular Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, Quebec, Canada.
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