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Solomon Y, Marcaccio CL, Rastogi V, Lu JJ, Malas MB, Wang GJ, Schneider PA, de Borst GJ, Schermerhorn ML. In-hospital outcomes after carotid endarterectomy for stroke stratified by modified Rankin scale score and time of intervention. J Vasc Surg 2023; 77:529-537.e1. [PMID: 36395901 DOI: 10.1016/j.jvs.2022.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 09/09/2022] [Accepted: 09/19/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Although the benefits of carotid endarterectomy (CEA) for treating symptomatic carotid stenosis are well known, the optimal timing of intervention after acute stroke and whether the optimal timing will vary with preoperative stroke severity has remained unclear. Therefore, we assessed the effect of stroke severity and timing of the intervention on the postoperative outcomes for patients who had undergone CEA for stroke. METHODS We identified all patients in the Vascular Quality Initiative who had undergone CEA from 2012 to 2020 for prior stroke. The patients were stratified using the preoperative modified Rankin scale score (mRS score, 0-5) and time to CEA after stroke onset (≤2 days, 3-14 days, 15-90 days, 91-180 days). After univariate comparisons, the patients were stratified into the following mRS cohorts for further analysis: 0 to 1, 2, 3 to 4, and 5. The primary outcome was in-hospital stroke/death. RESULTS We identified 15,601 patients, of whom 30% had had an mRS score of 0, 34% an mRS score of 1, 17% an mRS score of 2, 11% an mRS score of 3, 8% an mRS score of 4, and 1% an mRS score of 5. Overall, 9.3% of the patients had undergone CEA within ≤2 days, 46% within 3 to 14 days, 36% in 15 to 90 days, and 8.4% within 90 to 180 days. A decreasing mRS score and an increasing time to CEA were associated with lower rates of perioperative stroke/death (Ptrend < .01). After risk adjustment, with CEA at 3 to 14 days as the comparator group, the mRS score 0 to 1 group had had a higher incidence of stroke/death after CEA within ≤2 days (3.6% vs 2.0%; odds ratio [OR], 1.8; 95% confidence interval [CI], 1.2-2.7). The mRS score 2 group had had a similar incidence of stroke/death after CEA within ≤2 days (4.4% vs 3.9%; OR, 1.2; 95% CI, 0.6-2.3) but a lower incidence after CEA at 15 to 90 days (2.1% vs 3.9%; OR 0.5; 95% CI, 0.3-0.96). The mRS score 3 to 4 group had had a higher incidence of stroke/death after CEA within ≤2 days (8.0% vs 3.8%; OR, 2.4; 95% CI, 1.5-3.9) but a similar incidence of stroke/death after CEA at 15 to 90 days (3.0% vs 3.8%; OR, 0.8; 95% CI, 0.5-1.3). For the mRS score 5 group, the stroke/death rates were ≥6.5% across all the time to CEA groups. However, the low sample size limited meaningful comparisons. CONCLUSIONS Patients with minimal disability after stroke (mRS score, 0-1) seemed to benefit from CEA within 3 to 14 days. However, those with severe disability (mRS score 5) have a very high risk from CEA at any time point given the poor outcomes. In contrast to the current guidelines, patients with mild disability (mRS score 2) could benefit from delaying CEA to 15 to 90 days, and those with moderate disability (mRS score 3-4) might benefit from CEA within 3 to 90 days given the acceptable in-hospital outcomes. These data should be considered within the context of the clinical situation in the weeks after index event to determine the net benefit of delayed CEA.
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Affiliation(s)
- Yoel Solomon
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christina L Marcaccio
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vinamr Rastogi
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Jinny J Lu
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego Health System, San Diego, CA
| | - Grace J Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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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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Impact of the first COVID-19 pandemic peak and lockdown on the interventional management of carotid artery stenosis in France. J Vasc Surg 2021; 75:1670-1678.e2. [PMID: 34921965 PMCID: PMC8684845 DOI: 10.1016/j.jvs.2021.11.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 11/12/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the impact of the COVID-19 pandemic on the trends of carotid revascularization (endarterectomy (CEA), transfemoral stenting (TFCAS)) for symptomatic and asymptomatic carotid stenosis before, during and after the end of the first lockdown in 2020 in France. METHODS Nationwide data were provided by the French National Hospital Discharge database (Programme de Médicalisation des Systèmes d'Information). We retrospectively analyzed patients admitted for CEA or TFCAS in all French public and private hospitals during a nine-month period (January-September) in 2017, 2018, 2019 and 2020. Procedures were identified using the French Common Classification of Medical Procedures. Stenoses were considered symptomatic in the presence of stroke and/or transient ischemic attack codes (according to the International Classification of Diseases-Tenth Revision) during the stay, and asymptomatic in the absence of these codes. Hospitalization rates in 2020 were compared with the rates in the same period in the three previous years. RESULTS Between January and September 2020, 12 546 patients were hospitalized for carotid artery surgery (CEA and TFCAS) in France. Compared with the three previous years, there was a decline in hospitalization rates for asymptomatic (-68.9%) and symptomatic (-12.6%) CEA procedures in April, starting at the pandemic peak concomitant with the first national lockdown. This decrease was significant for asymptomatic CEA (p<0.001). After the lockdown, while CEA for asymptomatic stenosis returned to usual activity, CEA for symptomatic stenosis presented a significant rebound, up 18.52% in August compared with previous years. Lockdown also had consequences on TFCAS procedures, with fewer interventions for both asymptomatic (-60.53%) and symptomatic stenosis (-16.67%) in April. CONCLUSIONS This study demonstrates a severe drop for all interventions during the first peak of the COVID-19 pandemic in France. However, the trends in the post-lockdown period were different for the various procedures. These data can be used to anticipate future decisions and organization for cardiovascular care.
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Eckstein HH, Kühnl A, Berkefeld J, Lawall H, Storck M, Sander D. Diagnosis, Treatment and Follow-up in Extracranial Carotid Stenosis. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:801-807. [PMID: 33549156 PMCID: PMC7947643 DOI: 10.3238/arztebl.2020.0801] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 05/05/2020] [Accepted: 06/22/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Around 15% of cerebral ischemias are caused by lesions of the extracranial carotid artery. The goal of this guideline is to provide evidence- and consensus-based recommendations for the management of patients with extracranial carotid stenoses throughout Germany and Austria. METHODS A systematic literature search (1990-2019) and methodical assessment of existing guidelines and systematic reviews; consensus-based answers to 37 key questions with evidence-based recommendations. RESULTS The prevalence of extracranial carotid artery stenoses is around 4% overall, higher from the age of 65 years. The most important examination modality is duplex sonography. Randomized trials have shown that carotid endarterectomy (CEA) significantly reduces the 5-year risk of stroke in patients with 60-99 % asymptomatic stenoses (absolute risk reduction [ARR] 4.1% over 5 years, number needed to treat [NNT] 24) or 50-99% symptomatic stenoses (50-69%: ARR 4.6 % over 5 years, NNT 22; 70-99%: 15.9 % over 5 years, NNT 6). With the aid of intensive conservative treatment, the carotid artery-associated risk of stroke can be reduced to as little as 1% per year. Critical determination of indications and strict quality criteria are therefore necessary for CEA and carotid artery stenting (CAS). Systematic reviews of controlled trials comparing CEA and CAS show that the procedural risk of stroke is higher for CAS (asymptomatic: 2.6% versus 1.3%; symptomatic: 6.2% versus 3.8%). There are no differences in the long term. CEA is recommended as standard procedure for high-grade asymptomatic and moderate to high-grade symptomatic carotid artery stenoses; CAS may be considered as an alternative. For both procedures, the periprocedural combined rate of stroke or death should not exceed 2% for asymptomatic stenoses or 4% for symptomatic stenoses. CONCLUSION Future studies should evaluate even better selection criteria for optimal individualized treatment, whether conservative, surgical, or endovascular.
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Affiliation(s)
- Hans-Henning Eckstein
- Spokesman (HHE) and Secretary (AK) of the Steering Group, Department forf Vascular and Endovascular Surgery, University Hospital “rechts der Isar”, Technical University of Munich
- German Vascular Society (DGG)
| | - Andreas Kühnl
- Spokesman (HHE) and Secretary (AK) of the Steering Group, Department forf Vascular and Endovascular Surgery, University Hospital “rechts der Isar”, Technical University of Munich
| | - Joachim Berkefeld
- Member of the Steering Group, Institute for Neuroradiology, University Hospital Frankfurt
- German Society of Neuroradiology (DGNR)
| | - Holger Lawall
- Member of the Steering Group, Ettlingen
- German Society for Angiology/Vascular Medicine (DGA)
| | - Martin Storck
- Member of the Steering Group, Department of Vascular and Thoracic Surgery, Karlsruhe Municipal Hospital
- German Society of Surgery (DGCH)
| | - Dirk Sander
- Member of the Steering Group, Department of Neurology and Stroke Unit, Benedictus Hospital Tutzing
- German Society of Neurology (DGN)
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Naylor AR, McCabe DJH. New Data and the Covid-19 Pandemic Mandate a Rethink of Antiplatelet Strategies in Patients With TIA or Minor Stroke Associated With Atherosclerotic Carotid Stenosis. Eur J Vasc Endovasc Surg 2020; 59:861-865. [PMID: 32362487 PMCID: PMC7183953 DOI: 10.1016/j.ejvs.2020.04.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/09/2020] [Accepted: 04/16/2020] [Indexed: 11/30/2022]
Affiliation(s)
- A R Naylor
- Leicester Vascular Institute, Glenfield Hospital, Leicester, UK.
| | - D J H McCabe
- Department of Neurology and Stroke Service, The Adelaide and Meath Hospital, Incorporating the National Children's Hospital - Tallaght University Hospital, Dublin, Ireland; Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland
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Lippi G, Plebani M. Integrated diagnostics: the future of laboratory medicine? Biochem Med (Zagreb) 2019; 30:010501. [PMID: 31839719 PMCID: PMC6904966 DOI: 10.11613/bm.2020.010501] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 10/12/2019] [Indexed: 01/01/2023] Open
Abstract
The current scenario of in vitro and in vivo diagnostics can be summarized using the “silo metaphor”, where laboratory medicine, pathology and radiology are three conceptually separated diagnostic disciplines, which will increasingly share many comparable features. The substantial progresses in our understanding of biochemical-biological interplays that characterize many human diseases, coupled with extraordinary technical advances, are now generating important multidisciplinary convergences, leading the way to a new frontier, called integrated diagnostics. This new discipline, which is currently defined as convergence of imaging, pathology and laboratory tests with advanced information technology, has an enormous potential for revolutionizing diagnosis and therapeutic management of human diseases, including those causing the largest number of worldwide deaths (i.e. cardiovascular disease, cancer and infectious diseases). However, some important drawbacks should be overcome, mostly represented by insufficient information technology infrastructures, costs and enormous volume of different information that will be integrated and delivered. To overcome these hurdles, some specific strategies should be defined and implemented, such as planning major integration of exiting information systems or developing innovative ones, combining bioinformatics and imaging informatics, using health technology assessment for assessing cost and benefits, providing interpretative comments in integrated reports, developing and using expert systems and neural networks, overcoming cultural and political boundaries for generating multidisciplinary teams and integrated diagnostic algorithms.
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Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
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Naylor AR. Early carotid surgery versus stenting in younger patients. Lancet Neurol 2019; 18:718. [PMID: 31301745 DOI: 10.1016/s1474-4422(19)30236-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/30/2019] [Indexed: 10/26/2022]
Affiliation(s)
- A Ross Naylor
- Department of Cardiovascular Sciences, The Leicester Vascular Institute, Glenfield Hospital, Leicester LE3 9QP, UK.
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Alcalde-López J, Zapata-Arriaza E, Cayuela A, Moniche F, Escudero-Martínez I, Ortega-Quintanilla J, de Torres-Chacón R, Montaner J, Mayol A, González A. Safety of Early Carotid Artery Stenting for Symptomatic Stenosis in Daily Practice. Eur J Vasc Endovasc Surg 2018; 56:776-782. [PMID: 30177414 DOI: 10.1016/j.ejvs.2018.07.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 07/20/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE/BACKGROUND In 2006, the American Heart Association recommended that for preference carotid endarterectomy (CEA) or, alternatively, carotid angioplasty and stenting (CAS) for symptomatic carotid artery stenosis should ideally occur within 14 days of an ischaemic event. The aim was to determine the safety of CAS according to those recommendations in daily practice. METHODS A retrospective analysis was performed of all consecutive patients (2000-16), with ipsilateral carotid symptoms who underwent CAS for extracranial carotid stenosis ≥70%, who were previously included in a prospective database. Thirty day morbidity was assessed (any stroke without transient ischaemic attack [TIA]/amaurosis fugax), along with mortality of the procedure in the early (≤14 days after stroke onset) and delayed phases (15-180 days after stroke onset). Patients who received CAS and/or mechanical thrombectomy for acute ischaemic stroke treatment were not included. RESULTS In total, 1227 patients with symptomatic carotid stenosis who underwent CAS were identified. Early and delayed CAS was performed in 291 and 936 patients, respectively. Morbidity (any stroke) and mortality was 2.2% (n = 27) in the whole cohort (n = 8 [2.7%] in early vs. n = 19 [2%] in delayed CAS; p = .47). There were no differences in morbidity between early and delayed CAS regarding TIA (n = 15 vs. 36 [5.2% vs. 3.9%]; p = .33), minor stroke (n = 4 vs. 5 [1.4% vs. 0.5%]; p = .14), or major stroke (n = 2 vs. 6 [0.7% vs. 0.6%]; p = .59). Two patients (0.7%) died after early CAS and eight (0.9%) after delayed CAS (p = .56). CONCLUSION CAS may be safely performed in the early phase after an ischaemic stroke with low clinical complication rates. Further studies are needed to validate CAS safety conducted even earlier in the acute phase of ischaemic stroke.
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Affiliation(s)
- Jesús Alcalde-López
- Interventional Neuroradiology, Department of Radiology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Elena Zapata-Arriaza
- Interventional Neuroradiology, Department of Radiology, Hospital Universitario Virgen del Rocío, Sevilla, Spain; Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain
| | - Aurelio Cayuela
- Unidad de Gestión Clínica de Salud Pública, Prevención y Promoción de la Salud, Área de Gestión Sanitaria Sur de Sevilla, Sevilla, Spain
| | - Francisco Moniche
- Department of Neurology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Joaquín Ortega-Quintanilla
- Interventional Neuroradiology, Department of Radiology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | | | - Joan Montaner
- Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Sevilla, Spain; Head of Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Antonio Mayol
- Interventional Neuroradiology, Department of Radiology, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Alejandro González
- Interventional Neuroradiology, Department of Radiology, Hospital Universitario Virgen del Rocío, Sevilla, Spain.
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Huang Y, Gloviczki P, Duncan AA, Kalra M, Oderich GS, DeMartino RR, Harmsen WS, Bower TC. Outcomes after early and delayed carotid endarterectomy in patients with symptomatic carotid artery stenosis. J Vasc Surg 2018; 67:1110-1119.e1. [DOI: 10.1016/j.jvs.2017.09.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 09/05/2017] [Indexed: 11/25/2022]
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Paraskevas KI, Veith FJ. Will Carotid Artery Stenting Become a Safer Procedure Than Carotid Endarterectomy? J Endovasc Ther 2017; 24:297-298. [PMID: 28335708 DOI: 10.1177/1526602817691753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Frank J Veith
- 2 Division of Vascular Surgery, New York University Langone Medical Center, New York, NY, USA.,3 The Cleveland Clinic, Cleveland, OH, USA
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Eckstein HH. Editorial on "Delays to Surgery and Procedural Risks Following Carotid Endarterectomy in the UK National Vascular Registry". Eur J Vasc Endovasc Surg 2016; 52:425-426. [PMID: 27552932 DOI: 10.1016/j.ejvs.2016.07.085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 07/22/2016] [Indexed: 11/16/2022]
Affiliation(s)
- H-H Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675 Munich, Germany.
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Qureshi MI, Davies AH. Carotid intervention following transient ischaemic attack: What are we waiting for? Vascular 2016; 24:556-8. [PMID: 27136949 DOI: 10.1177/1708538116648063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Transient ischaemic attack secondary to carotid stenosis has the highest risk of stroke recurrence compared with other aetiological subtypes. International guidelines advocate carotid intervention within one to two weeks of the index neurological event. Traditionally, delayed carotid intervention was perceived to be a safer management strategy, yet classic trials of endarterectomy and recent meta-analysis of carotid intervention demonstrate the safety of hyperacute carotid intervention. Data from international studies suggest that targets are not being met, the reasons for which are multifactorial, but patients suffering transient or ocular symptoms are particularly delayed. Efforts should be made to conduct regional studies investigating the root causes of delayed intervention, with subsequent policy adjustment to expedite intervention, and interim optimisation of medical management to reduce the incidence of recurrent stroke.
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Affiliation(s)
| | - Alun H Davies
- Section of Vascular Surgery, Imperial College London, UK
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