Editor's Choice - The National Norwegian Carotid Study: Time from Symptom Onset to Surgery is too Long, Resulting in Additional Neurological Events

OBJECTIVE/BACKGROUND

The objective was to observe for 1 year all patients in Norway operated on for symptomatic carotid stenosis with respect to (i) the time from the index event to surgery and neurological events during this time; (ii) the level in the healthcare system causing delay of surgical treatment; and (iii) the possible relationship between peri-operative use of platelet inhibitors and neurological events while awaiting surgery.

METHODS

This was a prospective national multicentre study of a consecutive series of symptomatic patients. Patients were eligible for inclusion when referred for surgery. An index event was defined as the neurological event prompting contact with the healthcare system. All 15 departments in Norway performing carotid endarterectomy (CEA) participated.

RESULTS

Three hundred and seventy one patients were eligible for inclusion between 1 April 2014 and 31 March 2015, and 368 patients (99.2%) were included. Fifty-four percent of the patients contacted their general practitioner on the day of the index event. Primary healthcare referred 84.2% of the patients to hospital on the same day as examined. In hospital median time from admission to referral for vascular surgery was 3 days. Median time between referral to the operating unit and actual CEA was 5 days. Overall, 61.7% of the patients were operated on within 2 weeks of the index event. Twelve patients (3.3%) suffered a new neurological event while awaiting surgery. The percentage of patients on dual antiplatelet therapy was lower (25.0%) in this group than among the other patients (62.6%) (p = .008). The combined 30 day mortality and stroke rate was 3.8%.

CONCLUSION

This national study with almost complete inclusion and follow-up shows that the delays occur mainly at patient level and in hospital. The delay is associated with new neurological events. Dual antiplatelet therapy is associated with reduced risk of having a new neurological event before surgery.

Endovascular treatment of calcified plaque in the thoracic aorta after recurrent massive embolization

A 65 year old female patient was admitted with acute onset of severe intermittent claudication in the right lower extremity. Angiography revealed embolic material in the right femoral artery and peripheral arterial thrombosis in the right leg. She was treated with thrombolysis first, thereafter calcified embolic material was removed by open embolectomy. A CT scan showed massive calcification in the thoracic aorta at the level of the occluded left subclavian artery, obviously the origin of embolization. On the second postoperative day she developed critical ischemia in the left lower limb. Angiography showed massive embolization in the left common and external iliac arteries. Following open embolectomy, stentgrafting of the descending thoracic aorta was performed. At one year the patient is in good condition.