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Hakeem A, Najem M. Impact of Vascular Service Centralization on the Carotid Endarterectomy Pathway: A Study at the Bedfordshire, Luton, and Milton Keynes Vascular Network. Cureus 2023; 15:e49726. [PMID: 38050531 PMCID: PMC10693671 DOI: 10.7759/cureus.49726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 12/06/2023] Open
Abstract
Introduction Carotid endarterectomy (CEA) is the gold standard intervention for patients experiencing transient ischemic attacks (TIAs) or embolic strokes with >50% internal carotid artery (ICA) stenosis supplying index hemispheric territory. The recommended period for CEA is 14 days post-index event; this period carries a heightened risk for second ischemic events. However, implementation of this stringent timeline often encounters delays stemming from multifaceted factors. The centralization of vascular services, designed to enhance patient care, introduces a paradigm shift. Centralization's efficacy in improving patient outcomes, particularly in the CEA pathway, is a subject of ongoing investigation. Our study aims to discern the impact of centralized services on the timeliness of CEA for symptomatic carotid artery stenosis, shedding light on this complex interplay of factors. Methods This retrospective study analyzed CEA data at the Bedfordshire, Luton, and Milton Keynes Vascular Network between January 2021 and June 2023. Eligible patients exhibited symptomatic carotid artery stenosis, with asymptomatic cases; those unfit for surgery or receiving best medical therapy only were excluded. Patients were categorized by their primary referral location: Hub, Spoke-1, or Spoke-2. Demographic and referral data were collected, and timelines from symptom onset to surgery were recorded. Continuous variables were expressed as means and standard deviations, and categorical variables as counts and percentages. Box plots illustrated the relationship between referral origin and surgery timing, and the Classification and Regression Tree (CART) assessed second events. Statistical significance was determined using Fisher's exact and chi-square tests, with p<0.05 indicating significance. Results A total of 148 patients underwent CEA after implementing exclusion criteria. 35.5% (n=53) of patients were referred from the Hub, while 45.6% (n=67) and 18.8% (n=28) were from Spoke-1 and Spoke-2, respectively. 40% (n=59) received CEA within the recommended timeframe, and 15.4% (n=23) experienced a second ischemic event pre-surgery. Time from TIA clinic review to referral was 5.5±8 days and 16.4±20 days from vascular referral to surgery. Patterns of delays were observed, with Spoke-2 exhibiting the most significant delays. Notably, amaurosis fugax and embolic stroke correlated with recurrent ischemic events, emphasizing the importance of timely care in CEA. Conclusion Our study underscores the significant benefits and challenges of the Hub and Spoke model in vascular surgery. The growing referral delays from Spoke sites are concerning, emphasizing the need for a multi-disciplinary team approach within Spoke sites to ensure efficient and standardized care delivery.
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Affiliation(s)
- Abdul Hakeem
- Vascular Surgery, Bedfordshire-Milton Keynes Vascular Centre, Bedford, GBR
| | - Mojahid Najem
- Vascular Surgery, Bedfordshire-Milton Keynes Vascular Centre, Bedford, GBR
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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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Soenens G, Moreels N, Vermassen F, De Herdt V, Hemelsoet D, Van Herzeele I. Evolution of surgical treatment of carotid artery stenosis: a single center observational study. Acta Chir Belg 2020; 120:301-309. [PMID: 30995167 DOI: 10.1080/00015458.2019.1607489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background: In 2009 and 2011 respectively ESVS and AHA/ASA guidelines recommended to operate patients with a symptomatic carotid artery stenosis within 14 days. This study aimed primarily to determine if an academic hospital has implemented these international guidelines about indication and timing of surgical treatment of carotid stenosis. Second, the influence of referral from another hospital on time from symptoms to surgery and the influence of time between neurological event and surgery on 30-day complication rate was studied. Third, the number of asymptomatic carotid artery lesions treated surgically was also evaluated in both periods.Methods: Retrospective study to compare patients with significant atherosclerotic carotid stenosis who underwent carotid endarterectomy (CEA) or carotid artery stenting (CAS) in 2005-2006 versus patients treated in 2014-2016. Demographic data, treatment characteristics, interval between symptom and surgery and 30-day outcomes were collected.Results: In 2005-2006 38.1% (59/155) of the patients were treated for symptomatic carotid artery stenosis, in 2014-2016 this increased to 66.5% (121/182) (p < .001, 95% CI: 0.179-0.383). Median time from neurological symptom to surgery in symptomatic patients decreased from 30 to 13 d (p <.001, 95% CI: 1.476-2.763). Early surgery did not increase the 30-day postoperative complications (p = .19, 95% CI: 0.987-1.003). Referral from another hospital almost doubled the time interval between symptoms and surgery in 2014-2016 (p <.001, 95% CI: 1.386-2.827).Conclusions: Since the publication of the international guidelines, patients with symptomatic carotid artery stenosis were preferably surgically treated within 2 weeks at an academic institution. The number of treated asymptomatic carotid stenoses was drastically reduced.
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Affiliation(s)
- Gilles Soenens
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Nathalie Moreels
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Frank Vermassen
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
| | - Veerle De Herdt
- Department of Neurology, Ghent University Hospital, Ghent, Belgium
| | | | - Isabelle Van Herzeele
- Department of Thoracic and Vascular Surgery, Ghent University Hospital, Ghent, Belgium
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de Oliveira PP, Vieira JLDC, Guimarães RB, Almeida ED, Savaris SL, Portal VL. Risk-Benefit Assessment of Carotid Revascularization. Arq Bras Cardiol 2018; 111:618-625. [PMID: 30365684 PMCID: PMC6199518 DOI: 10.5935/abc.20180208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 06/21/2018] [Accepted: 07/02/2018] [Indexed: 12/24/2022] Open
Abstract
Severe carotid atherosclerotic disease is responsible for 14% of all strokes, which result in a high rate of morbidity and mortality. In recent years, advances in clinical treatment of cardiovascular diseases have resulted in a significant decrease in mortality due to these causes. To review the main studies on carotid revascularization, evaluating the relationship between risks and benefits of this procedure. The data reviewed show that, for a net benefit, carotid intervention should only be performed in cases of a periprocedural risk of less than 6% in symptomatic patients. The medical therapy significantly reduced the revascularization net benefit ratio for stroke prevention in asymptomatic patients. Real life registries indicate that carotid stenting is associated with a greater periprocedural risk. The operator annual procedure volume and patient age has an important influence in the rate of stroke and death after carotid stenting. Symptomatic patients have a higher incidence of death and stroke after the procedure. Revascularization has the greatest benefit in the first weeks of the event. There is a discrepancy in the scientific literature about carotid revascularization and/or clinical treatment, both in primary and secondary prevention of patients with carotid artery injury. The identification of patients who will really benefit is a dynamic process subject to constant review.
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Affiliation(s)
- Pedro Piccaro de Oliveira
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - José Luiz da Costa Vieira
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Raphael Boesche Guimarães
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Eduardo Dytz Almeida
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Simone Louise Savaris
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Vera Lucia Portal
- Instituto de Cardiologia - Fundação
Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
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Tse GTW, Kilkenny MF, Bladin C, Grigg M, Dewey HM. Carotid endarterectomy: the change in practice over 11 years in a stroke centre. ANZ J Surg 2017; 89:314-319. [PMID: 29132196 DOI: 10.1111/ans.14241] [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] [Received: 03/28/2017] [Revised: 07/26/2017] [Accepted: 08/24/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Recent research evidence has impacted the practice of carotid endarterectomy (CEA). We aim to characterize changes in the practice and outcome of CEA over time in a single large-volume stroke centre. METHODS All patients who underwent CEA from 2004 to 2014 and carotid angioplasty and stenting (CAS) from 2003 to 2008 at an Australian metropolitan tertiary stroke centre hospital were included. Clinical data were analysed to identify time trends in choice of intervention, patient selection, preoperative imaging utilization, surgical timing and outcome. RESULTS There were 510 CEAs performed during 2004-2014 and 95 CASs during 2003-2008. The proportion of patients undergoing CEA compared to CAS increased from 60% to 90% from 2004 to 2008 (P < 0.001). CAS patients were more likely to have cardiac co-morbidities. From 2004 to 2014, the proportion of CEA patients aged ≥80 years increased (P = 0.001) and the proportion of asymptomatic patients decreased (P = 0.003) over time. Median time from symptom onset to surgery decreased from 52 days (Q1: 25, Q3: 74) in 2004 to 8 days (Q1: 5, Q3: 37) in 2014 (P < 0.001). Use of preoperative ultrasonography decreased whilst CT angiography and the number of imaging modalities applied to each patient increased over time (P < 0.001). Overall, 5.9% of CEAs were complicated by death, stroke or acute myocardial infarction with no significant change over time. CONCLUSION The trends in CEA practice at our centre align with international trends and guidelines. This study provides a representative indicator of Australian hospital practice, and illustrates how evidence from research is translated into clinical care.
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Affiliation(s)
- Gabrielle T W Tse
- Department of Neurosciences, Eastern Health, Melbourne, Victoria, Australia
| | - Monique F Kilkenny
- Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Chris Bladin
- Department of Neurosciences, Eastern Health, Melbourne, Victoria, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Michael Grigg
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Department of Vascular Surgery, Eastern Health, Melbourne, Victoria, Australia
| | - Helen M Dewey
- Department of Neurosciences, Eastern Health, Melbourne, Victoria, Australia.,Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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Kjørstad KE, Baksaas ST, Bundgaard D, Halbakken E, Hasselgård T, Jonung T, Jørgensen GT, Jørgensen JJ, Krog AH, Krohg-Sørensen K, Laxdal E, Mathisen SR, Oskarsson GV, Seljeskog S, Settemsdal I, Vetrhus M, Viddal BA, Wesche J, Aasgaard F, Mattsson E. Editor's Choice - The National Norwegian Carotid Study: Time from Symptom Onset to Surgery is too Long, Resulting in Additional Neurological Events. Eur J Vasc Endovasc Surg 2017; 54:415-422. [PMID: 28844552 DOI: 10.1016/j.ejvs.2017.07.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 07/19/2017] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- K E Kjørstad
- University Hospital of North Norway, Tromsø, Norway.
| | | | | | | | | | - T Jonung
- Haukeland University Hospital, University of Bergen, Bergen, Norway
| | | | - J J Jørgensen
- Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway
| | - A H Krog
- Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway
| | - K Krohg-Sørensen
- Oslo University Hospital, Oslo, Norway; University of Oslo, Oslo, Norway
| | - E Laxdal
- Haukeland University Hospital, University of Bergen, Bergen, Norway
| | | | | | - S Seljeskog
- Akershus University Hospital, Lørenskog, Norway
| | | | - M Vetrhus
- Stavanger University Hospital, Stavanger, Norway
| | - B A Viddal
- Stavanger University Hospital, Stavanger, Norway
| | - J Wesche
- University of Oslo, Oslo, Norway; Akershus University Hospital, Lørenskog, Norway
| | - F Aasgaard
- St. Olav's University Hospital, Trondheim, Norway
| | - E Mattsson
- St. Olav's University Hospital, Trondheim, Norway; Norwegian University of Science and Technology, Trondheim, Norway
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Kvickström P, Lindblom B, Bergström G, Zetterberg M. Amaurosis fugax - delay between symptoms and surgery by specialty. Clin Ophthalmol 2016; 10:2291-2296. [PMID: 27895459 PMCID: PMC5117882 DOI: 10.2147/opth.s115660] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Purpose To describe the time course of management of patients with amaurosis fugax and analyze differences in management by different specialties. Methods Patients diagnosed with amaurosis fugax and subjected to carotid ultrasound in 2004–2010 at the Sahlgrenska University Hospital, Gothenburg, Sweden (n=302) were included in this retrospective cohort study, and data were collected from medical records. Results The prevalence of significant carotid stenosis was 18.9%, and 14.2% were subjected to carotid endarterectomy. A trend of longer delay for surgery was noted for patients first consulting a general practitioner (P=0.069) as compared to hospital-based specialties. For 46.3% of the patients, an ophthalmologist was their first medical contact. No significant difference in time interval to endarterectomy was seen between ophthalmologists and neurologists/internists. Only 31.8% of the patients with significant carotid stenosis had carotid endarterectomy within 2 weeks from the debut of symptoms, and this proportion was smaller for patients residing outside the Gothenburg city area (P=0.038). Conclusion Initially consulting an ophthalmologist does not delay the time to ultrasound or carotid endarterectomy. The overall time from symptoms to surgery is longer than recommended for a majority of the patients, especially for patients from rural areas and for patients initially consulting a general practitioner.
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Affiliation(s)
| | - Bertil Lindblom
- Department of Clinical Neuroscience/Ophthalmology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg; Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal
| | - Göran Bergström
- Department of Molecular and Clinical Medicine, The Sahlgrenska Academy at University of Gothenburg; Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Madeleine Zetterberg
- Department of Clinical Neuroscience/Ophthalmology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg, Gothenburg; Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal
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Tsantilas P, Kühnl A, Kallmayer M, Pelisek J, Poppert H, Schmid S, Zimmermann A, Eckstein HH. A short time interval between the neurologic index event and carotid endarterectomy is not a risk factor for carotid surgery. J Vasc Surg 2016; 65:12-20.e1. [PMID: 27838111 DOI: 10.1016/j.jvs.2016.07.116] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 07/17/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Current guidelines recommend that carotid endarterectomy (CEA) be performed as early as possible after the neurologic index event in patients with 50% to 99% carotid artery stenosis. However, recent registry data showed that patients treated ≤48 hours had a significantly increased perioperative risk. Therefore, the aim of this single-center study was to determine the effect of the time interval between the neurologic index event and CEA on the periprocedural complication rate at our institution. METHODS Prospectively collected data for 401 CEAs performed between 2004 and 2014 for symptomatic carotid stenosis were analyzed. Patients were divided into four groups according to the interval between the last neurologic event and surgery: group I, 0 to 2 days; group II, 3 to 7 days; group III, 8 to 14 days; and group IV, 15 to 180 days. The primary end point was the combined rate of in-hospital stroke or mortality. Data were analyzed by way of χ2 tests and multivariable regression analysis. RESULTS The patients (68% men) had a median age of 70 years (interquartile range, 63-76 years). The index events included transient ischemic attack in 43.4%, amaurosis fugax in 25.4%, and an ipsilateral stroke in 31.2%. CEA was performed using the eversion technique in 61.1% of patients, and 50.1% were treated under locoregional anesthesia. The perioperative combined stroke and mortality rate was 2.5% (10 of 401), representing a perioperative mortality rate of 1.0% and stroke rate of 1.5%. Overall, myocardial infarction, cranial nerve injuries, and postoperative bleeding occurred in 0.7%, 2.2%, and 1.7%, respectively. We detected no significant differences for the combined stroke and mortality rate by time interval: 3% in group I, 3% in group II, 2% in group III, and 2% in group IV. Multivariable regression analysis showed no significant effect of the time interval on the primary end point. CONCLUSIONS The combined mortality and stroke rate was 2.5% and did not differ significantly between the four different time interval groups. CEA was safe in our cohort, even when performed as soon as possible after the index event.
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Affiliation(s)
- Pavlos Tsantilas
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Andreas Kühnl
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Michael Kallmayer
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jaroslav Pelisek
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Holger Poppert
- Department of Neurology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Sofie Schmid
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Alexander Zimmermann
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
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Kvickström P, Lindblom B, Bergström G, Zetterberg M. Amaurosis fugax: risk factors and prevalence of significant carotid stenosis. Clin Ophthalmol 2016; 10:2165-2170. [PMID: 27826182 PMCID: PMC5096748 DOI: 10.2147/opth.s115656] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose The purpose of this study was to describe clinical characteristics and prevalence of carotid stenosis in patients with amaurosis fugax (AF). Method Patients diagnosed with AF and subjected to carotid ultrasound in 2004–2010 in Sahlgrenska University Hospital, Gothenburg (n=302), were included, and data were retrospectively collected from medical records. Results The prevalence of significant carotid stenosis was 18.9%, and 14.2% of the subjects were subjected to carotid endarterectomy. Significant associations with risk of having ≥70% stenosis were male sex (adjusted odds ratio [aOR]: 2.62; 95% confidence interval [CI]: 1.26–5.46), current smoking (aOR: 6.26; 95% CI: 2.62–14.93), diabetes (aOR: 3.68; 95% CI: 1.37–9.90) and previous vasculitis (aOR: 10.78; 95% CI: 1.36–85.5). A majority of the patients (81.4%) was seen by an ophthalmologist prior to the first ultrasound. Only 1.7% of the patients exhibited retinal artery emboli at examination. Conclusion The prevalence of carotid stenosis among patients with AF is higher than has previously been demonstrated in stroke patients. An association with previously reported vascular risk factors and with vasculitis is seen in this patient group. Ocular findings are scarce.
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Affiliation(s)
| | - Bertil Lindblom
- Department of Clinical Neuroscience/Ophthalmology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal
| | - Göran Bergström
- Department of Molecular and Clinical Medicine, The Sahlgrenska Academy at University of Gothenburg; Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Madeleine Zetterberg
- Department of Clinical Neuroscience/Ophthalmology, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at University of Gothenburg; Department of Ophthalmology, Sahlgrenska University Hospital, Mölndal
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Editor's Choice – Delays to Surgery and Procedural Risks Following Carotid Endarterectomy in the UK National Vascular Registry. Eur J Vasc Endovasc Surg 2016; 52:438-443. [DOI: 10.1016/j.ejvs.2016.05.031] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 05/29/2016] [Indexed: 11/20/2022]
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Tempos de espera na endarterectomia carotídea: realidade institucional e estratégias de melhoria. ANGIOLOGIA E CIRURGIA VASCULAR 2016. [DOI: 10.1016/j.ancv.2015.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Pacheco FT, Alves CAPF, Gagliardi RJ, da Rocha AJ. Thrombus Features in Hyperacute Ischemic Stroke: A Perspective on Using Length and Density Evaluation. J Stroke Cerebrovasc Dis 2016; 25:144-9. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 07/09/2015] [Accepted: 09/09/2015] [Indexed: 10/22/2022] Open
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De Rango P, Brown MM, Chaturvedi S, Howard VJ, Jovin T, Mazya MV, Paciaroni M, Manzone A, Farchioni L, Caso V. Summary of Evidence on Early Carotid Intervention for Recently Symptomatic Stenosis Based on Meta-Analysis of Current Risks. Stroke 2015; 46:3423-36. [DOI: 10.1161/strokeaha.115.010764] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 09/14/2015] [Indexed: 12/16/2022]
Abstract
Background and Purpose—
This study aimed to assess the evidence on the periprocedural (<30 days) risks of carotid intervention in relation to timing of procedure in patients with recently symptomatic carotid stenosis.
Methods—
A systematic literature review of studies published in the past 8 years reporting periprocedural stroke/death after carotid endarterectomy (CEA) and carotid stenting (CAS) related to the time between qualifying neurological symptoms and intervention was performed. Pooled estimates of periprocedural risk for patients treated within 0 to 48 hours, 0 to 7 days, and 0 to 15 days were derived with proportional meta-analyses and reported separately for patients with stroke and transient ischemic attack as index events.
Results—
Of 47 studies included, 35 were on CEA, 7 on CAS, and 5 included both procedures. The pooled risk of periprocedural stroke was 3.4% (95% confidence interval [CI], 2.6–4.3) after CEA and 4.8% (95% CI, 2.5–7.8) after CAS performed <15 days; stroke/death rates were 3.8% and 6.9% after CEA and CAS, respectively. Pooled periprocedural stroke risk was 3.3% (95% CI, 2.1–4.6) after CEA and 4.8% (95% CI, 2.5–7.8) after CAS when performed within 0 to 7 days. In hyperacute surgery (<48 hours), periprocedural stroke risk after CEA was 5.3% (95% CI, 2.8–8.4) but with relevant risk differences among patients treated after transient ischemic attack (2.7%; 95% CI, 0.5–6.9) or stroke (8.0%; 95% CI, 4.6–12.2) as index.
Conclusions—
CEA within 15 days from stroke/transient ischemic attack can be performed with periprocedural stroke risk <3.5%. CAS within the same period may carry a stroke risk of 4.8%. Similar periprocedural risks occur after CEA and CAS performed earlier, within 0 to 7 days. Carotid revascularization can be safely performed within the first week (0–7 days) after symptom onset.
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Affiliation(s)
- Paola De Rango
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Martin M. Brown
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Seemant Chaturvedi
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Virginia J. Howard
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Tudor Jovin
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Michael V. Mazya
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Maurizio Paciaroni
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Alessandra Manzone
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Luca Farchioni
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
| | - Valeria Caso
- From the Unit of Vascular and Endovascular Surgery, Department of Surgical and Biomedical Sciences (P.D.R., A.M., L.F.) and Stroke Unit, Division of Cardiovascular Medicine (M.P., V.C.), Hospital S.M. Misericordia, Perugia, Italy; Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, University College London, London, United Kingdom (M.M.B.); Department of Neurology and Stroke Program, University of Miami Miller School of Medicine, FL (S.C.); Department of Epidemiology, School
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Rantner B, Schmidauer C, Knoflach M, Fraedrich G. Very urgent carotid endarterectomy does not increase the procedural risk. Eur J Vasc Endovasc Surg 2014; 49:129-36. [PMID: 25445726 DOI: 10.1016/j.ejvs.2014.09.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 09/16/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The timing of CEA for symptomatic internal carotid artery (ICA) stenosis remains a matter of controversy. Recent registry data showed a significantly increased risk, especially in the very early days after the onset of symptoms. In this study the outcome of CEA in the hyperacute phase has been investigated. METHODS The outcome of CEA for symptomatic ICA stenosis between January 2004 and December 2013 has been retrospectively analyzed. Patients were divided into four timing groups: surgery within 0 and 2 days, between 3 and 7 days, 8 and 14 days, and thereafter. The post-operative 30 day stroke and death rates were assessed. RESULTS A total of 761 symptomatic patients (40.1% with transient ischemic attack [TIA], 21.3% with amaurosis fugax, and 38.6% with ischemic stroke) were included, with an overall peri-operative stroke and death rate of 3.3%. A stroke and death rate of 4.4% (9/206) for surgery within 0 and 2 days, 1.8% (4/219) between 3 and 7 days, 4.4% (6/136) between 8 and 14 days, and 2.5% (5/200) in the period thereafter (p = .25 for the difference between the groups) was observed. The timing of surgery did not influence the peri-operative outcome in a multivariate regression analysis (OR 0.93 [0.63-1.36], p = .71). CONCLUSIONS These data show that very urgent surgery in symptomatic patients can be performed without increased procedural risk. Given the fact that ruptured plaques with neurological symptoms carry the highest risk of a recurrent ischemic event in the first 2 days, treating patients as soon as possible to offer the highest benefit in stroke prevention is recommended.
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Affiliation(s)
- B Rantner
- Department of Vascular Surgery, Innsbruck Medical University, Innsbruck, Austria.
| | - C Schmidauer
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - M Knoflach
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - G Fraedrich
- Department of Vascular Surgery, Innsbruck Medical University, Innsbruck, Austria
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Delay between symptoms and surgery for carotid artery stenosis: modification of our practice. Ann Vasc Surg 2014; 29:426-34. [PMID: 25461754 DOI: 10.1016/j.avsg.2014.07.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 07/01/2014] [Accepted: 07/27/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Recent data from the literature concerning symptomatic carotid stenosis show that the long-term benefits of surgery are greater when the surgery is performed soon after the neurologic event, ideally within 2 weeks. Since 2009, following recommendations, we decided to perform surgery as quick as possible. The aim of the study was to determine whether this approach increased postoperative morbimortality and the way it could change our practice. METHODS Using a prospective database containing a consecutive and continuous series of 1,500 carotid endarterectomies performed between 2003 and 2012, we extracted the records concerning the 417 symptomatic carotid stenoses (27.8%). We compared the 30-day and long-term outcome in 3 groups of patients: those operated within 2 weeks of the neurologic event (early surgery group [ESG], n = 158, 37.9%), those operated between 16 days and 6 weeks after the event (deferred surgery group [DSG], n = 79, 18.9%), and those operated more than 6 weeks after the event (late surgery group [LSG], n = 180, 43.2%). In the second part, to assess the new management beginning 2009, patients were divided in 2 periods 2003-2008 (period A) and 2009-2012 (period B) and we compared the 2 period's descriptive data and outcome. The primary outcome was the 30-day combined stroke and death rate. Secondary end points were follow-up freedoms from mortality and stroke. RESULTS The mean time between symptom onset and surgery was 7.7 ± 3.8 days for the ESG, 28.3 ± 8.6 days for the DSG, and 89.4 ± 36.7 days for the LSG. In the 3 groups, the types of symptoms leading to the indication for carotid surgery were comparable, with a stroke in 221 cases (53.0%), a transient ischemic attack in 146 cases (35.40%), and amaurosis fugax in 50 cases (12.0%). The groups were comparable in terms of comorbidities. The overall 30-day stroke rate was 1.4% (6 cases), the 30-day death rate was 1.7% (7 cases), and the combined stroke and death rate was 3.4% (3.2% in the ESG, 5.1% in the DSG, and 2.8% in the LSG [P = 0.808]). Survival rates at 24, 48, and 60 months were, respectively, 95%, 78%, and 78% in ESG, 86%, 81%, and 81% in DSG, and 91%, 83%, and 74% in LSG (P = 0.78). Freedom from stroke at 60 months showed to be, respectively, 97% in ESG, 96% in DSG, and 91% in LSG (P = 0.32). During the period A (2003-2008), we had taken care of 217 symptomatic carotid artery stenosis patients (22.3% of stenosis) and during the period B (2009-2012), 200 symptomatic stenosis (37.9% of stenosis). During the period A, an early surgery (<15 days) had place in 31 cases (14.3%), and during the period B, in 127 cases (63.5%). The 30-day stroke and death rate was of 3.7% during the period A and of 3.0% during the period B (P = 0.455). The 24-month survival and stroke-free survival rates were comparable between the 2 periods. CONCLUSIONS In our experience, surgery for symptomatic carotid stenosis can be performed early without increasing the rate of postoperative and long-term outcome. We have modified our practice, performing more and more early surgery for symptomatic stenosis without any impact on the outcome.
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Abstract
Objective:To examine time delays and identify factors that affect wait times from index neurological event to carotid endarterectomy in patients with symptomatic carotid stenosis treated at a regional neurosurgical referral centre.Methods:We performed a retrospective audit over two years of all patients who underwent a carotid endarterectomy at University Hospital, London, Ontario. The number of days was calculated from first neurological event through until surgery.Results:Eighty-nine carotid endarterectomies (CEAs) were performed by four surgeons during the years 2006 and 2007. From the first neurological event, the median wait time for surgery was 111 days, while from the last event the median wait time was 83 days. There was 19 days' wait between specialist / TIA clinic appointment and the receipt of neurosurgical referral. Median wait time for diagnostic imaging was eight days for carotid Doppler ultrasound and 15 days for CT or MR angiography. There was a 44 day wait from receipt of neurosurgical referral to the date of surgery. Only three patients (4%) received CEA within two weeks of their last neurological event. There was a trend towards a difference in wait times between inpatients and outpatients, but no difference between females compared with males, or between patients presenting with stroke versus TIA.Discussion:Median wait times for CEA after first neurological event was over three months at our center, reflecting the diagnostic workup required in TIA as well as the lack of a systematic approach. This is the subject of continued study at our institution.
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den Hartog A, Moll F, van der Worp H, Hoff R, Kappelle L, de Borst G. Delay to Carotid Endarterectomy in Patients with Symptomatic Carotid Artery Stenosis. Eur J Vasc Endovasc Surg 2014; 47:233-9. [DOI: 10.1016/j.ejvs.2013.12.013] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 12/02/2013] [Indexed: 11/16/2022]
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18
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Reducing the delay for carotid endarterectomy in South-East Scotland. Surgeon 2014; 12:11-6. [DOI: 10.1016/j.surge.2013.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Revised: 07/23/2013] [Accepted: 09/09/2013] [Indexed: 11/20/2022]
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19
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Faggioli G, Pini R, Mauro R, Gargiulo M, Freyrie A, Stella A. Perioperative Outcome of Carotid Endarterectomy According to Type and Timing of Neurologic Symptoms and Computed Tomography Findings. Ann Vasc Surg 2013; 27:874-82. [DOI: 10.1016/j.avsg.2012.12.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 11/11/2012] [Accepted: 12/28/2012] [Indexed: 11/16/2022]
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20
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McCulloch P, Nagendran M, Campbell WB, Price A, Jani A, Birkmeyer JD, Gray M. Strategies to reduce variation in the use of surgery. Lancet 2013; 382:1130-9. [PMID: 24075053 DOI: 10.1016/s0140-6736(13)61216-7] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Provision rates for surgery vary widely in relation to identifiable need, suggesting that reduction of this variation might be appropriate. The definition of unwarranted variation is difficult because the boundaries of acceptable practice are wide, and information about patient preference is lacking. Very little direct research evidence exists on the modification of variations in surgery rates, so inferences must be drawn from research on the alteration of overall rates. The available evidence has large gaps, which suggests that some proposed strategies produce only marginal change. Micro-level interventions target decision making that affects individuals, whereas macro-level interventions target health-care systems with the use of financial, regulatory, or incentivisation strategies. Financial and regulatory changes can have major effects on provision rates, but these effects are often complex and can include unintended adverse effects. The net effects of micro-level strategies (such as improvement of evidence and dissemination of evidence, and support for shared decision making) can be smaller, but better directed. Further research is needed to identify what level of variation in surgery rates is appropriate in a specific context, and how variation can be reduced where desirable.
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Affiliation(s)
- Peter McCulloch
- Nuffield Department of Surgical Science, University of Oxford, Oxford, UK.
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21
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Carotid endarterectomy—safe and effective in a neurosurgeon's hands: a 25-year single-surgeon experience. World Neurosurg 2013; 83:74-9. [PMID: 23474183 DOI: 10.1016/j.wneu.2013.02.088] [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] [Received: 08/29/2012] [Revised: 01/08/2013] [Accepted: 02/28/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) is a procedure performed by both vascular surgeons and neurosurgeons in the UK. We present a single neurosurgeon's experience of 728 CEAs over 25 years, performed under both general and local anesthesia, and discuss the results in this context. Our objective was to report on the efficacy of CEA in the hands of a neurosurgeon. METHODS Prospective outcome data were collected for all patients who underwent CEA performed by the senior author (A.D.M.) from 1987 to 2011. Data evaluated included patient age, sex, surgical indication, preoperative characteristics, diagnostic modalities used, shunt usage, operative time, any neurological deterioration during or after surgery, and early postoperative problems. Outcome measures used were 30-day death and 30-day disabling stroke. The results were tabulated and analyzed using JMP 8.0.2 (SAS Inc., Cary, NC). RESULTS The 30-day death rate was 0.8% and the 30-day disabling stroke rate was 1.7% in our series. The mean operative time was 135 minutes (±38.1), and the mean clamp time was 28.4 minutes (±8.5). In the subset of patients who had the operation performed under local anesthesia (n = 616), the disabling stroke rate was 1.6% and the death rate was 0.6%. In the subset of asymptomatic patients (n = 194), the 30-day death and 30-day disabling stroke rates were each 1%. Postoperative complications were uncommon. CONCLUSIONS According to our data, CEA under local anesthesia is safe procedure in the hands of a neurosurgeon and would be recommended according to the clinical presentation and local guidelines.
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Witt AH, Johnsen SP, Jensen LP, Hansen AK, Hundborg HH, Andersen G. Reducing Delay of Carotid Endarterectomy in Acute Ischemic Stroke Patients. Stroke 2013; 44:686-90. [DOI: 10.1161/strokeaha.111.678565] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Guidelines recommend carotid endarterectomy (CEA) within 2 weeks from an ischemic event. However, previous studies have shown that only a minority of patients undergo CEA within this period. The aim of this study was to examine the effect of a multidisciplinary nationwide initiative aimed at reducing time to CEA after acute ischemic stroke.
Methods—
We examined a historic population-based observational cohort based on individual patient-level records from the Danish Stroke Registry and the Danish Vascular Registry. The implementation of early ultrasound examination of the carotids (within 4 days from admission) in medical departments coupled with fast CEA after referral to a department of vascular surgery were monitored and audited systematically from 2008 and onward.
Results—
A total of 813 acute ischemic stroke patients underwent CEA during 2007-2010. The percentage of patients undergoing CEA within 2 weeks increased from 13% in 2007 to 47% in 2010 (adjusted odds ratio, 5.8 [95% CI, 3.4–10.1]). The overall median time decreased from 31 days to 16 days. The percentage of relevant acute ischemic stroke patients receiving early ultrasound examination of the carotids increased from 41% in 2008 to 72% in 2010. The time from referral to operation at a vascular department was reduced by ≈40%.
Conclusions—
Establishing time limits of 4 days to ultrasound examination of the carotids and of 2 weeks to CEA from onset of stroke followed by a systematic multidisciplinary monitoring and auditing of processes was associated with a substantial increase in the proportion of acute ischemic stroke patients who undergo CEA within 2 weeks in Denmark.
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Affiliation(s)
- Agnes Hauschultz Witt
- From the Departments of Neurology (A.H.W., G.A.) and Clinical Epidemiology (S.P.J., H.H.H.), Aarhus University Hospital, Aarhus, Denmark; Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark (L.P.J.); and Department of Vascular Surgery, Aalborg Hospital, Aalborg, Denmark (A.H.)
| | - Soren Paaske Johnsen
- From the Departments of Neurology (A.H.W., G.A.) and Clinical Epidemiology (S.P.J., H.H.H.), Aarhus University Hospital, Aarhus, Denmark; Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark (L.P.J.); and Department of Vascular Surgery, Aalborg Hospital, Aalborg, Denmark (A.H.)
| | - Leif Panduro Jensen
- From the Departments of Neurology (A.H.W., G.A.) and Clinical Epidemiology (S.P.J., H.H.H.), Aarhus University Hospital, Aarhus, Denmark; Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark (L.P.J.); and Department of Vascular Surgery, Aalborg Hospital, Aalborg, Denmark (A.H.)
| | - Allan Kornmaaler Hansen
- From the Departments of Neurology (A.H.W., G.A.) and Clinical Epidemiology (S.P.J., H.H.H.), Aarhus University Hospital, Aarhus, Denmark; Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark (L.P.J.); and Department of Vascular Surgery, Aalborg Hospital, Aalborg, Denmark (A.H.)
| | - Heidi Holmager Hundborg
- From the Departments of Neurology (A.H.W., G.A.) and Clinical Epidemiology (S.P.J., H.H.H.), Aarhus University Hospital, Aarhus, Denmark; Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark (L.P.J.); and Department of Vascular Surgery, Aalborg Hospital, Aalborg, Denmark (A.H.)
| | - Grethe Andersen
- From the Departments of Neurology (A.H.W., G.A.) and Clinical Epidemiology (S.P.J., H.H.H.), Aarhus University Hospital, Aarhus, Denmark; Department of Vascular Surgery, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark (L.P.J.); and Department of Vascular Surgery, Aalborg Hospital, Aalborg, Denmark (A.H.)
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Stiehm M, Björses K, Kremer C. Management of the Treatment Delay in Symptomatic Carotid Artery Stenosis. Eur Neurol 2013; 70:179-84. [DOI: 10.1159/000351118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 04/03/2013] [Indexed: 11/19/2022]
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Hædersdal C, Søndergaard MP, Olsen TS. Costs of secondary prevention of stroke by carotid endarterectomy. Eur Neurol 2012; 68:42-6. [PMID: 22738993 DOI: 10.1159/000337864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 02/27/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND We estimated the costs to the Danish National Health Service of preventing stroke due to carotid artery stenosis by carotid endarterectomy (CEA), including costs of identifying patients, Doppler ultrasound (DUS) examination and CEA. METHODS Estimations are based on patients with stroke, transient ischemic attacks (TIA) or amaurosis fugax referred for carotid DUS in the municipality of Frederiksberg, Denmark (127,184 residents), within an 18-month period in 2008-2009. RESULTS In total, 372 patients with stroke (n = 194), TIA (n = 157) or amaurosis fugax (n = 21) were referred for DUS. We identified 12 patients with 50-70% stenosis and 20 patients with >70% stenosis. Six had CEA, all of whom had stenosis >70%. Waiting time from symptom to CEA was a median of 38 days. Costs of preventing 1 recurrent stroke in the study period [number needed to treat (NNT) = 13] was in the range of EUR 207,675-333,918. If CEA had been performed within 2 weeks after onset of symptoms (NNT = 4), costs would be in the range of EUR 63,900-102,744. CONCLUSION Costs of preventing stroke by CEA were high. Substantial reductions of costs (by about 2/3) can be achieved if CEA is performed <2 weeks after the ischemic event.
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Affiliation(s)
- Carsten Hædersdal
- Department of Clinical Physiology, Frederiksberg University Hospital, Frederiksberg, Denmark
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Delayed Carotid Surgery: What Are the Causes in the North West of England? Eur J Vasc Endovasc Surg 2012; 43:637-41. [DOI: 10.1016/j.ejvs.2012.03.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 03/21/2012] [Indexed: 11/20/2022]
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Rudarakanchana N, Halliday AW, Kamugasha D, Grant R, Waton S, Horrocks M, Naylor AR, Rudd AG, Cloud GC, Mitchell D. Current practice of carotid endarterectomy in the UK. Br J Surg 2011; 99:209-16. [DOI: 10.1002/bjs.7810] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2011] [Indexed: 11/09/2022]
Abstract
Abstract
Background
Carotid endarterectomy (CEA) reduces the risk of stroke in patients with internal carotid stenosis of 50–99 per cent. This study assessed national surgical practice through audit of CEA procedures and outcomes.
Methods
This was a prospective cohort study of UK surgeons performing CEA, using clinical audit data collected continuously and reported in two rounds, covering operations from December 2005 to December 2007, and January 2008 to September 2009.
Results
Some 352 (92·6 per cent) of 380 eligible surgeons contributed data. Of 19 935 CEAs recorded by Hospital Episode Statistics, 12 496 (62·7 per cent) were submitted to the audit. A total of 10 452 operations (83·6 per cent) were performed for symptomatic carotid stenosis; among these patients, the presenting symptoms were transient ischaemic attack in 4507 (43·1 per cent), stroke in 3572 (34·2 per cent) and amaurosis fugax in 1965 (18·8 per cent). The 30-day mortality rate was 1·0 per cent (48 of 4944) in round 1 and 0·8 per cent (50 of 6151) in round 2; the most common cause of death was stroke, followed by myocardial infarction. The rate of death or stroke within 30 days of surgery was 2·5 per cent (124 of 4918) in round 1 and 1·8 per cent (112 of 6135) in round 2.
Conclusion
CEA is performed less commonly in the UK than in other European countries and probably remains underutilized in the prevention of stroke. Increasing the number of CEAs done in the UK, together with reducing surgical waiting times, could prevent more strokes.
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Affiliation(s)
| | | | | | - R Grant
- St George's, University of London and Kingston University, UK
| | - S Waton
- Royal College of Physicians, UK
| | | | - A R Naylor
- Leicester Royal Infirmary, Leicester, UK
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Rantner B, Kollerits B, Schmidauer C, Willeit J, Thauerer M, Rieger M, Fraedrich G. Carotid Endarterectomy within Seven Days after the Neurological Index Event is Safe and Effective in Stroke Prevention. Eur J Vasc Endovasc Surg 2011; 42:732-9. [DOI: 10.1016/j.ejvs.2011.08.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 08/04/2011] [Indexed: 11/30/2022]
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Andgren S, Sjöberg L, Norrving B, Lindgren A. Time delay between symptom and surgery in patients with carotid artery stenosis. Acta Neurol Scand 2011; 124:329-33. [PMID: 21250946 DOI: 10.1111/j.1600-0404.2010.01478.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Many severe strokes are preceded by warning signs such as a transient ischemic attack or stroke with minor deficits. Carotid endarterectomy (CEA) of a symptomatic carotid artery stenosis can prevent future strokes, but should be performed within 2 weeks after the initial symptom to maximize the benefit. The aim of this study was to determine the time delays between symptom and CEA. METHODS We performed a single center observational retrospective study at a tertiary stroke center. A total of 142 carotids in 139 patients with symptomatic stenoses between 2002 and 2006 were included. The main outcome measure was time between qualifying cerebrovascular symptom and CEA. RESULTS The median time between symptom and CEA was 26 days. The longest delays were between the last diagnostic examination and carotid conference, and between carotid conference and surgery. The median time was shorter for those who received emergency medical care (median 21 days) and for those who were admitted immediately to hospital (median 20 days). CONCLUSIONS The time between symptom and surgery is often longer than desirable. There are several measures to improve the chain of procedures for patients with carotid artery stenosis. These may include omitting the formal carotid conference for uncomplicated cases and minimizing waiting time for surgery.
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Affiliation(s)
- S Andgren
- Department of Internal Medicine, Helsingborg Hospital, Sweden.
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Abbas K, Vohra RS, Salhab M, Sinclair MD, Kent PJ, Gough MJ. A strategy to meet the 'two-week' target for carotid endarterectomy in symptomatic patients. Clin Med (Lond) 2011; 11:452-5. [PMID: 22034704 PMCID: PMC4954238 DOI: 10.7861/clinmedicine.11-5-452] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Carotid endarterectomy (CEA) within two weeks of the index neurological event (INE) achieves maximum stroke prevention. This study assesses the impact of institution-wide policy changes on CEA performance in symptomatic patients. Between two study periods (1 January 2007 and 31 December 2007; 1 August 2008 and 31 July 2009) transient ischaemic attack (TIA) clinics, an acute stroke protocol and utilisation of vascular operating lists, were adopted. Following the changes, the interval between the INE and CEA fell from 23 (n = 65; interquartile range (IQR) 9-66) to 6.5 (n = 52; IQR 2-13.5) days (p < 0.001) with 32.3% v 82.7% performed within two weeks (p < 0.001). Significant improvements were seen in the time taken from onset of symptoms to presentation, and presentation to a carotid duplex and surgical review. Univariate analyses suggest this improvement is associated with the type of INE, point of presentation and the need for further imaging. Implementation of these policies has produced a significant improvement in service provision largely meeting the two-week target.
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Affiliation(s)
- K Abbas
- Leeds Vascular Institute, General Infirmary at Leeds
| | - RS Vohra
- Leeds Vascular Institute, General Infirmary at Leeds
| | - M Salhab
- Leeds Vascular Institute, General Infirmary at Leeds
| | - MD Sinclair
- Leeds Vascular Institute, General Infirmary at Leeds
| | - PJ Kent
- Leeds Vascular Institute, General Infirmary at Leeds
| | - MJ Gough
- Leeds Vascular Institute, General Infirmary at Leeds
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Vikatmaa P, Sairanen T, Lindholm JM, Capraro L, Lepäntalo M, Venermo M. Structure of Delay in Carotid Surgery – An Observational Study. Eur J Vasc Endovasc Surg 2011; 42:273-9. [DOI: 10.1016/j.ejvs.2011.04.021] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Accepted: 04/08/2011] [Indexed: 01/01/2023]
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Naggara O, Soares F, Touze E, Roy D, Leclerc X, Pruvo JP, Mas JL, Meder JF, Oppenheim C. Is it possible to recognize cervical artery dissection on stroke brain MR imaging? A matched case-control study. AJNR Am J Neuroradiol 2011; 32:869-73. [PMID: 21493767 DOI: 10.3174/ajnr.a2553] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Extracranial CAD accounts for nearly 20% of cases of stroke in young adults. The mural hematoma frequently extends cranially to the petrous carotid segment in cCAD or is distally located in vCAD. We hypothesized that standard brain MR imaging could allow the early detection of CAD of the upper portion of carotid and vertebral arteries. MATERIALS AND METHODS Our prospectively maintained stroke data base was retrospectively queried to identify all patients with the final diagnosis of CAD. In the 103 consecutive patients studied, analysis of cervical fat-suppressed T1-weighted sequences demonstrated that the mural hematoma was located in the FOV of brain MR imaging in 77 patients. Subsequent to enrollment of a patient, a control patient was extracted from the same data base, within a similar categories for sex, age, NIHSS score, and stroke on DWI. Two blinded observers independently reviewed the 5 brain MR sequences of each examination and determined whether a CAD was present. RESULTS Fifty-nine of the 77 patients with CAD (76.6%) and 73 of the 77 patients without CAD (94.8%) were correctly classified. Brain MR imaging demonstrated cCAD more frequently than vCAD in 54/58 (93.1%) and 5/19 (26.3%) patients, respectively, (P < .0001). CONCLUSIONS Initial brain MR imaging can correctly suggest CAD in more than two-thirds of patients. This may have practical implications in patients with stroke with delayed cervical MRA or in those who are not initially suspected of having CAD.
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Affiliation(s)
- O Naggara
- Department of Neuroradiology, Paris-Descartes University, INSERM U, Centre Hospitalier Sainte-Anne, France.
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Makris GC, Nicolaides AN, Geroulakos G. Histological analysis of the carotid plaque post-endarterectomy: a waste of time or a wasted piece of information? Eur J Vasc Endovasc Surg 2011; 42:13-4. [PMID: 21498091 DOI: 10.1016/j.ejvs.2011.03.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Accepted: 03/20/2011] [Indexed: 11/25/2022]
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Gröschel K, Schnaudigel S, Wasser K, Pilgram-Pastor SM, Ernemann U, Knauth M, Kastrup A. Factors associated with time delay to carotid stenting in patients with a symptomatic carotid artery stenosis. J Neurol 2011; 258:1228-33. [PMID: 21264472 PMCID: PMC3132402 DOI: 10.1007/s00415-011-5909-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 01/02/2011] [Accepted: 01/10/2011] [Indexed: 12/14/2022]
Abstract
Treatment of a symptomatic stenosis is known to be most beneficial within 14 days after the presenting event but this can frequently not be achieved in daily practice. The aim of this study was the assessment of factors responsible for this time delay to treatment. A retrospective analysis of a prospective two-center CAS database was carried out to investigate the potential factors that influence a delayed CAS treatment. Of 374 patients with a symptomatic carotid stenosis, 59.1% were treated beyond ≥14 days. A retinal TIA event (OR = 3.59, 95% CI 1.47–8.74, p < 0.01) was found to be a predictor for a delayed treatment, whereas the year of the intervention (OR = 0.32, 95% CI 0.20–0.50, p < 0.01) and a contralateral carotid occlusion (OR = 0.42, 95% CI 0.21–0.86, p = 0.02) were predictive of an early treatment. Similarly, within the subgroup of patients with transient symptoms, the year of the intervention (OR = 0.28, 95% CI 0.14–0.59, p < 0.01) was associated with an early treatment, whereas a retinal TIA as the qualifying event (OR = 6.96, 95% CI 2.37–20.47, p < 0.01) was associated with a delayed treatment. Treatment delay was most pronounced in patients with an amaurosis fugax, whereas a contralateral carotid occlusion led to an early intervention. Although CAS is increasingly performed faster in the last years, there is still scope for an even more accelerated treatment strategy, which might prevent future recurrent strokes prior to treatment.
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Affiliation(s)
- Klaus Gröschel
- Department of Neurology, University of Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Germany.
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Abstract
Carotid endarterectomy (CEA) has been proven to reduce the risk of stroke and death in both asymptomatic and symptomatic patients with carotid occlusive disease. Stroke is the third leading cause of death in the USA. Since up to one-third of stroke patients have a stroke secondary to carotid occlusive disease, it is important to offer CEA to this subgroup of patients that meet indications for surgery. Historically, literature has suggested that the optimal timing to perform CEA is approximately 6 weeks after an acute stroke. This was concluded owing to high perioperative morbidity and mortality if CEA was performed too early. However, data are increasingly showing that some patients do benefit from CEA earlier than 6 weeks after an acute stroke. This article discusses mid-20th Century literature and focuses on more recent 21st Century literature discussing the timing of CEA after acute stroke. Although there are data to support delayed CEA, it is reasonable to perform early CEA in select stroke patient populations. Candidates for early CEA should have complete or near resolution of symptoms, small infarcts on imaging and ipsilateral carotid stenosis.
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Affiliation(s)
- Mark L Keldahl
- Northwestern Memorial Hospital, Department of Vascular Surgery, 676 North St Clair, Chicago, IL 60611, USA
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Halliday A, Harrison M, Hayter E, Kong X, Mansfield A, Marro J, Pan H, Peto R, Potter J, Rahimi K, Rau A, Robertson S, Streifler J, Thomas D. 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. Lancet 2010; 376:1074-84. [PMID: 20870099 PMCID: PMC2956884 DOI: 10.1016/s0140-6736(10)61197-x] [Citation(s) in RCA: 588] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND If carotid artery narrowing remains asymptomatic (ie, has caused no recent stroke or other neurological symptoms), successful carotid endarterectomy (CEA) reduces stroke incidence for some years. We assessed the long-term effects of successful CEA. METHODS Between 1993 and 2003, 3120 asymptomatic patients from 126 centres in 30 countries were allocated equally, by blinded minimised randomisation, to immediate CEA (median delay 1 month, IQR 0·3-2·5) or to indefinite deferral of any carotid procedure, and were followed up until death or for a median among survivors of 9 years (IQR 6-11). The primary outcomes were perioperative mortality and morbidity (death or stroke within 30 days) and non-perioperative stroke. Kaplan-Meier percentages and logrank p values are from intention-to-treat analyses. This study is registered, number ISRCTN26156392. FINDINGS 1560 patients were allocated immediate CEA versus 1560 allocated deferral of any carotid procedure. The proportions operated on while still asymptomatic were 89·7% versus 4·8% at 1 year (and 92·1%vs 16·5% at 5 years). Perioperative risk of stroke or death within 30 days was 3·0% (95% CI 2·4-3·9; 26 non-disabling strokes plus 34 disabling or fatal perioperative events in 1979 CEAs). Excluding perioperative events and non-stroke mortality, stroke risks (immediate vs deferred CEA) were 4·1% versus 10·0% at 5 years (gain 5·9%, 95% CI 4·0-7·8) and 10·8% versus 16·9% at 10 years (gain 6·1%, 2·7-9·4); ratio of stroke incidence rates 0·54, 95% CI 0·43-0·68, p<0·0001. 62 versus 104 had a disabling or fatal stroke, and 37 versus 84 others had a non-disabling stroke. Combining perioperative events and strokes, net risks were 6·9% versus 10·9% at 5 years (gain 4·1%, 2·0-6·2) and 13·4% versus 17·9% at 10 years (gain 4·6%, 1·2-7·9). Medication was similar in both groups; throughout the study, most were on antithrombotic and antihypertensive therapy. Net benefits were significant both for those on lipid-lowering therapy and for those not, and both for men and for women up to 75 years of age at entry (although not for older patients). INTERPRETATION Successful CEA for asymptomatic patients younger than 75 years of age reduces 10-year stroke risks. Half this reduction is in disabling or fatal strokes. Net benefit in future patients will depend on their risks from unoperated carotid lesions (which will be reduced by medication), on future surgical risks (which might differ from those in trials), and on whether life expectancy exceeds 10 years. FUNDING UK Medical Research Council, BUPA Foundation, Stroke Association.
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Affiliation(s)
- Alison Halliday
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, UK.
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Maruthappu M, Shalhoub J, Thapar A, Jayasooriya G, Franklin IJ, Davies AH. The patients' perspective of carotid endarterectomy. Vasc Endovascular Surg 2010; 44:529-34. [PMID: 20675333 DOI: 10.1177/1538574410374657] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION No studies as yet have directly evaluated the patients' perspective of carotid endarterectomy (CEA). Here, we determine patient satisfaction, understanding, and perception of CEA. METHODS Consecutive patients were identified from a prospectively maintained carotid database. A validated 10-point telephone questionnaire was conducted. Questions related to preoperative symptoms, experience of procedure, future interventions, and overall patient satisfaction. RESULTS Of the 192 patients included, 136 completed the questionnaire (71% response rate). Ninety-two percent were satisfied with the explanation received, however, only 48% understood that CEA aimed to prevent future stroke. Eighty-five percent of patients received local anesthesia (LA) CEA, with 16% reporting severe or unbearable pain. Most patients (83%) would repeat CEA if necessary and 67% stated a future preference for LA CEA. The majority of patients (96%) were satisfied with their treatment overall. CONCLUSIONS Most patients were satisfied with CEA. Greater emphasis could be placed on improving preoperative information-giving and intraoperative analgesia.
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Harris JP. Carotid intervention: and so it goes, guidelines and timing. ANZ J Surg 2010; 80:386-7. [PMID: 20618186 DOI: 10.1111/j.1445-2197.2010.05303.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- John P Harris
- Division of Surgery, Royal Prince Alfred Hospital, University of Sydney, New South Wales 2006, Australia
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Abstract
INTRODUCTION Rapid-access carotid endarterectomy (RACE) is an evidence-based treatment for symptomatic carotid stenosis. Our vascular centre aims to provide this service within 48 h of symptoms in appropriate patients. This study audits safety and efficacy of the first year of RACE. SUBJECTS AND METHODS A clear trust protocol was publicised for the RACE pathway. A prospective database was established for all carotid endarterectomies (CEAs) performed. Outcomes were compared between elective (ECE) and rapid-access operations. RESULTS In 1 year, 96 patients received CE; 20 were performed urgently. There were no significant differences in age or gender between ECE and RACE groups. Twenty-three (30%) of ECE were for asymptomatic stenoses; no other significant differences in surgical indication were seen. Of symptomatic ECE, 43% were for completed stroke versus 55% for RACE. Median delay between diagnosis and surgery was 113 days for elective and 2 days for RACE patients. There was one death following ECE (1.3%) and one stroke after RACE (5%), all not significant. Anaesthetic method did not influence outcome. The main reasons for delaying surgery in RACE patients were optimisation of patient fitness and availability of theatre time. CONCLUSIONS The RACE pathway dramatically reduces delay without compromising patient safety. In the first year of service, we have treated 50% of suitable patients within 48 h. Further education of patients and colleagues should reduce delay and improve outcomes for symptomatic carotid disease.
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Affiliation(s)
- Thomas E Rix
- Department of Vascular Surgery, East Kent Vascular Centre, Canterbury Hospital, Canterbury, Kent, CT1 3NG, UK.
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Khashram M, Roake JA, Lewis DR. Patient flow to carotid endarterectomy: hastening the patient journey. ANZ J Surg 2010; 80:406-10. [DOI: 10.1111/j.1445-2197.2010.05308.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Gamie Z, Wood F, Vohra RS, Gough MJ. Comment on: Changes required to improve CEA outcomes. Ann R Coll Surg Engl 2010; 92:173. [PMID: 20353647 DOI: 10.1308/003588410x12628812459175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Ross Naylor A. Known knowns, known unknowns and unknown unknowns: a 2010 update on carotid artery disease. Surgeon 2010; 8:79-86. [PMID: 20303888 DOI: 10.1016/j.surge.2010.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 01/24/2010] [Indexed: 10/19/2022]
Abstract
The management of carotid artery disease never ceases to attract controversy. The last 12 months has seen publication of a number of important studies which have informed debate and 2010 holds the prospect of much more. This update offers a personal review of a number of contemporary issues including; (i) guidelines for non-invasive imaging in rapid access clinics, (ii) whether improvements in best medical therapy have rendered many of the conclusions from ACAS and ACST obsolete, (iii) is carotid disease really just a marker for increased stroke risk following cardiac surgery (rather than being an important cause), (iv) what is the current status of endarterectomy and stenting in patients with symptomatic carotid disease and (v) why we must offer expedited interventions to TIA/minor stroke patients. The available evidence suggests that while most 'known knowns' will endure, quite a few may be returning to the category of 'known unknowns' once again. Who knows what 'unknown unknowns' await us in 2010 and beyond.
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Affiliation(s)
- A Ross Naylor
- Department of Vascular Surgery, Clinical Sciences Building, Leicester Royal Infirmary, Leicester, UK.
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