Urgent Carotid Endarterectomy for Patients With Unstable Symptoms
Urgent Carotid Endarterectomy for Patients With Unstable Symptoms
Current evidence suggests that carotid endarterectomy (CEA) performed within 2 weeks of symptoms produces better long-term results than if it is delayed. Urgent endarterectomy following unstable presentations such as crescendo transient ischemic attack (cTIA) or progressive stroke has been associated with variable results. The evidence for this treatment strategy required reviewing. A systematic review of articles related to urgent CEA between 1980 and 2008 was performed. For cTIA, there was an odds ratio of 5.6 (95% confidence interval 3.3–9.7, p ≤ .0001) for combined stroke or death compared with surgery for "standard" indications. For unstable stroke, the odds ratio was 5.5 (95% confidence interval 3.1–9.3, p ≤ .0001). Patients with unstable neurologic presentations are at higher risk of complications if operated on urgently. Clearer definitions would help more precise patient selection to avoid inadvertently operating on patients with an unacceptably high risk of poor outcome.
Carotid endarterectomy (CEA) is the treatment of choice for severe, symptomatic carotid atherosclerosis. Reanalysis of data from two large randomized trials brought compelling evidence that CEA within 2 weeks of the index symptom prevented further disabling neurologic events. A recent meta-analysis suggested that the risk of recurrent major stroke after a transient ischemic attack (TIA) was significant, and observational studies have described these events in patients awaiting CEA. Furthermore, it appeared that as the interval between symptoms and surgery increased, the benefit obtained from CEA declined proportionately. This effect was especially pronounced in females. In the United Kingdom, this evidence has been used in synthesis of documents such as the National Stroke Strategy (UK Department of Health) and the National Clinical Guidelines for Stroke (Royal College of Physicians). Most recently, the National Institute of Clinical Excellence (NICE) recommended that patients at high risk of stroke should undergo urgent imaging within 1 week and surgery within 2 weeks.
Despite recent interest, acute CEA following stroke and TIA has historically produced poor results. Early studies included patients with severe neurologic deficit, including coma, and no reliable method was available to differentiate hemorrhagic strokes. These factors may have contributed to the high stroke and mortality rates of up to 42%. This helped support the notion that a 6-week delay prior to surgery was required to allow stabilization of the cerebral infarction, thus avoiding hemorrhagic transformation. More recently, improvements in preoperative planning and perioperative care have allowed early CEA performed in the weeks or days after symptom onset with acceptable risk. Despite this, some continue to report comparatively poor results from early surgery and to advocate an interval of 4 to 6 weeks between symptoms and surgery. At present, the recommendation from NICE is not to operate on patients with unstable presentations, based on a systematic review from 2005. The review contained only two studies that pertain to crescendo transient ischemic attack (cTIA), which reported poor results.
Owing to the lack of consensus regarding the appropriateness of urgent surgery in cTIA and progressive stroke, a systematic review of the literature and meta-analysis was performed. This conformed to the QUOROM statement.
Abstract and Introduction
Abstract
Current evidence suggests that carotid endarterectomy (CEA) performed within 2 weeks of symptoms produces better long-term results than if it is delayed. Urgent endarterectomy following unstable presentations such as crescendo transient ischemic attack (cTIA) or progressive stroke has been associated with variable results. The evidence for this treatment strategy required reviewing. A systematic review of articles related to urgent CEA between 1980 and 2008 was performed. For cTIA, there was an odds ratio of 5.6 (95% confidence interval 3.3–9.7, p ≤ .0001) for combined stroke or death compared with surgery for "standard" indications. For unstable stroke, the odds ratio was 5.5 (95% confidence interval 3.1–9.3, p ≤ .0001). Patients with unstable neurologic presentations are at higher risk of complications if operated on urgently. Clearer definitions would help more precise patient selection to avoid inadvertently operating on patients with an unacceptably high risk of poor outcome.
Introduction
Carotid endarterectomy (CEA) is the treatment of choice for severe, symptomatic carotid atherosclerosis. Reanalysis of data from two large randomized trials brought compelling evidence that CEA within 2 weeks of the index symptom prevented further disabling neurologic events. A recent meta-analysis suggested that the risk of recurrent major stroke after a transient ischemic attack (TIA) was significant, and observational studies have described these events in patients awaiting CEA. Furthermore, it appeared that as the interval between symptoms and surgery increased, the benefit obtained from CEA declined proportionately. This effect was especially pronounced in females. In the United Kingdom, this evidence has been used in synthesis of documents such as the National Stroke Strategy (UK Department of Health) and the National Clinical Guidelines for Stroke (Royal College of Physicians). Most recently, the National Institute of Clinical Excellence (NICE) recommended that patients at high risk of stroke should undergo urgent imaging within 1 week and surgery within 2 weeks.
Despite recent interest, acute CEA following stroke and TIA has historically produced poor results. Early studies included patients with severe neurologic deficit, including coma, and no reliable method was available to differentiate hemorrhagic strokes. These factors may have contributed to the high stroke and mortality rates of up to 42%. This helped support the notion that a 6-week delay prior to surgery was required to allow stabilization of the cerebral infarction, thus avoiding hemorrhagic transformation. More recently, improvements in preoperative planning and perioperative care have allowed early CEA performed in the weeks or days after symptom onset with acceptable risk. Despite this, some continue to report comparatively poor results from early surgery and to advocate an interval of 4 to 6 weeks between symptoms and surgery. At present, the recommendation from NICE is not to operate on patients with unstable presentations, based on a systematic review from 2005. The review contained only two studies that pertain to crescendo transient ischemic attack (cTIA), which reported poor results.
Owing to the lack of consensus regarding the appropriateness of urgent surgery in cTIA and progressive stroke, a systematic review of the literature and meta-analysis was performed. This conformed to the QUOROM statement.
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