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Interact CardioVasc Thorac Surg 2009;8:534-537. doi:10.1510/icvts.2008.200659 © 2009 European Association of Cardio-Thoracic Surgery
Is the urgent carotid endarterectomy in patients with acute neurological symptoms a safe procedure?
a Department of Cardiovascular Surgery, Hietzing Hospital, Wolkersbergenstr. 1, A-1130 Vienna, Austria Received 14 December 2008; received in revised form 16 January 2009; accepted 19 January 2009
*Corresponding author. Tel.: +43-1-80110; fax: +43-1-80110-2729.
The aim of the present case-control study was to assess patients with acute neurological symptoms requiring urgent carotid endarterectomy (CEA) and compare the outcome of the procedure in this group with that achieved in stable patients. Twenty-eight CEAs were performed in patients with an acute neurological deficit and 302 in stable patients from December 2006 to April 2008. Those selected for urgent surgery fulfilled the following criteria: acute onset of hemispheric neurological symptoms or crescendo TIAs, significant carotid pathology, the absence of cerebral hemorrhage, uncompromised vigilance, and stable cardiopulmonary conditions. Perioperative mortality in the stable patients' cohort was 0.33%. One patient died during the hospital stay because of myocardial infarction. Perioperative neurological events were observed in 2.2%: one ipsilateral stroke in stage II A, one contralateral stroke in stage I A, and a prolonged neurological deficit with complete restitution at the time of discharge in five patients. No mortality or neurological morbidity was encountered in those who underwent urgent CEA. Compared to stable patients with stage I, II or IV disease, neither mortality nor morbidity was increased in those who underwent urgent CEA. Urgent CEA after non-disabling stroke or crescendo TIAs is a safe procedure with a favorable outcome.
Key Words: Carotid endarterectomy; Crescendo TIA; Acute stroke
Carotid endarterectomy (CEA) is one of the most effective surgical interventions in vascular surgery, as has been demonstrated in several randomized, prospective clinical trials. Indications for carotid disobliteration in patients with acute neurological symptoms still are a debated issue. The policy to delay surgery for at least six weeks in patients with acute stroke is based on historical data confirming the risk of secondary cerebral hemorrhage into the ischemic infarction area and the risk of clinical deterioration. In contrast, recent studies have emphasized the safety and the acceptable perioperative stroke or mortality rate after early CEA in patients after non-disabling stroke or acute neurological events [1–5]. The aim of the present study was to assess patients with acute neurological symptoms requiring urgent CEA and compare the outcome of the procedure in this group with that achieved in stable patients.
Three-hundred and two CEAs and 28 urgent CEAs were performed at our department from December 2006 to April 2008. Preoperative diagnostic procedures consisted of documentation of the patients' medical history, a neurological examination, duplex ultrasound, and a computed tomography of the brain with contrast medium. All patients gave their informed consent prior to surgery. The work had been approved by the local ethics committee. General patient characteristics are summarized in Table 1.
In 28 cases (8.4% of all cases) CEA was performed in patients with an acute neurological deficit. Those selected for urgent surgery fulfilled the following criteria: significant carotid pathology, the absence of cerebral hemorrhage, uncompromised vigilance, and stable cardiopulmonary conditions. Prior neurological histories included crescendo transient ischemic attack (TIA) classified as stage IIIA in two patients and stroke in evolution (stage IIIB) in two (14.3%), and acute stroke in 24 patients (85.7%) (Table 2).
The interval between the onset of symptoms and CEA was on average four days (range, 9 h–2 weeks). The patients' disability was assessed by the use of a modified Rankin scale. Twelve patients (42.9%) had severe disability: they were unable to walk or attend to their bodily needs without assistance (Rankin 4). Thirteen patients (46.4%) were moderately disabled as they needed some help but were able to walk without assistance (Rankin 3). Two patients (7.1%) had mild disability: they were unable to perform all of their previous activities but could tend to their needs without assistance (Rankin 2). All patients received oral aspirin or clopidogrel without interruption. The urgent operations were conducted under general anesthesia and intravenous administration of 5000 units of heparin. Carotid reconstruction was performed on a vein or using a PTFE patch and inserting a shunt. In all patients who underwent urgent CEA, shunt insertion was performed immediately after arteriotomy before removing the atherosclerotic plaque to provide instantly cerebral protection. After urgent CEA all patients were transferred to the intensive care or stroke unit for 24–48 h. The preoperative cerebrovascular status of the control group was as follows: stage IA and IB in 151 patients (50%), stage II A+B in 123 patients (40.7%) and stroke (stage IV) in 28 patients (9.3%). In agreement with NASCET, the degree of the stenosis in the internal carotid artery was calculated as the percentage of diameter reduction. A 70% stenosis was noted in 25 patients (8.3%), 70–90% in 148 patients (49%), and more than 90% in 128 patients (42.4%); one patient had an occlusion based on a thrombosis after attempted placement of a stent graft (0.3%). General (90.7%) or regional (9.3%) anesthesia was performed due to patients' choice. A thrombendarterectomy with a vein patch obtained from the great saphenous vein (84.2%) or synthetic patch plasty (15.8%) was performed in 152 patients (50.3%) while an endarterectomy by the eversion technique was performed in 150 (49.7%) depending on surgeon's choice. In 33.1% of elective cases a shunt was inserted, predominately in patients with contralateral occlusion or high-grade stenosis of the internal carotid artery. Hemostatic agent made of oxidized cellulose gauze (Tabotamp®, Johnson & Johnson Gateway Inc, Norderstedt, Germany) and 0.5 ml fibrin glue (Tissucol®, Baxter Inc, Deerfield, IL) was used to avoid hemorrhages after carotid endarterectomy. Postoperative controls by a consultant neurologist and ultrasound scanning were conducted on a routine basis. The outcome was obtained from our vascular database (S2 Engineering Ltd, Steyr, Austria). Standard statistical analysis was performed using Fisher's exact test (NCSS Inc, Kaysville, UT) and Fisher–Freeman–Halton Test (Cytel Inc, Cambridge, MA) for categorical variables, where appropriate. A result was considered to be statistically significant at P<0.05.
In patients who underwent urgent carotid endarterectomy no mortality or neurological morbidity were encountered. Hyperlipidemia was identified as a significant risk factor in the urgent patient group (P<0.005, test power 0.931). All other risk factors did not reach statistical significance or test power. Although high-grade stenosis, more than 90% of the ipsilateral carotid artery was tendentiously higher in the control group (P=0.074), most of plaques in the urgent patient group examined by duplex ultrasound revealed irregular surfaces and displayed mixed (i.e. heterogeneous) echogenic patterns (92.8%) comparing with the control group (22.5%). The combined postoperative stroke and mortality rate in all 302 patients was 1%. One patient died because of myocardial infarction on postoperative day 3. Two patients suffered a stroke: one in stage IIA on the ipsilateral side, and one asymptomatic patient on the contralateral side. Five patients (three in stage II B and two in stage I B) had a prolonged neurological deficit with complete restitution at the time of discharge. One patient in stage IA had an asymptomatic occlusion of the internal carotid artery postoperatively. Minor complications consisted of reoperation due to bleeding in three cases (1%); none of these occurred in the urgent CEA group. The periprocedural risk of undertaking urgent CEA comparing with the control group was not increased (P=0.609, Fisher's exact test). Out of 28, seven patients (25%) who underwent urgent CEA improved their neurological disability by one unit on the Rankin scale (4 to 3) during their hospital stay. Consequently, the postoperative period of neurorehabilitation was reduced. Five patients with severe motor deficit in Rankin scale IV and all patients with mild and moderate deficits in Rankin scale II and III remained stable.
The rationale for urgent carotid endarterectomy in patients presenting with crescendo transient ischemic attacks, acute stroke or stroke in evolution is to improve cerebral perfusion in order to ensure blood flow to ischemic areas of the brain and eradicate the source of embolic events secondary to unstable atheromatous plaque in the internal carotid artery. An interval of four to six weeks after acute stroke has been recommended in the past because of the risk of converting a non-hemorrhagic infarct into a hemorrhagic one and consequent extension of the infracted area. In a large investigation of 1046 cases, Rockman et al. [6] stated that patients who underwent early CEA were significantly more likely to experience a perioperative stroke than those who underwent delayed CEA (5.1% early CEA vs. 1.6% delayed CEA). However, patients with symptoms of crescendo transient ischemic attacks or stroke-in-evolution were excluded from this analysis (n=25).
In contrast to these studies, an increasing number of publications support CEA in the early period after ischemic stroke. In addition, recent prospective studies confirmed the safety and effectiveness of early surgery [2, 3]. Most importantly, a subgroup analysis of the European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET) by Rothwell et al. [7] showed greater benefit of surgery when performed close to the last symptomatic event. The authors registered an absolute risk reduction of 23% (95% CI 3.8–15.7) in patients with The prevention of recurrent stroke is one of the foremost goals of urgent treatment of carotid lesions. Thirty per cent of all recurrent strokes occur within 30 days. The recurrence rate of ipsilateral stroke ranges between 9.5% within six weeks and 17% within one year [8]. In the NASCET study, 4.9% of 103 medically treated patients experienced a recurrent carotid-related stroke within 30 days [1]. The hypothesis of embolization from unstable carotid plaques supports the strategy for urgent carotid endarterectomy. No postoperative strokes occurred in our cohort. Similar to the investigators of NASCET, we encountered no bleeding of parenchyma after urgent surgery. In their prospective study, Eckstein and coworkers [2] report one postoperative cerebral hemorrhage, while nine patients with newly identified hemorrhagic transformations showed no clinical impairment. In a further study, postoperative cerebral bleeding was noted in 0.7% of patients (11 of 1500); none of these patients had previously experienced a stroke [9]. The assertion of increased cerebral hemorrhage after early CEA performed in the past is supported neither by studies focusing on early CEA nor by the overall risk of cerebral bleeding as reported earlier or registered in the present study. Pre- and postoperative neurological assessment in urgent CEA after crescendo TIA or acute stroke revealed a remarkable improvement in subjects with a Rankin score of 4. Of our subgroup with this score, 58% improved their score by one unit (Rankin score 3; moderate neurological deficit) during their hospital stay. In a comparative study, urgent carotid surgery resulted in a recovery rate of 70%; of those who underwent conservative treatment only 19% recovered while 65% remained unchanged [10]. In a study investigating carotid surgery for ischemic stroke, comprising 164 subjects, neurological improvement was achieved in a large number of patients during the first few weeks after surgery [2]. The majority of other studies report that early CEA performed within two weeks of ischemic stroke or crescendo TIA improved the patients' functional outcome and was also associated with a shorter hospital stay [11, 12]. Bond et al. [13] performed a meta-analysis of thirteen studies, showing a higher operative risk in urgent cases, whereas early surgery for evolving symptoms, performed in 794 patients, was associated with no additional risk compared to late CEA. An overview of reported urgent CEAs is summarized in Table 3.
The American Heart Association's Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack recommend surgery within two weeks when CEA is indicated for patients with TIA or stroke (Class IIa, level of evidence B) [14]. The study is limited by the small sample size of the urgent CEA group and by additional biases that are associated with retrospective analysis. Additional information such as histopathological plaque morphology and follow-up data will be assessed in the future and will provide more information to investigate this issue. The findings of the present study support urgent carotid endarterectomy in patients presenting with acute neurological symptoms. Interdisciplinary cooperation between neurologists, anesthesiologists and vascular surgeons is mandatory to ensure correct decision-making in these clinically demanding patients.
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Abstract
1. Introduction
70% stenosis of the ICA operated within two weeks. Our results, in conjunction with the above mentioned findings, have major implications for urgent revascularization.