Unit:
Faculty of MedicineLibrary of the School of Health Sciences
Author:
Roussopoulou Andromachi
Dissertation committee:
Βασδέκης Σπυρίδων, Καθηγητής Αγγειοχειρουργικής, Ιατρική Σχολή ΕΚΠΑ
Πικουλής Εμμανουήλ, Καθηγητής Χειρουργικής, Ιατρική Σχολή ΕΚΠΑ
Βουμβουράκης Κωνσταντίνος, Καθηγητής Νευρολογίας, Ιατρική Σχολή ΕΚΠΑ
Τσιβγούλης Γεώργιος, Καθηγητής Νευρολογίας, Ιατρική Σχολή ΕΚΠΑ
Γεωργόπουλος Σωτήριος, Καθηγητής Αγγειοχειρουργικής, Ιατρική Σχολή ΕΚΠΑ
Λάζαρης Ανδρέας του Μιχ., Αναπληρωτής καθηγητής Αγγειοχειρουργικής, Ιατρική Σχολή ΕΚΠΑ
Παρασκευάς Γεώργιος, Αναπληρωτής καθηγητής Νευρολογίας, Ιατρική Σχολή ΕΚΠΑ
Original Title:
Υπερεπείγουσα ενδαρτηρεκτομή καρωτίδων σε ασθενείς με συμπτωματική στένωση καρωτίδων.
Translated title:
Urgent carotid endarterectomy in patients with symptomatic carotid stenosis
Summary:
Backround and Purpose: International recommendations advocate that carotid endarterectomy (CEA) should be performed within two weeks from the index event in symptomatic carotid artery stenosis (sCAS) patients. However, there are controversial data regarding the safety of CEA performed during the first two days of ictus. Perioperative neck hematoma (PNH) requiring re-intervention is an important complication after CEA. There are limited data regarding the potential risk factors associated with PNH. The aim of this international, multicenter study was to prospectively evaluate the safety of urgent (0-2 days) in comparison to early (3-14 days) CEA in patients with sCAS and to identify possible predictors related to PNH.
Methods: 1) Consecutive patients with non-disabling (mRS scores≤2) acute ischemic strokes (AIS) or Transient Ischemic Attacks (TIA) due to sCAS (≥70%) underwent urgent or early CEA at five tertiary-care stroke centers during a six-year period. The primary outcome events included stroke, myocardial infarction (MI) or death during the 30-day follow-up period.
2) Patients with non-disabling (mRS ≤2) acute ischemic stroke or transient ischemic attack due to sCAS (≥70%) underwent CEA at three stroke-centers during a seven-year period. PNH requiring surgical re-intervention or transfusion during a 30-day follow-up period was determined by the attending surgeon but was also confirmed by an independent neurologist.
Results:
1) A total of 311 patients with sCAS underwent urgent (n=63) or early (n=248) CEA. The two groups did not differ in baseline characteristics with the exception of crescendo TIAs (21% in urgent vs. 7% in early CEA; p=0.001). The 30-day rates of stroke did not differ (p=0.333) between patients with urgent (7.9%; 95% CI: 3.1%-17.7%) and early (4.4%; 95% CI: 2.4%-7.9%) CEA. The mortality and MI rates were similar between the two groups. The median length of hospitalization was shorter in urgent CEA [6 days (IQR 4-10) vs. 10 days (IQR 7-14); p<0.001].
2) A total of 280 patients with sCAS underwent CEA within 14 days of ictus. PNH occurred in 10 cases (3.6%; 95%CI: 1.4%-5.8%). Pretreatment with therapeutic anticoagulation (TA) and history of atrial fibrillation were more prevalent in patients with PNH (20% vs. 3.1%, p=0.047 and 30% vs. 8.2%, p=0.05 respectively). Elapsed time between symptom onset and carotid surgery, pretreatment with dual antiplatelets, intravenous thrombolysis or prophylactic anticoagulation were not related to PNH in univariable analyses. Pretreatment with TA was independently associated with higher likelihood of PNH [OR: 10.69, 95%CI (1.74-65.72), p= 0.011] in multivariate logistic regression models adjusting for potential confounders.
Conclusions:
1) Our findings highlight that urgent CEA performed within two days from the index event is related to a non-significant increase in the risk of peri-procedural stroke. The safety of urgent CEA requires further evaluation in larger datasets that can additionally evaluate in detail if urgent procedure might also be related to reduced length of hospitalization and diminished hospital costs.
2) PNH is uncommon in patients with sCAS that are operated during the first 14 days of ictusand is not related to increased risk of cardiovascular or poor functional outcomes. Pretreatment with therapeutic anticoagulation and low-molecularweight heparin in particular appears to be associated with a higher risk of PNH, however this finding needs to be further evaluated in larger, international registries.
Main subject category:
Health Sciences
Keywords:
Endarterectomy, Carotid, Surgery, Stroke, Neck, Symptomatic, Hematoma, Urgent, Stenosis.
Number of references:
192
