Clinical Research
A Stroke/Vascular Neurology Service Increases the Volume of Urgent Carotid Endarterectomies Performed in a Tertiary Referral Center

https://doi.org/10.1016/j.avsg.2013.10.002Get rights and content

Background

Increasing evidence supports that urgent carotid endarterectomy (CEA), defined as CEA during the index hospitalization, may be undertaken in select patients with acute carotid-related neurologic symptoms to prevent recurrent ischemic events. We aimed to determine the effect of a stroke/vascular neurology service on the volume of urgent CEAs performed and assess perioperative outcomes.

Methods

A retrospective review from a single tertiary referral center between June 2005 through December 2011 revealed 393 patients who underwent CEA. We identified the number of urgent CEAs before (June 2005–August 2008) and after (September 2008–December 2011) a stroke/vascular neurology service was implemented, as well as asymptomatic CEAs and symptomatic but electively performed CEAs. Demographic data as well as 30-day adverse outcomes (transient ischemic attack [TIA], stroke, myocardial infarction, and mortality) were analyzed for each group. In patients undergoing urgent CEA, TIA and stroke severity were assessed by a stroke neurologist using the ABCD2 TIA score and National Institutes of Health Stroke Scale (NIHSS), respectively. The χ2 test was used to compare differences between the urgent CEA volume before and after a stroke/vascular neurology service. Fisher's exact test was used to analyze perioperative outcomes.

Results

Demographics and comorbidities were similar between the 2 groups. The proportion of urgent CEAs performed increased significantly after initiation of a vascular neurology service (4.1% [7 of 172] vs. 22.2% [49 of 221], P < 0.0001). Per annum, urgent CEAs increased from 5.3% (4/75) in 2005 to 39.6% (25/63) in 2011. A vascular neurology service did not increase the number of nonurgent referrals. Urgent CEA indications were ocular ischemic events 4% (2/49), cerebral ischemic/infarction events 35% (17/49), crescendo TIAs 6% (3/49), acute stroke 45% (22/49), and stroke-in-evolution 10% (5/49). Mean NIHSS was 3.5 (range 0–24); mean TIA score was 5 (range 1–8). Although there were no statistical differences in 30-day outcomes, there was a trend toward a higher combined complication rate (stroke, death, myocardial infarction) in the urgent compared with the symptomatic but electively performed CEA group (7.1 % [3/49] vs. 2% [1/49]; P = .36). However, patients undergoing urgent CEA with an NIHSS <10 had no perioperative complications.

Conclusions

Collaboration with a vascular neurology team increased the volume of urgent CEAs over a 3-year period. In patients with mild-to-moderate strokes (NIHSS <10), urgent CEA perioperative outcomes approximate those for electively performed CEAs, suggesting improved care through a multidisciplinary approach.

Introduction

Patients presenting with acute carotid-related neurologic symptoms are at a heightened risk of a stroke.1 Natural history data suggests that the risk of stroke after a transient ischemic attack (TIA) is 6.7% at 2 days and up to 11.7% at 7 days.2 This significant stroke rate was found in patients presenting with TIAs aged over 60 years, hypertensive patients, diabetics, and those experiencing unilateral weakness for 60 minutes or more. Several groups have thus advocated for carotid endarterectomy (CEA) during the index hospitalization (urgent CEA) in select patients with acute neurologic symptoms to minimize the risk of recurrent ipsilateral cerebral ischemic events.3, 4, 5, 6, 7 Moreover, a subset of patients with few comorbidities undergoing urgent CEA were found to have low rates of perioperative complications.8

The effect of rapid-access TIA clinics on procedures performed and outcomes has been recently described.9, 10 Implementation of a 24-hour TIA clinic in France led to earlier medical optimization and identified a subset of patients (5%) who underwent urgent CEA.9 Moreover, the expected 90-day stroke rate was reduced from 5.96% to 1.24%, based on predicted ABCD2 TIA scores. In the United Kingdom, Naylor and colleagues recently demonstrated that establishment of a TIA clinic led to decreased delays in referral to CEA from the index ischemic event from 9 to 4 days.10

However, the effects of a dedicated stroke/vascular neurology service on the inpatient management of patients presenting with acute carotid-related events has not been described. Because the majority of patients with acute neurologic symptoms present acutely to the emergency department, the inpatient management of such patients through coordinated service lines is important. We sought to determine whether a dedicated stroke/vascular neurology service increases the volume of urgent CEAs performed in a tertiary referral center and assess perioperative outcomes.

Section snippets

Methods

All CEA procedures performed for asymptomatic and symptomatic carotid stenosis at the Ochsner Clinic in New Orleans, Louisiana, between June 1, 2005 and December 31, 2011 were retrospectively reviewed after obtaining institutional review board approval. Symptomatic but electively performed CEA patients were defined as those presenting with an ocular ischemic events, cerebral TIAs, or stroke within 6 months.

Urgent CEA patients were defined as those with recent (<10 days) ischemic symptoms who

Results

A retrospective review of all CEA for the 39-month period before and after initiation of a stroke/vascular neurology service (between June 2005 thru December 2011) revealed 393 patients that underwent CEA. Demographics and comorbidities were similar between the 2 groups (Table 1). The proportion of urgent CEAs performed increased significantly after initiation of a vascular neurology service (4.1% [7/172] vs. 22.2% [49/221], P < 0.0001 via contingency table; Fig. 1A). Per annum, urgent CEAs

Discussion

Our study demonstrates the novel finding that a stroke/vascular neurology service positively affects the volume of urgent CEAs performed over a 3-year period in a tertiary referral center. We cannot find any reports in the literature that describe the practice pattern effects between a stroke/vascular neurology team and vascular surgery on the proportion of urgent CEAs performed. Our data also suggest that periprocedural outcomes for urgent CEAs in patients with stable and unstable neurologic

Conclusions

Our study demonstrates that close collaboration between vascular surgery and a dedicated stroke/vascular neurology service positively affects the volume and outcome of urgent CEAs performed in a tertiary referral center. No complications were noted in patients who presented with NIHSS <10.

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