Clinical ResearchA Stroke/Vascular Neurology Service Increases the Volume of Urgent Carotid Endarterectomies Performed in a Tertiary Referral Center
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.
References (17)
- et al.
Risk of stroke after TIA: a systemic review and meta-analysis
Lancet Neurol
(2007) - et al.
Validation and refinement of scores to predict very early stroke risk after TIA
Lancet
(2007) - et al.
Carotid endarterectomy after ischemic stroke—is there justification for delayed surgery?
Eur J Vasc Endovasc Surg
(2005) Occam's razor: intervene early to prevent more strokes!
J Vasc Surg
(2008)- et al.
Early versus delayed carotid endarterectomy in symptomatic patients
J Vasc Surg
(2012) - et al.
Urgent carotid endarterectomy is safe in patients with few comorbid medical conditions
Ann Vasc Surg
(2008) - et al.
A transient ischaemic attack clinic with round-the-clock access (SOS-TIA): feasibility and effects
Lancet Neurol
(2007) - et al.
Rapid access carotid endarterectomy can be performed in the hyperacute period without a significant increase in procedural risks
Eur J Vasc Endovasc Surg
(2011)
Cited by (13)
Editor's Choice – European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease
2023, European Journal of Vascular and Endovascular SurgeryCitation Excerpt :This advice is supported by the 2021 ESO and German-Austrian guidelines.2,3 MDTs increase the proportion undergoing urgent CEA (22% vs. 4%, p < .001).201 Waiting for MDT meetings should not introduce unnecessary delay and urgent decisions can be made by at least two members.
Editor's Choice – Management of Atherosclerotic Carotid and Vertebral Artery Disease: 2017 Clinical Practice Guidelines of the European Society for Vascular Surgery (ESVS)
2018, European Journal of Vascular and Endovascular SurgeryCirculating inflammation-resolving lipid mediators RvD1 and DHA are decreased in patients with acutely symptomatic carotid disease
2017, Prostaglandins Leukotrienes and Essential Fatty AcidsCitation Excerpt :Asymptomatic patients with high-grade carotid stenosis (≥ 80% internal carotid stenosis based on duplex ultrasound imaging) were included in the stable or asymptomatic carotid atherosclerotic plaque group. Patients presenting with symptoms of temporary or partial/complete loss of vision, a transient ischemic attack, and/or an established stroke with good neurologic recovery in the index hospitalization and deemed safe to undergo CEA were included as urgent or unstable carotid plaques [6]. The cohort included 24 asymptomatic and 21 acutely symptomatic patients deemed candidates for an urgent carotid endarterectomy (CEA) during the index hospitalization [7]; mean time to intervention for acute interventions was 2.6 days (Table 1).
Urgent carotid intervention is safe after thrombolysis for minor to moderate acute ischemic stroke
2015, Journal of Vascular SurgeryCitation Excerpt :Informed consent was waived by our Institutional Review Board. Carotid interventions (CEA and CAS) performed during the same (index) hospitalization for an acute cerebral TIA or stroke were deemed urgent, as previously defined.6,14 These patients underwent CEA or CAS for ischemic symptoms during the same admission as their initial presenting acute neurologic event, that is, during the index hospitalization.
Frequency of inter-specialty consensus decisions and adherence to advice following discussion at a weekly neurovascular multidisciplinary meeting
2023, Irish Journal of Medical Science