When is it safe to surgically intervene on symptomatic carotid stenosis? A meta-analysis of periprocedure risk.
De Rango P, Brown MM, Chaturvedi S, Howard VJ, Jovin T, Mazya MV, et al. Summary of Evidence on Early Carotid Intervention for Recently Symptomatic Stenosis Based on Meta-Analysis of Current Risks. Stroke. 2015
Carotid surgery is recommended for stroke prevention in patients with symptomatic severe carotid stenosis. However, the appropriate timing of intervention remains ambiguous. Trials assessing carotid endarterectomy (CEA) were conducted in the early 1990’s when medical therapy may have been less optimal compared to current standards. Current guidelines recommend revascularization within 2 weeks of index event. This study reviewed data for periprocedure stroke and death following CEA and carotid artery stenting (CAS) in recently symptomatic carotid stenosis in three stratified timeframes: Timing was stratified into 3 timeframes: 0-48 hours, 0-7 days, and 0-15 days.
The authors reviewed outcome data on patients undergoing CEA and CAS from 2008 to 2015 within 15 days of index ischemic event. Of note, there were no randomized clinical trials with direct comparison of outcomes according to timing and studies included case series. The pooled risk of stroke and death within 15 days of CEA or CAS were 3.8% and 6.9%, respectively. CEA performed within 7 days, pooled risk was 3.6% and 6.6% in CAS. Risk of CEA and CAS performed within 40 hours was 5.7% and 5.4%, respectively. This risk was higher when the index event was an infarct versus TIA for both interventions at all three time points.
This data suggests very early carotid revascularization (within 48 hours) may be associated with increased periprocedural stroke risks but revascularization within the first week is associated with a more favorable risk. This data also suggests that risk profile is more optimal in patients with TIA rather than infarction. However, this data is not derived from studies that randomized patients to intervention based on timing. Furthermore, patients included in these studies were not randomized to aggressive medical therapy, which perhaps could be an appropriate alternate strategy. The authors pointed out that reporting of indication of urgent revascularization and patient criteria was variable thereby limiting its interpretation. This can introduce a self-fulfilling prophecy where patients who are felt to be ideal candidates for early intervention are selectively chosen. Prospective randomized trials should be conducted to shed light on ideal timing of revascularization in the background of modern medical therapy.