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Carotid endarterectomy in the acute phase of stroke-in-evolution is safe and effective in selected patients.
J Vasc Surg. 2012 Mar; 55(3):701-7.JV

Abstract

OBJECTIVE

This study documented with independent neurologic assessment the 30-day and 90-day outcomes in selected patients with severe internal carotid artery (ICA) stenosis who underwent carotid endarterectomy (CEA) in the acute phase of stroke-in-evolution (SIE).

METHODS

From January 2003 to December 2010, data from patients who had surgery ≤2 weeks of an SIE with high-grade carotid stenosis were extracted from two prospectively collected databases. Clinical assessment was by the vascular neurologist using the National Institute of Health Stroke Scale (NIHSS) and the modified Rankin Scale score. All patients had computed tomography or magnetic resonance brain imaging ≤3 hours of stroke onset. Those eligible received thrombolysis. Duplex ultrasound imaging was initially used for the diagnosis of severe (≥60%) ICA stenosis, and further assessment was by magnetic resonance or computed tomography angiography, or both. Perioperative medical treatment and operative techniques were standardized. Stroke, death, major cardiac events, and functional outcome were analyzed.

RESULTS

Twenty-seven patients underwent carotid revascularization in the acute phase of SIE. Fluctuating or progressive neurologic deficit was the presenting pattern in 20 patients and occurred after otherwise successful thrombolytic therapy in the remaining 7 (26%). Median NIHSS score at admission was 8. Median delay to surgery from the index event was 6 days. The mean degree of ICA stenosis was 87%. All patients received antiplatelet and statin therapy during the intervening period. Procedures were conventional CEA with patch angioplasty (polytetrafluoroethylene) in 26 patients (96.3%) and redo interposition bypass grafting in 1 patient. CEA was done under local anesthesia in 23 patients (85.2%), with selective shunting in 3 (13.0%), and under general anesthesia, with systematic shunting in 4. At discharge and at 1 and 3 months, no recurrent stroke or death, and one nonfatal myocardial infarction occurred in this series, with a 100% complete follow-up. At 3 months, all patients had a favorable functional outcome defined as a modified Rankin Scale score of ≤2.

CONCLUSIONS

This short series demonstrates that CEA in the acute phase of SIE with strict selection criteria and close blood pressure monitoring is safe, even after recent thrombolytic therapy, and is effective in functional outcome at 3 months. Larger series of patients are required to confirm the safety and efficacy of this management.

Authors+Show Affiliations

Department of Vascular and Thoracic Surgery, Bichat-Claude Bernard University Hospital, Denis Diderot University and Medical School Paris VII, Assistance Publique-Hopitaux de Paris, Paris, France. guy.leseche@bch.aphpNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article

Language

eng

PubMed ID

22070936

Citation

Leseche, Guy, et al. "Carotid Endarterectomy in the Acute Phase of Stroke-in-evolution Is Safe and Effective in Selected Patients." Journal of Vascular Surgery, vol. 55, no. 3, 2012, pp. 701-7.
Leseche G, Alsac JM, Houbbalah R, et al. Carotid endarterectomy in the acute phase of stroke-in-evolution is safe and effective in selected patients. J Vasc Surg. 2012;55(3):701-7.
Leseche, G., Alsac, J. M., Houbbalah, R., Castier, Y., Fady, F., Mazighi, M., & Amarenco, P. (2012). Carotid endarterectomy in the acute phase of stroke-in-evolution is safe and effective in selected patients. Journal of Vascular Surgery, 55(3), 701-7. https://doi.org/10.1016/j.jvs.2011.09.054
Leseche G, et al. Carotid Endarterectomy in the Acute Phase of Stroke-in-evolution Is Safe and Effective in Selected Patients. J Vasc Surg. 2012;55(3):701-7. PubMed PMID: 22070936.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Carotid endarterectomy in the acute phase of stroke-in-evolution is safe and effective in selected patients. AU - Leseche,Guy, AU - Alsac,Jean-Marc, AU - Houbbalah,Rabih, AU - Castier,Yves, AU - Fady,Francis, AU - Mazighi,Mikael, AU - Amarenco,Pierre, Y1 - 2011/11/08/ PY - 2011/06/29/received PY - 2011/09/12/revised PY - 2011/09/13/accepted PY - 2011/11/11/entrez PY - 2011/11/11/pubmed PY - 2012/5/2/medline SP - 701 EP - 7 JF - Journal of vascular surgery JO - J. Vasc. Surg. VL - 55 IS - 3 N2 - OBJECTIVE: This study documented with independent neurologic assessment the 30-day and 90-day outcomes in selected patients with severe internal carotid artery (ICA) stenosis who underwent carotid endarterectomy (CEA) in the acute phase of stroke-in-evolution (SIE). METHODS: From January 2003 to December 2010, data from patients who had surgery ≤2 weeks of an SIE with high-grade carotid stenosis were extracted from two prospectively collected databases. Clinical assessment was by the vascular neurologist using the National Institute of Health Stroke Scale (NIHSS) and the modified Rankin Scale score. All patients had computed tomography or magnetic resonance brain imaging ≤3 hours of stroke onset. Those eligible received thrombolysis. Duplex ultrasound imaging was initially used for the diagnosis of severe (≥60%) ICA stenosis, and further assessment was by magnetic resonance or computed tomography angiography, or both. Perioperative medical treatment and operative techniques were standardized. Stroke, death, major cardiac events, and functional outcome were analyzed. RESULTS: Twenty-seven patients underwent carotid revascularization in the acute phase of SIE. Fluctuating or progressive neurologic deficit was the presenting pattern in 20 patients and occurred after otherwise successful thrombolytic therapy in the remaining 7 (26%). Median NIHSS score at admission was 8. Median delay to surgery from the index event was 6 days. The mean degree of ICA stenosis was 87%. All patients received antiplatelet and statin therapy during the intervening period. Procedures were conventional CEA with patch angioplasty (polytetrafluoroethylene) in 26 patients (96.3%) and redo interposition bypass grafting in 1 patient. CEA was done under local anesthesia in 23 patients (85.2%), with selective shunting in 3 (13.0%), and under general anesthesia, with systematic shunting in 4. At discharge and at 1 and 3 months, no recurrent stroke or death, and one nonfatal myocardial infarction occurred in this series, with a 100% complete follow-up. At 3 months, all patients had a favorable functional outcome defined as a modified Rankin Scale score of ≤2. CONCLUSIONS: This short series demonstrates that CEA in the acute phase of SIE with strict selection criteria and close blood pressure monitoring is safe, even after recent thrombolytic therapy, and is effective in functional outcome at 3 months. Larger series of patients are required to confirm the safety and efficacy of this management. SN - 1097-6809 UR - https://www.unboundmedicine.com/medline/citation/22070936/Carotid_endarterectomy_in_the_acute_phase_of_stroke_in_evolution_is_safe_and_effective_in_selected_patients_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0741-5214(11)02160-4 DB - PRIME DP - Unbound Medicine ER -