Early carotid endarterectomy performed 2 to 5 days after the onset of neurologic symptoms leads to comparable results to carotid endarterectomy performed at later time points

Abstract

Background: Timing of carotid endarterectomy (CEA) after onset of neurologic symptoms remains controversial. We assessed the association of CEA timing with postoperative outcomes.

Methods: The Vascular Study Group of New England (VSGNE) database (2003-2014) was queried to identify CEA performed for symptomatic carotid stenosis during the same hospitalization. Cases were divided into four groups based on the time from onset of neurologic symptoms to CEA: group I, <2 days; group II, 2 to 5 days; group III, ≥6 days; and group IV, same-day CEA. The χ² test and t-test were used to compare demographics, medical history, modified Rankin scores, and outcomes (30-day postoperative death, stroke, myocardial infarction, and aggregate events [stroke/myocardial infarction]). Multivariable logistic regression was used to compare the association of time to surgery with outcomes while adjusting for confounding variables. Kaplan-Meier and Cox proportional hazards regression analyses were performed at 1 year to evaluate survival and stroke rates between the groups.

Results: There were 989 of 14,864 VSGNE CEA cases that fit the inclusion criteria. The frequency of cases was highest in group II (36.6%), followed by groups I (31.9%), III (18.9%), and IV (12.4%). Age, gender, and comorbidity compositions were similar between groups, although group III had the highest rates of diabetes mellitus, coronary artery disease, coronary artery bypass graft procedures, congestive heart failure, and American Society of Anesthesiologists class 4 and the highest modified Rankin score (P < .05). Stroke rates were highest in group I (7.3%; P = .016), whereas group III had the highest rate of discharges to nursing facilities (37.2%; P < .001); other adverse outcomes were comparable among groups. CEAs in group I had significantly increased adjusted odds of stroke; adverse outcomes of CEAs in groups II and III were comparable to those in group IV.

Conclusions: Our results suggest that CEAs performed 2 to 5 days after a neurologic event have similar outcomes to CEAs performed ≥6 days later. Early CEA should be considered an area for quality improvement among these patients.