East Bay Cardiovascular & Thoracic Associates, Danville, CA.
North Bay Healthcare, Fairfield, CA.
Ann Vasc Surg. 2022 Jul;83:26-34. doi: 10.1016/j.avsg.2022.02.015. Epub 2022 Mar 4.
With the risk of recurrent ischemic stroke being highest in the first week following transient ischemic attack or stroke, the current guidelines of "early" endarterectomy within 2 weeks still leave potential vulnerability for patients with a significant bifurcation lesion and a new stroke. The intent of this analysis is to determine the safety of carotid endarterectomy even earlier than the current guidelines, based on a single surgeon experience of more than 12 years.
Although there has been a progressive movement toward earlier intervention following acute ischemic stroke in the presence of a culprit bifurcation lesion, most of the recommendations still are for performance of endarterectomy within two weeks following the event. This compression is welcome but given that the risk of recurrent stroke is highest within the first week following stroke, there is a reason to evaluate an earlier time frame for carotid endarterectomy (CEA).
A retrospective review of all CEA performed by a single surgeon over a 12-year period was performed. Patient demographics, Modified Rankin score (mRS) whenever documented, degree of internal carotid artery (ICA) stenosis, and preoperative neurologic symptoms were recorded. The 30-day outcomes including stroke, transient ischemic attack, death, and other major complications were tabulated.
A total of 444 patients (mean age 74 ± 10.1) underwent a total of 465 CEAs. Two hundred and twenty-eight (49%) CEAs were for a symptomatic disease: of these, 194 had a documented stroke. One hundred and eighty-one stroke patients (93%) underwent CEA within 72 hr and the remaining 13 patients within 5 days. Of the stroke cohort, for whom the mRS was available, the mean preCEA mRS was 3.4. One patient in the stroke cohort had a postoperative stroke (0.5%, 1/194). In the total CEA cohort, there were 3 total postoperative strokes (0.6%, 3/465). There was one death in the total cohort (0.2%). The mean operative time was 45 min ± 4 min.
Early CEA for recurrent stroke prevention can be performed safely, at an earlier time frame than current recommendations. Given the safety of early CEA and the risk of recurrent stroke, CEA for stroke is best done early with no additional increase in morbidity or mortality.
短暂性脑缺血发作或中风后第一周内再次发生缺血性中风的风险最高，目前的指南仍然建议在 2 周内进行早期颈动脉内膜切除术，这为分叉病变严重且发生新中风的患者留下了潜在的风险。本分析的目的是根据一位外科医生超过 12 年的经验，确定即使比目前的指南更早进行颈动脉内膜切除术的安全性。
尽管在存在责任分叉病变的急性缺血性中风后，已经朝着早期干预的方向发展，但大多数建议仍然是在事件发生后两周内进行内膜切除术。这种限制是受欢迎的，但由于中风后第一周内再次中风的风险最高，因此有理由评估颈动脉内膜切除术（CEA）的更早时间框架。
对一位外科医生在 12 年期间进行的所有 CEA 进行了回顾性审查。记录患者的人口统计学资料、记录的改良 Rankin 评分（mRS）、颈内动脉（ICA）狭窄程度以及术前神经症状。将包括中风、短暂性脑缺血发作、死亡和其他主要并发症在内的 30 天结果进行了列表。
共有 444 名患者（平均年龄 74 ± 10.1 岁）接受了 465 次 CEA。228 次 CEA 用于治疗症状性疾病：其中 194 例有记录的中风。181 例中风患者（93%）在 72 小时内进行了 CEA，其余 13 例在 5 天内进行了 CEA。在中风组中，对于有 mRS 可用的患者，术前 mRS 的平均值为 3.4。中风组中有 1 例术后中风（0.5%，1/194）。在总 CEA 组中，有 3 例术后总中风（0.6%，3/465）。总队列中有 1 例死亡（0.2%）。平均手术时间为 45 分钟±4 分钟。
早期进行颈动脉内膜切除术以预防中风复发是安全的，可以早于目前的建议。鉴于早期 CEA 的安全性和中风复发的风险，早期进行 CEA 治疗中风不会增加发病率或死亡率。
