Carotid endarterectomy in the acute phase of crescendo cerebral transient ischemic attacks is safe and effective
Leseche, G.; Alsac, J.-M.; Castier, Y.; Fady, F.; Lavallee, P.C.; Mazighi, M.; Amarenco, P.
Journal of Vascular Surgery 53(3): 637-642
ISSN/ISBN: 1097-6809 PMID: 21129902 DOI: 10.1016/j.jvs.2010.09.055
To document the 30- and 90-day outcomes in patients with severe internal carotid artery stenosis who underwent carotid endarterectomy in the acute phase of crescendo cerebral transient ischemic attacks (CcTIAs). From January 2003 to December 2009, data from patients suffering CcTIAs with an ipsilateral severe internal carotid artery stenosis and consecutively operated in our department were prospectively collected. CcTIA patients operated in the acute phase were those who had experienced ≥ two cerebral TIAs and had been consecutively operated within 2 weeks of their first-ever TIA. Clinical assessment was by the vascular neurologist. Duplex ultrasonography was initially used for the diagnosis of severe (>70%) ipsilateral internal carotid artery and further assessed by magnetic resonance angiography and/or computed tomography angiography. Brain damage was assessed by magnetic resonance imaging or at default computed tomography scan. Perioperative medical treatment and operative techniques were standardized. Stroke, death, and major cardiac events were analyzed. Sixty-four patients sustained a median of four cerebral TIAs. Median delay to surgery from initial examination was 5 days. The mean degree of internal carotid artery stenosis was 87.9%. Of the 55 patients who had magnetic resonance imaging with diffusion-weighted imaging, 43 (78%) patients had new acute infarction in an area that corresponded to the clinical symptoms. All patients received antiplatelet therapy and statin during the intervening period. All patients underwent conventional carotid endarterectomy (CEA) with patch angioplasty (polytetrafluoroethylene). Fifty-six patients (87.5%) underwent CEA under local anesthesia with two (3.5%) utilizing selective shunting, and eight patients had general anesthesia with systematic shunting. From CEA to discharge, all patients had complete recovery of their unstable clinical syndrome. At discharge and at 1 and 3 months postoperatively, no stroke or death, or major cardiac event occurred in this series with a 100% complete follow-up. Short delay between symptom onset and neurological assessment, immediate start of secondary stroke prevention, optimal perioperative medical treatment, and standardized operative techniques enabled performance of CEA in the acute phase of CcTIAs with low combined risk of stroke, death, and major cardiac event.