Symptomatic Carotid Stenosis: Urgent Best Medical Therapy May Obviate the Need for Urgent Surgery Interview with: Saeid Shahidi, MD.

Chief Consultant in supra-aortic surgery.
Vascular Unit, Regional Hospital Slagelse,
Region Zealand, Denmark. What is the background of your study?

Answer: Our Prospective Population-based study showed, an expedited CEA can be performed in the subacute period ( >2 – <30 days) without significantly increasing the operative risk. The acute admission and urgent aggressive BMT with dual therapy in our cohort was associated with significant reduction P<0.00001 in the risk of early neurological recurrent (NR) in the CEA patient. It seems that in neurologically stable patients CEA can wait up to 30 days provided urgent BMT has been started in specialized stroke/ TIA clinics. Our study also adds to the data on the benefit of specialist TIA clinics. What are the main findings of the study?

Answer:  The most guidelines recommend subacute <14 days CEA after the last neurologic carotid attacks and a few Guidelines recommend Urgent CEA (24h-7 days) after the last attack, as it is believed that the early risk of stroke in patients with moderate and severe carotid stenosis is about 25 % in the first 14 days after the index event and highest in the first 72 hours after neurological attack (NR). Some vascular surgeons are concerned about outcomes. Large retrospective and prospective studies showed that the risk of stroke and death are high 8-10% in patients who are operated on very early <14 days after the index event compared with patients who undergo surgery 30 days after their last attack. The risk of serious complication (stroke and death) is highest in those operated urgent in the first (0-3 days) after the attack. Our studies show an acute hospitalization and aggressive BMT in the specialist stroke clinics can obviate the need of urgent surgery. Acute aggressive BMT reduced neurological attack by a factor of 10 in our study prior CEA, where the median delay was 26 days after the index event. We had no 30 days mortality, stroke while waiting time to CEA and no stroke or death after CEA. This is fairly new and a different way of thinking and treat patients with symptomatic carotid stenosis. Our study also discusses the logistical challenges that exist to implement a fast-track CEA, despite centralization and follow-up checks. Where any of the findings unexpected?

Answer: Our study is in accordance with EXPRES and other studies that showing urgent BMT reduces the early NR but WE focused on symptomatic carotid stenosis patients. It was unexpected that:

The reduction in early incidence of NR after BMT was remarkable low and significant in all subgroups and the median delay from index event to surgery was 26 days.  In our 2 year study, there was no significant difference in outcome between 48 early CEA (<14 days), 46 intermediate (14-30 days) and 21 delayed (>30 days) CEAs in patients who received BMT.” This is not entirely in line with the Guidelines and old RCT Trials. What do you recommend to physicians and patients as a result of your study?

Answer: More information about the symptoms of TIA and Ocular events. Implementation of specialized stroke / TIA clinic. Acute hospitalization of patients suspected TIA and ocular events even if the attack is short time (10-30 seconds). Acute aggressive BMT in patients with ischemic stroke, suspected carotid stenosis prior CEA. What further research do you recommend as a result of your work?

Answer:  Our results need to be tested andconfirmed elsewhere. Perhaps we are approaching the time that we needed a new randomized trials comparing Modern BMT vs. Surgery.


Urgent Best Medical Therapy May Obviate the Need for Urgent Surgery in Patients With Symptomatic Carotid Stenosis

Shahidi S, Owen-Falkenberg A, Hjerpsted U, Rai A, Ellemann K.

From the Departments of Vascular Surgery (S.S., U.H., A.A.) and Anesthesiology (A.O.-F.), Regional Hospital Slagelse and Department of Neurology (K.E.), University Hospital Roskilde, Region Zealand, Denmark.

Stroke. 2013 Jun 11. [Epub ahead of print]

Last Updated on June 22, 2013 by Marie Benz MD FAAD