Systematic review of the operative risks of carotid endarterectomy for recently symptomatic stenosis in relation to the timing of surgery.
OBJECTIVE
Reliable data on the risk of carotid endarterectomy (CEA) in relation to timing of surgery are necessary to plan CEA most effectively, to adjust risks for case-mix, and to understand the mechanisms of operative stroke.


METHODS
We performed a systematic review of all studies published from 1980 to 2008 inclusive that reported the risk of stroke and death due to CEA in relation to the time between presenting symptom and surgery. Pooled estimates of risk by the time since the last event were obtained by Mantel-Haenszel meta-analysis.


RESULTS
Of 494 published operative series, only 47 stratified risk by timing of surgery. The pooled absolute risks of stroke and death after urgent CEA were high in patients with stroke-in-evolution (20.2%, 95% CI 12.0 to 28.4) and in patients with crescendo TIA (11.4%, 6.1 to 16.7), with no trends toward reduced risks in more recent studies. However, there was no significant difference between early and later CEA in neurologically stable patients with recent TIA or nondisabling stroke (<1 week versus > or = 1 week, OR=1.2, 0.9 to 1.7, P=0.17; <2 weeks versus > or = 2 weeks, OR=1.2, 0.9 to 1.6, P=0.13).


CONCLUSIONS
Emergency endarterectomy for stroke-in-evolution has a high operative risk, but the risk may be somewhat lower in patients with crescendo TIA. Surgery in the first week in neurologically stable patients with TIA or minor stroke is not associated with a substantially higher operative risk than delayed surgery. More data are required on the risk and benefit of more urgent surgery for TIA and minor stroke and for early versus delayed surgery in patients with major nondisabling stroke.
Rerkasem
Kittipan
K
Vascular Surgery Division, Department of Surgery, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.
Rothwell
Peter M
PM
D016893:Carotid Stenosis / Q000601:surgery*; D016894:Endarterectomy, Carotid / Q000009:adverse effects* / Q000401:mortality* / Q000706:statistics & numerical data; D006801:Humans; D002546:Ischemic Attack, Transient / Q000453:epidemiology; D009026:Mortality; D011183:Postoperative Complications / Q000453:epidemiology*; D016032:Randomized Controlled Trials as Topic / Q000706:statistics & numerical data; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome