title: Delays in carotid endarterectomy: the process is the problem.
abstract: BACKGROUND
  Current recommendations for carotid endarterectomy (CEA) for symptomatic carotid stenosis state benefit is greatest when performed within two weeks of symptoms. However, only a minority of cases are operated on within this guideline, and no systematic examinations of reasons for these delays exist.
  
  
  METHODS
  All CEA cases performed at our institution by vascular surgery for symptomatic carotid stenosis after neurologist referral in 2008-2009 were reviewed. Dates of symptom onset, initial presentation, referral to and evaluation by neurology and vascular surgery, vascular imaging, and CEA were collected, and the length of time between each analysed. Reasons for delays were noted where available.
  
  
  RESULTS
  Of 36 included patients, 34 had CEA more than two weeks after symptom onset. Median time to CEA from onset was 76 days (IQR, 38-105 days). Longest intervals were between surgeon assessment and CEA (14 days; IQR, 9-21 days), neurology referral and neurologist assessment (9 days; IQR, 2-26 days), vascular imaging and referral to vascular surgery (9 days; IQR, 2-35 days) and vascular surgery referral and assessment (8 days; IQR, 6-15 days). Few patients (44.1%) had reasons for delays identified; of these, process-related delays were related to delayed vascular imaging, delayed referral by primary care physicians, or multiple conflicting referrals.
  
  
  CONCLUSIONS
  There are significant delays between symptom onset and CEA in patients referred for CEA, with delay highest between specialist referral and evaluation. Strategies to reduce these delays may be effective in increasing the proportion of procedures performed within two weeks of symptom onset.
authors.affiliation: Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa, Ontario, Canada. dblacquiere@toh.on.ca
authors.forename: Dylan
authors.initials: D
authors.lastname: Blacquiere
authors.forename: Michael
authors.initials: M
authors.lastname: Sharma
authors.forename: Prasad
authors.initials: P
authors.lastname: Jetty
mesh_terms: D000368:Aged; D016893:Carotid Stenosis / Q000175:diagnosis* / Q000601:surgery*; D016894:Endarterectomy, Carotid; D005260:Female; D006801:Humans; D008297:Male; D012017:Referral and Consultation; D012189:Retrospective Studies; D013997:Time Factors