title: A stroke/vascular neurology service increases the volume of urgent carotid endarterectomies performed in a tertiary referral center.
abstract: BACKGROUND
  Increasing evidence supports that urgent carotid endarterectomy (CEA), defined as CEA during the index hospitalization, may be undertaken in select patients with acute carotid-related neurologic symptoms to prevent recurrent ischemic events. We aimed to determine the effect of a stroke/vascular neurology service on the volume of urgent CEAs performed and assess perioperative outcomes.
  
  
  METHODS
  A retrospective review from a single tertiary referral center between June 2005 through December 2011 revealed 393 patients who underwent CEA. We identified the number of urgent CEAs before (June 2005-August 2008) and after (September 2008-December 2011) a stroke/vascular neurology service was implemented, as well as asymptomatic CEAs and symptomatic but electively performed CEAs. Demographic data as well as 30-day adverse outcomes (transient ischemic attack [TIA], stroke, myocardial infarction, and mortality) were analyzed for each group. In patients undergoing urgent CEA, TIA and stroke severity were assessed by a stroke neurologist using the ABCD2 TIA score and National Institutes of Health Stroke Scale (NIHSS), respectively. The χ2 test was used to compare differences between the urgent CEA volume before and after a stroke/vascular neurology service. Fisher's exact test was used to analyze perioperative outcomes.
  
  
  RESULTS
  Demographics and comorbidities were similar between the 2 groups. The proportion of urgent CEAs performed increased significantly after initiation of a vascular neurology service (4.1% [7 of 172] vs. 22.2% [49 of 221], P<0.0001). Per annum, urgent CEAs increased from 5.3% (4/75) in 2005 to 39.6% (25/63) in 2011. A vascular neurology service did not increase the number of nonurgent referrals. Urgent CEA indications were ocular ischemic events 4% (2/49), cerebral ischemic/infarction events 35% (17/49), crescendo TIAs 6% (3/49), acute stroke 45% (22/49), and stroke-in-evolution 10% (5/49). Mean NIHSS was 3.5 (range 0-24); mean TIA score was 5 (range 1-8). Although there were no statistical differences in 30-day outcomes, there was a trend toward a higher combined complication rate (stroke, death, myocardial infarction) in the urgent compared with the symptomatic but electively performed CEA group (7.1 % [3/49] vs. 2% [1/49]; P=.36). However, patients undergoing urgent CEA with an NIHSS<10 had no perioperative complications.
  
  
  CONCLUSIONS
  Collaboration with a vascular neurology team increased the volume of urgent CEAs over a 3-year period. In patients with mild-to-moderate strokes (NIHSS<10), urgent CEA perioperative outcomes approximate those for electively performed CEAs, suggesting improved care through a multidisciplinary approach.
authors.affiliation: Section of Vascular/Endovascular Surgery, Department of Surgery and Vascular Neurology Service, and Department of Neurology, Ochsner Clinic, New Orleans, LA. Electronic address: hbazan@ochsner.org.
authors.forename: Hernan A
authors.initials: HA
authors.lastname: Bazan
authors.affiliation: Section of Vascular/Endovascular Surgery, Department of Surgery and Vascular Neurology Service, and Department of Neurology, Ochsner Clinic, New Orleans, LA.
authors.forename: Gentry
authors.initials: G
authors.lastname: Caton
authors.affiliation: Section of Vascular/Endovascular Surgery, Department of Surgery and Vascular Neurology Service, and Department of Neurology, Ochsner Clinic, New Orleans, LA.
authors.forename: Shahrzad
authors.initials: S
authors.lastname: Talebinejad
authors.affiliation: Section of Vascular/Endovascular Surgery, Department of Surgery and Vascular Neurology Service, and Department of Neurology, Ochsner Clinic, New Orleans, LA.
authors.forename: Ross
authors.initials: R
authors.lastname: Hoffman
authors.affiliation: Section of Vascular/Endovascular Surgery, Department of Surgery and Vascular Neurology Service, and Department of Neurology, Ochsner Clinic, New Orleans, LA.
authors.forename: Taylor A
authors.initials: TA
authors.lastname: Smith
authors.affiliation: Section of Vascular/Endovascular Surgery, Department of Surgery and Vascular Neurology Service, and Department of Neurology, Ochsner Clinic, New Orleans, LA.
authors.forename: Gabriel
authors.initials: G
authors.lastname: Vidal
authors.affiliation: Section of Vascular/Endovascular Surgery, Department of Surgery and Vascular Neurology Service, and Department of Neurology, Ochsner Clinic, New Orleans, LA.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Gaines
authors.affiliation: Section of Vascular/Endovascular Surgery, Department of Surgery and Vascular Neurology Service, and Department of Neurology, Ochsner Clinic, New Orleans, LA.
authors.forename: W Charles
authors.initials: WC
authors.lastname: Sternbergh
mesh_terms: D000368:Aged; D002545:Brain Ischemia / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control*; D016893:Carotid Stenosis / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D004630:Emergencies; D016894:Endarterectomy, Carotid / Q000706:statistics & numerical data*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D015994:Incidence; D008145:Louisiana / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D062606:Tertiary Care Centers / Q000706:statistics & numerical data*; D014057:Tomography, X-Ray Computed; D018616:Ultrasonography, Doppler, Duplex