title: Acute stroke after carotid endarterectomy: time for a paradigm shift? Multicenter experience with emergent carotid artery stenting with or without intracranial tandem occlusion thrombectomy.
abstract: BACKGROUND
  Stroke in the immediate postoperative period after carotid endarterectomy is a rare complication. Many centers have begun incorporating angiography before surgical re-exploration, which has the advantage of confirming carotid occlusion and treating tandem intracranial lesions if present.
  
  
  OBJECTIVE
  To determine the safety and efficacy of this strategy.
  
  
  METHODS
  A retrospective review was performed of all patients undergoing acute stenting of the carotid artery after carotid endarterectomy from November 2009 to June 2013 at 4 centers. Charts and angiographic images were reviewed. Eleven cases of carotid thrombosis within 72 hours of carotid endarterectomy and subsequent treatment strategies are summarized.
  
  
  RESULTS
  All patients had >50% carotid stenosis before carotid endarterectomy. One patient had intraoperative occlusion and dissection of the internal carotid artery, which was noted on intraoperative carotid duplex ultrasound. All patients underwent postoperative computed tomography or computed tomography perfusion scans with subsequent cerebral angiography and stent reconstruction within 11 hours of symptom onset. In all cases, carotid recanalization was successfully completed between 32 and 160 minutes from groin puncture. There were no procedural complications. Four patients had a tandem middle cerebral artery occlusion, 3 of whom underwent successful recanalization.
  
  
  CONCLUSIONS
  Emergent endovascular evaluation in the setting of acute post--carotid endarterectomy thrombosis is a safe and timely treatment option, with the benefit of detecting and treating embolic intracranial lesions. Immediate angiography and intervention in this rare surgical complication show promising initial results.
authors.affiliation: *Division of Neurosurgery, Department of Neurosciences, Medical University of South Carolina, Charleston, South Carolina; ‡Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee; §Department of Neurosurgery, University of South Florida, Tampa, Florida; ¶Department of Neurosurgery, University of Wisconsin School of Medicine, Madison, Wisconsin; ‖Department of Radiology and Radiological Sciences, Medical University of South Carolina, Charleston, South Carolina; and #Department of Neurosurgery, Columbia University, New York, New York.
authors.forename: Alejandro M
authors.initials: AM
authors.lastname: Spiotta
authors.forename: Jan
authors.initials: J
authors.lastname: Vargas
authors.forename: Scott
authors.initials: S
authors.lastname: Zuckerman
authors.forename: Maxim
authors.initials: M
authors.lastname: Mokin
authors.forename: Azam
authors.initials: A
authors.lastname: Ahmed
authors.forename: J
authors.initials: J
authors.lastname: Mocco
authors.forename: Raymond D
authors.initials: RD
authors.lastname: Turner
authors.forename: Aquilla S
authors.initials: AS
authors.lastname: Turk
authors.forename: M Imran
authors.initials: MI
authors.lastname: Chaudry
authors.forename: Phil
authors.initials: P
authors.lastname: Myers
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002343:Carotid Artery, Internal / Q000601:surgery; D016893:Carotid Stenosis / Q000000981:diagnostic imaging / Q000601:surgery; D002533:Cerebral Angiography / Q000379:methods*; D016894:Endarterectomy, Carotid / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D015607:Stents / Q000009:adverse effects; D020521:Stroke / Q000000981:diagnostic imaging* / Q000209:etiology* / Q000601:surgery; D017131:Thrombectomy / Q000379:methods