Time From Symptoms to Carotid Endarterectomy or Stenting and Perioperative Risk.
OBJECTIVE
Prior meta-analysis showed that carotid endarterectomy benefits decline with increasing surgical delay following symptoms. For symptomatic patients in the Carotid Revascularization Endarterectomy Versus Stenting Trial (CREST), we assessed if differences in time between symptoms and carotid endarterectomy or carotid artery stenting are associated with differences in risk of periprocedural stroke or death.


METHODS
We analyzed the 1180 symptomatic patients in CREST who received their assigned procedure and had clearly defined timing of symptoms. Patients were classified into 3 groups based on time from symptoms to procedure: <15, 15 to 60, and >60 days.


RESULTS
For carotid endarterectomy, risk of periprocedural stroke or death was not significantly different for the 2 later time periods relative to the earliest time period (hazard ratio, 0.74; 95% confidence interval, 0.22-2.49 for 15-60 days and hazard ratio, 0.91; 95% confidence interval, 0.25-3.33 for >60 days; P=0.89). For carotid artery stenting, risk of periprocedural stroke or death was also not significantly different for later time periods relative to the earliest time period (hazard ratio, 1.12; 95% confidence interval, 0.53-2.40 for 15-60 days and hazard ratio, 1.15; 95% confidence interval, 0.48-2.75 for >60 days; P=0.93).


CONCLUSIONS
Time from symptoms to carotid endarterectomy or carotid artery stenting did not alter periprocedural safety, supporting early revascularization regardless of modality.


BACKGROUND
URL: http://www.clinicaltrials.gov. Unique identifier: NCT00004732.
From the Department of Neurology, Mayo Clinic, Jacksonville, FL (J.F.M., T.G.B.); Department of Neurosurgery, University at Buffalo-SUNY, NY (L.N.H.); Minneapolis Clinic of Neurology, Golden Valley (I.A.); Department of Neurology, University of Pittsburgh School of Medicine, PA (L.R.W.); Department of Neurology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (G.S.); Department of Neurology, University of Texas Medical School, Houston (N.R.G.); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Department of Biostatistics, Ryals School of Public Health, University of Alabama at Birmingham (G.H.). meschia.james@mayo.edu.
James F
JF
Meschia
From the Department of Neurology, Mayo Clinic, Jacksonville, FL (J.F.M., T.G.B.); Department of Neurosurgery, University at Buffalo-SUNY, NY (L.N.H.); Minneapolis Clinic of Neurology, Golden Valley (I.A.); Department of Neurology, University of Pittsburgh School of Medicine, PA (L.R.W.); Department of Neurology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (G.S.); Department of Neurology, University of Texas Medical School, Houston (N.R.G.); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Department of Biostatistics, Ryals School of Public Health, University of Alabama at Birmingham (G.H.).
L Nelson
LN
Hopkins
From the Department of Neurology, Mayo Clinic, Jacksonville, FL (J.F.M., T.G.B.); Department of Neurosurgery, University at Buffalo-SUNY, NY (L.N.H.); Minneapolis Clinic of Neurology, Golden Valley (I.A.); Department of Neurology, University of Pittsburgh School of Medicine, PA (L.R.W.); Department of Neurology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (G.S.); Department of Neurology, University of Texas Medical School, Houston (N.R.G.); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Department of Biostatistics, Ryals School of Public Health, University of Alabama at Birmingham (G.H.).
Irfan
I
Altafullah
From the Department of Neurology, Mayo Clinic, Jacksonville, FL (J.F.M., T.G.B.); Department of Neurosurgery, University at Buffalo-SUNY, NY (L.N.H.); Minneapolis Clinic of Neurology, Golden Valley (I.A.); Department of Neurology, University of Pittsburgh School of Medicine, PA (L.R.W.); Department of Neurology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (G.S.); Department of Neurology, University of Texas Medical School, Houston (N.R.G.); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Department of Biostatistics, Ryals School of Public Health, University of Alabama at Birmingham (G.H.).
Lawrence R
LR
Wechsler
From the Department of Neurology, Mayo Clinic, Jacksonville, FL (J.F.M., T.G.B.); Department of Neurosurgery, University at Buffalo-SUNY, NY (L.N.H.); Minneapolis Clinic of Neurology, Golden Valley (I.A.); Department of Neurology, University of Pittsburgh School of Medicine, PA (L.R.W.); Department of Neurology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (G.S.); Department of Neurology, University of Texas Medical School, Houston (N.R.G.); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Department of Biostatistics, Ryals School of Public Health, University of Alabama at Birmingham (G.H.).
Grant
G
Stotts
From the Department of Neurology, Mayo Clinic, Jacksonville, FL (J.F.M., T.G.B.); Department of Neurosurgery, University at Buffalo-SUNY, NY (L.N.H.); Minneapolis Clinic of Neurology, Golden Valley (I.A.); Department of Neurology, University of Pittsburgh School of Medicine, PA (L.R.W.); Department of Neurology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (G.S.); Department of Neurology, University of Texas Medical School, Houston (N.R.G.); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Department of Biostatistics, Ryals School of Public Health, University of Alabama at Birmingham (G.H.).
Nicole R
NR
Gonzales
From the Department of Neurology, Mayo Clinic, Jacksonville, FL (J.F.M., T.G.B.); Department of Neurosurgery, University at Buffalo-SUNY, NY (L.N.H.); Minneapolis Clinic of Neurology, Golden Valley (I.A.); Department of Neurology, University of Pittsburgh School of Medicine, PA (L.R.W.); Department of Neurology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (G.S.); Department of Neurology, University of Texas Medical School, Houston (N.R.G.); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Department of Biostatistics, Ryals School of Public Health, University of Alabama at Birmingham (G.H.).
Jenifer H
JH
Voeks
From the Department of Neurology, Mayo Clinic, Jacksonville, FL (J.F.M., T.G.B.); Department of Neurosurgery, University at Buffalo-SUNY, NY (L.N.H.); Minneapolis Clinic of Neurology, Golden Valley (I.A.); Department of Neurology, University of Pittsburgh School of Medicine, PA (L.R.W.); Department of Neurology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (G.S.); Department of Neurology, University of Texas Medical School, Houston (N.R.G.); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Department of Biostatistics, Ryals School of Public Health, University of Alabama at Birmingham (G.H.).
George
G
Howard
From the Department of Neurology, Mayo Clinic, Jacksonville, FL (J.F.M., T.G.B.); Department of Neurosurgery, University at Buffalo-SUNY, NY (L.N.H.); Minneapolis Clinic of Neurology, Golden Valley (I.A.); Department of Neurology, University of Pittsburgh School of Medicine, PA (L.R.W.); Department of Neurology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (G.S.); Department of Neurology, University of Texas Medical School, Houston (N.R.G.); Department of Neurology, Medical University of South Carolina, Charleston (J.H.V.); and Department of Biostatistics, Ryals School of Public Health, University of Alabama at Birmingham (G.H.).
Thomas G
TG
Brott
D000368:Aged; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000639:trends*; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000175:diagnosis* / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care / Q000009:adverse effects / Q000639:trends*; D012307:Risk Factors; D015607:Stents / Q000009:adverse effects / Q000639:trends*; D013997:Time Factors; D016896:Treatment Outcome
carotid stenosis; endarterectomy, carotid; humans; stents; stroke