While the benefits of carotid endarterectomy (CEA) in treating symptomatic carotid stenosis are well known, the optimal timing of intervention after acute stroke and whether optimal timing varies with preoperative stroke severity remains unclear. Therefore, we assessed the impact of stroke severity and timing of intervention on post-operative outcomes in patients undergoing CEA for stroke.
We identified all patients in the Vascular Quality Initiative who underwent CEA between 2012-2020 for symptomatic carotid stenosis with stroke. Patients were stratified by preoperative modified Rankin Scale (mRS 0-5) and time-to-CEA after stroke onset (≤2 days, 3-14 days, 15-90 days, and 91-180 days). After univariate comparisons, patients were stratified into the following mRS cohorts for further analysis: 0-1, 2, 3-4, and 5. Our primary outcome was a composite endpoint of in-hospital stroke/death.
We identified 15,601 patients, of whom 30% had mRS 0, 34% had mRS 1, 17% had mRS 2, 11% had mRS 3, 8% had mRS 4, and 1% had mRS 5. Overall, 9.3% of patients underwent CEA in ≤2 days, 46% in 3-14 days, 36% in 15-90 days, and 8.5% in 90-180 days. Decreasing mRS and increasing time-to-CEA were associated with lower rates of stroke/death (Ptrend<.01). After risk adjustment, compared with CEA in 3-14 days, mRS 0-1 patients had higher stroke/death after CEA in ≤2 days (3.6% vs 2.0%, odds ratio [OR] 1.8 [95% confidence interval 1.1-2.7]). Meanwhile, mRS 2 patients had similar stroke/death after CEA in ≤2 days (4.4% vs 3.9%; OR 1.1 [0.6-2.2]) but lower stroke/death after CEA in 15-90 days (2.1% vs 3.9%; OR 0.5 [0.3-0.9]). mRS 3-4 patients had higher stroke/death after CEA in ≤2 days (8.0% vs 3.8%; OR 2.3 [1.4-3.7]) but similar stroke/death after CEA in 15-90 days (3.0% vs 3.8%; OR 0.8 [0.5-1.2]). For mRS 5 patients, stroke/death rates were ≥6.5% across all time-to-CEA groups, but low sample size limited meaningful comparisons.
Patients with minimal disability after stroke (mRS 0-1) seem to benefit from CEA within 3-14 days, while those with severe disability (mRS 5) are unlikely to benefit from CEA at any timepoint given poor outcomes. Contrary to current guidelines, patients with mild disability (mRS 2) may benefit from delaying CEA to 15-90 days, and those with moderate disability (mRS 3-4) may benefit from CEA within 3-90 days given acceptable outcomes. These data need to be offset against the natural course outcome in the weeks after the index event, in order to determine the net benefit of delayed CEA.