VESS02 - Stroke after endarterectomy for symptomatic Carotid Stenosis : The role of intervention Timing and Preoperative Symptoms

Objectives: Carotid endarterectomy (CEA) for symptomatic carotid stenosis (SCS) carries a higher risk of post-operative stroke compared with asymptomatic cases, possibly for the haemorrhagic conversion of the ischemic lesion or technical flaws. The aim of the present study is to evaluate the outcome of CEA for SCS and to investigate the severity and the possible causes of post-operative strokes according to timing of intervention and preoperative symptoms.

Methods: All CEAs accomplished for SCS from 2012 to 2023 in two metropolitan hospitals were analyzed. CEAs were performed routinely with patches and shunts. Perioperative (30-day) strokes were investigated according to symptoms and timing of intervention ( < 48h, from 48h to 2 weeks, and >2 weeks). Post-operative strokes were defined technical in case of acute carotid thrombosis or in case of significant technical defects, haemorrhagic if due to intracranial bleeding, and embolic in the other cases. The severity of post-operative stroke was classified as minor for modified Rankin Scale (mRS) 0-2 or major for mRS ≥3.

Results: Over a total of 664 CEAs for SCS, 262 (39%) were performed for stroke, 322 (49%) for transient ischemic attack or amaurosis fugax (TIA/AF), and 80 (12%) for crescendo TIAs or recurrent stroke (cTIA/RS). Twenty-one (3.1%) post-operative strokes occurred, and the timing from symptoms to CEA significantly affected the post-operative stroke rate: 10% within 48h, 3.6% between 48h-2 weeks, and 1.7% after 2 weeks, P=.01. Similarly, the type of preoperative symptom affected the post-operative stroke rate: 3% after stroke, 1.8% after TIA/AF, and 8.7% after recurrent symptoms, P=.01. The causes of the 21 post-operative strokes were haemorrhagic in 4 (19%) cases, technical in 6 (28%), and embolic in 11 (52%). Only the timing of CEA was associated with the type of post-operative stroke, in particular: CEA performed < 48h was associated with haemorrhagic strokes (all 4 haemorrhagic strokes occurred in CEA < 48h, P=.01). Major post-operative strokes occurred in 7/21 (33%) cases and were significantly associated with the preoperative symptoms (1.5% for stroke, 0% for TIA/AF, and 3.8% for cTIA/RS, P=.03) and more frequent in haemorrhagic (75%) compared with ischemic strokes (technical 17% and embolic 27%) , P=.05. The timing of intervention was not associated with the severity of postoperative stroke.

Conclusions: CEA for SCS is associated with an acceptable post-operative stroke risk; however, early CEA (within 48h) carries a high risk of cerebral haemorrhage. Post-operative major stroke occurs prominently after CEA for cTIA/RS and in case of haemorrhagic strokes.