Response to Letter Regarding Article, “Very Urgent Carotid Endarterectomy Confers Increased Procedural Risk”
Thank you for your interest in our study1 regarding procedural risk with acute carotid endarterectomy.
First we would like to emphasize that one of the main findings of our study is that procedural risk is not increased even if the time from the index event to surgery is reduced to as few as 3 days (804 patients with carotid endarterectomy 3–7 days after an index event had 3.6% procedural risk). Many surgical centers still find it difficult to reduce the time to intervention to <1 week, and our study stresses the importance of continuing efforts to shorten the delay to surgery to prevent recurrent stroke.
However, as highlighted by Professor Naylor, we also report increased procedural risk in the hyperacute period (0–2 days) after a neurological event. Our register study did not allow us to assess the mechanism behind the increased procedural risk, but we agree with Professor Naylor that one possible explanation is embolization from an intraluminal thrombus overlying a disrupted plaque during the surgical procedure.
The high procedural risk 0 to 2 days after an index event is not easily explained by patient-inherent factors. For example, only one of the patients with a postoperative complication in this time group had crescendo transient ischemic attack as the index event. Furthermore, the multivariate regression analysis displayed a 4-fold increased risk after adjustment for covariates such as type of qualifying neurological event, comorbidity, and surgical technique. Thus, it is difficult to predict which patients have increased procedural risk in this hyperacute period.
We agree that it is of great importance to elucidate the natural history of early recurrent stroke within the first days after onset of symptoms to ascertain the benefit of carotid endarterectomy in this time period. Most of the studies in this area were performed before today's best medical treatment was given to all patients and before transient ischemic attack was considered to be an acute condition with high priority. It is true that we can accept an increased postoperative risk in the urgent phase2 and it is clear that carotid endarterectomy should be performed as early as possible to prevent more strokes. However, it is important to observe the risk and continue to evaluate the postoperative morbidity in the very urgent procedures. Further studies are needed to address this issue.
Sofia Strömberg, MD
Klas Österberg, MD, PhD
Department of Vascular Surgery
Sahlgrenska University Hospital
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- © 2012 American Heart Association, Inc.