‘Urgent’ Stenting or Surgery Safe After Thrombolysis for Stroke

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Carotid artery stenting (CAS) or carotid endarterectomy (CEA) performed early after thrombolysis for acute stroke appears safe, with no increased risk of serious complications, according to a Swedish registry study appearing online February 13, 2014, ahead of print in Stroke.

Researchers led by Carl-Magnus Wahlgren, MD, PhD, of Karolinska University Hospital (Stockholm, Sweden), looked at 3,998 patients from the Swedish National Registry for Vascular Surgery and the Swedish Stroke Registry who had undergone CEA or CAS for symptomatic carotid stenosis between May 2008 and December 2012. Of these, 2% (n = 79) had undergone previous thrombolysis for stroke, with a median time between thrombolysis and carotid procedure of 10 days.

tPA was administered within 360 minutes of the onset of symptoms. The median National Institutes of Health Stroke Scale score on arrival was 8, and the median score after lysis was 3. Median preoperative modified Rankin score was 2.0.

Three patients had CEA within 48 hours after administration of tPA, an additional 5 underwent CEA within 72 hours, and 50 received CEA/CAS within 2 weeks. In comparison, in the remaining 3,919 patients who had not undergone previous thrombolysis, CEA or CAS was performed at a median of 9 days after the index symptoms. In the thrombolysis group, cerebral embolic protection devices were used in all patients undergoing CAS (filter in 3 cases, flow reversal in 3).

Low 30-Day Death and Stroke Rates

There was no significant difference between patients who did and did not receive thrombolysis prior to CAS or CEA in terms of the 30-day rates of death and stroke (minor and major, 2.5% vs 3.8%; P = 0.55). In patients who received thrombolysis, 2 (2.5%) experienced a postoperative stroke at 30-day follow-up. Both had received CEA. The median postoperative modified Rankin score was 0.5. There were no cerebral hemorrhages, cranial nerve injuries, or cardiac events, and none of the 79 thrombolysis patients died within 2 years of CEA.

Three patients in the thrombolysis cohort (3.8%) required reoperation secondary to surgical site bleeding. Postoperative bleeding rates were not different between the thrombolysis (3.8%) and nonthrombolysis (3.3%) groups (P = 0.79). There was no correlation between time from lysis to CEA/CAS and the presence of any complications at 30 days postoperatively (P = 0.189). In addition, there was no increased likelihood of complications if surgery was undertaken within 2 weeks of thrombolysis compared with procedures undertaken outside this time frame (P = 0.15).

All 5 postoperative complications (6.3%) were seen in the CEA group (table 1), although the authors caution against drawing any conclusions from this due to the small CAS numbers.

Table 1. Major Complications After a Carotid Procedure with Previous Thrombolysis

^a Eversion CEA employs a transverse arteriotomy and reimplantation of the carotid artery.

“In this population-based study, there were low complication rates for patients undergoing CEA or CAS for carotid artery stenosis after systemic thrombolysis for stroke,” the authors affirm, adding that to their knowledge, the paper represents the largest reported cohort of such patients.

Overall, “[i]n this nationwide population-based study,” Dr. Wahlgren and colleagues continue, “urgent procedures for significant carotid artery stenosis do not seem to carry an increased . . . risk of complications after thrombolysis for stroke. However, it may be possible that earlier surgery could carry an increased risk of complications, a risk that must be balanced against that of further cerebral ischemic events.”

Elective, Not Urgent

In a telephone interview with TCTMD, Christopher J. White, MD, of the Ochsner Heart and Vascular Institute (New Orleans, LA), pointed out that patients in the study are not undergoing “urgent” CAS or CEA per se. “It isn’t that they’re emergently going back because they’re having a second stroke,” he said. “These guys are stabilized after their initial event, and then within 10 to 14 days they have to have a treatment of the carotid lesion so they don’t have a second stroke. It’s elective surgery, but they call it urgent because it has to be done within 10 days.”

Dr. White added that from trials such as CREST, it is known that event rates should be about equal between CEA and CAS, “and here these guys are saying that in this hyperacute setting with symptomatic patients, stents and surgery seem to be about the same and there isn’t a higher price to be paid for treating these patients early, so this is a reasonable thing to be doing.”

The key concern, he noted, is bleeding, “because once you’ve given the thrombolytic, you’ve upset the thrombotic cascade for a while, so there’s concern about perioperative bleeding that wouldn’t happen had thrombolytics not been used in the previous week.” This is a potential side effect that could sway some to favor CAS, “because you can do that from the radial access and have zero access site bleeding,” Dr. White said.

He added that the Swedish practice of performing CEA or CAS so soon after thrombolysis is years ahead of US practice. “It’s really cutting edge,” Dr. White said. “Most US programs are not doing this. It’s slowly changing here, but Sweden is way ahead of us; this is where we’ll be in 5 years. I think these results are the future.”

Just as important, he stressed, intervening “a little sooner is better, and it seems to be able to be done without increased risk. Clearly that’s better for patients because you decrease the number of recurrent strokes that would do them in,” Dr. White said.

In terms of everyday practice, “what this would mean to me is if there was a patient who for whatever reason was not a good candidate for surgery, carotid stenting should be done within 10 to14 days of the event, and if the patient was a low-risk candidate for surgery, then the patient would get a choice between a stent and surgery,” Dr. White said.

Study Details

Minor stroke (58%) was the dominant neurological presentation in the thrombolysis cohort. The median age of symptomatic patients who had undergone systemic thrombolysis for stroke before CEA/CAS was 71 years, and 68% were men.

 

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Source:
Koraen-Smith L, Troëng T, Björck M, et al. Urgent carotid surgery and stenting may be safe after systemic thrombolysis for stroke. Stroke. 2014;Epub ahead of print.

 

Disclosures:

• The study was supported by the steering committees of the Swedish Vascular Registry and the Riks-Stroke Collaboration.
• Dr. Wahlgren reports no relevant conflicts of interest.
• Dr. White reports serving as a steering committee chair for the NCDR CARE registry, a carotid database.

 

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