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Timing of Carotid Revascularization Procedures After Ischemic Stroke.

ABSTRACT: In 2006, the American Heart Association recommended that carotid revascularization generally occurs within 2 weeks of stroke based on data from 2 trials of carotid endarterectomy (CEA). We aimed to determine whether the time between stroke and CEA or carotid artery stenting (CAS) has decreased and whether the proportion of procedures occurring within 14 days has increased.Using validated International Classification of Diseases, Ninth Revision, Clinical Modification codes and administrative claims data from nonfederal hospitals in CA, FL, and NY, we identified patients with ischemic stroke who underwent CEA or CAS within 90 days of an ischemic stroke from 2005 to 2013. Our outcomes were the number of days between stroke and CEA/CAS and the proportion of patients undergoing CEA/CAS within the recommended 14-day period. We assessed temporal trends using nonparametric correlation, the ?2 test for trend, and logistic regression.We identified 16?298 patients with ischemic stroke who underwent CEA/CAS within 90 days. The time from stroke to CEA/CAS decreased from 25 days (interquartile range, 5-48 days) in 2005 to 6 days (interquartile range, 3-17 days) in 2013 (P<0.001). The proportion of patients who underwent CEA/CAS within 14 days of stroke increased from 40% (95% confidence interval, 37%-43%) in 2005 to 73% (95% confidence interval, 71%-76%) in 2013 (P<0.001). These temporal trends remained significant after adjustment for patient demographics and comorbidities.Since 2005, revascularization for symptomatic carotid disease has been occurring progressively sooner after ischemic stroke.

SUBMITTER: Reznik M

PROVIDER: S-EPMC5183494 | biostudies-literature | 2017 Jan

REPOSITORIES: biostudies-literature

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Timing of Carotid Revascularization Procedures After Ischemic Stroke.

Reznik Michael M Kamel Hooman H Gialdini Gino G Pandya Ankur A Navi Babak B BB Gupta Ajay A

Stroke 20161206 1

<h4>Background and purpose</h4>In 2006, the American Heart Association recommended that carotid revascularization generally occurs within 2 weeks of stroke based on data from 2 trials of carotid endarterectomy (CEA). We aimed to determine whether the time between stroke and CEA or carotid artery stenting (CAS) has decreased and whether the proportion of procedures occurring within 14 days has increased.<h4>Methods</h4>Using validated International Classification of Diseases, Ninth Revision, Clin ...[more]

PMID: 27924050

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Project description:Importance:The Carotid Revascularization Endarterectomy vs Stenting Trial (CREST) showed greater safety of carotid artery stenting (CAS) in patients younger than 70 years and carotid endarterectomy (CEA) in those older than 70 years. It is unknown how the result of CREST has influenced carotid revascularization choices in the United States. Objective:To evaluate national patterns in CAS performance in patients older than 70 years in the post-CREST (2011-2014) compared with the pre-CREST (2007-2010) era. Design, Setting, and Participants:All adults older than 70 years undergoing carotid revascularization in the United States from 2007 to 2014 were retrospectively identified from the 2007-2014 National Inpatient Sample using International Classification of Disease, Ninth Revision procedural codes. From 61 324 882 unweighted hospitalizations contained in the 2007-2014 National Inpatient Sample, 494 733 weighted carotid revascularization admissions in adults older than 70 years were identified using International Classification of Disease, Ninth Revision procedural codes. Main Outcomes and Measures:The proportion of CAS performed in all age groups over time was estimated and multivariable-adjusted models were used to compare the odds of receiving CAS in the pre-CREST with those in the post-CREST era in adults older than 70 years. Results:A total of 41.8% of all patients were women, and mean (SE) age at presentation was 78.1 (0.03) years. A total of 16.3% of CAS and 10.1% of CEA procedures were performed in patients with symptomatic stenosis. The proportion of patients older than 70 years receiving CAS increased from 11.9% in the pre-CREST to 13.8% in the post-CREST era (P = .005). In multivariable models, the odds of receiving CAS increased by 13% in all patients older than 70 years in the post-CREST compared with the pre-CREST period (odds ratio [OR], 1.13, 95% CI, 1.00-1.28, P = .04), including symptomatic women (OR, 1.31, 1.05-1.65, P = .02). Symptomatic stenosis (OR 1.39; 95% CI, 1.27-1.52; P < .001), congestive heart failure (OR, 1.48; 95% CI, 1.35-1.63; P < .001), and peripheral vascular disease (OR, 1.35; 95% CI, 1.27-1.43; P < .001) were associated with higher odds of CAS; comorbid hypertension (OR, 0.70; 95% CI, 0.66-0.74; P < .001), smoking (OR, 0.84; 95% CI, 0.78-0.91; P < .001), and weekend admission (OR, 0.77; 95% CI, 0.68-0.88; P < .001) were negatively associated with the odds of CAS. Conclusions and Relevance:Despite concerns for higher periprocedural complications with CAS in elderly patients, the odds of CAS increased in the post-CREST compared with pre-CREST era in patients older than 70 years, including symptomatic women.

Project description:BACKGROUND AND PURPOSE:Although onset-to-treatment time is associated with early clinical recovery in acute ischemic stroke (AIS) patients treated with intravenous tissue plasminogen activator (tPA), the effect of the timing of tPA-induced recanalization on functional outcomes remains debatable. METHODS:We conducted a multicenter, prospective observational cohort study to determine whether early (within 1-hour from tPA-bolus) complete or partial recanalization assessed during 2-hour real-time transcranial Doppler monitoring is associated with improved outcomes in patients with proximal occlusions. Outcome events included dramatic clinical recovery (DCR) within 2 and 24-hours from tPA-bolus, 3-month mortality, favorable functional outcome (FFO) and functional independence (FI) defined as modified Rankin Scale (mRS) scores of 0-1 and 0-2 respectively. RESULTS:We enrolled 480 AIS patients (mean age 66±15 years, 60% men, baseline National Institutes of Health Stroke Scale score 15). Patients with early recanalization (53%) had significantly (P<0.001) higher rates of DCR at 2-hour (54% vs. 10%) and 24-hour (63% vs. 22%), 3-month FFO (67% vs. 28%) and FI (81% vs. 39%). Three-month mortality rates (6% vs. 17%) and distribution of 3-month mRS scores were significantly lower in the early recanalization group. After adjusting for potential confounders, early recanalization was independently associated with higher odds of 3-month FFO (odds ratio [OR], 6.19; 95% confidence interval [CI], 3.88 to 9.88) and lower likelihood of 3-month mortality (OR, 0.34; 95% CI, 0.17 to 0.67). Onset to treatment time correlated to the elapsed time between tPA-bolus and recanalization (unstandardized linear regression coefficient, 0.13; 95% CI, 0.06 to 0.19). CONCLUSIONS:Earlier tPA treatment after stroke onset is associated with faster tPA-induced recanalization. Earlier onset-to-recanalization time. RESULTS:in improved functional recovery and survival in AIS patients with proximal intracranial occlusions.

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Timing of Carotid Revascularization Procedures After Ischemic Stroke.

Publications

Timing of Carotid Revascularization Procedures After Ischemic Stroke.

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