Delays in Carotid Endarterectomy with Symptomatic High-Grade Carotid Stenosis

Abstract

Background: Carotid endarterectomy (CEA) has a recognized time dependent benefit in reducing the risk of future stroke after an ischemic event. Despite many guidelines and efforts, few patients with symptomatic, severe carotid stenosis are treated within the recommended 2 weeks of the ischemic event. We investigate the delays surrounding access to surgical treatment at a designated stroke center in Canada. Methods: A retrospective chart-review of consecutive patients presenting to Sunnybrook Hospital, Toronto between January 2007 and January 2010, inclusive, with symptomatic, high-grade, extracranial, carotid artery stenosis receiving CEA within 1 year. Time intervals between emergency department presentation, neurologist assessment, carotid imaging, surgical referral, and carotid endarterectomy were calculated. Results: 124 patients were included. Presenting symptoms included unilateral weakness (58%), visual field defects (33%), unilateral sensory symptoms (13%), aphasia (11%), dysarthria (11%), and/ or other symptoms (5%). The longest wait was between surgical consultation and CEA (14 days; IQR: 6.5 to 36 days). Only 56 patients (44%) received carotid endarterectomy within 14 days of presentation. Motor deficit was the only statistically significant predictor of achieving a presentation to CEA time of within 2 weeks from the ischemic event (OR=9.6; p<0.001). Conclusions: Rates of carotid endarterectomy within the recommended 2 weeks of presentation have improved, however, delays due to long presentation to surgical consultation/surgery times are still worrisome. If tertiary care centres are to set an example for timely delivery of care, improvements such as fast-track dedicated ORs, single-visit imaging and interdisciplinary clinics, and education on the urgency of symptomatic carotid stenosis must be considered.