Rockman CB et al. (2006) Early carotid endarterectomy in symptomatic patients is associated with poorer perioperative outcomes. J Vasc Surg 44: 480–487

Carotid endarterectomy (CEA) is effective at preventing further strokes in patients who have experienced transient ischemic attack (TIA) or stroke, yet there is uncertainty regarding the optimum timing of the procedure after stroke. In this retrospective study, Rockman et al. reviewed data from 1,046 patients who had undergone CEA following TIA or completed stroke, comparing 'early' (≤4 weeks following symptoms) with 'delayed' (>4 weeks after last symptom) surgery.

Patients receiving early CEA were significantly more likely to experience perioperative stroke than those undergoing the delayed procedure within both the completed stroke (9.4% vs 2.4%; P = 0.003) and TIA (3.3% vs 0.9%; P = 0.05) groups. The authors recommend consideration of a waiting period of 4 weeks between last stroke symptoms and the performance of CEA for patients diagnosed with completed stroke. Despite the results, they do not suggest a change in practice for patients with TIA, for whom early CEA intervention is regarded as beneficial.

Recent institutional reports indicate that the greatest benefits from CEA occur when the procedure is performed within 2 weeks of initial symptoms. Such findings conflict with the results of this study; however, the patients reviewed by Rockman et al. were not randomized, and characteristics of clinical presentation could have affected both CEA timing and the likelihood of perioperative complications. The authors note marked heterogeneity in the clinical manifestation of stroke and suggest that analyses of additional data such as preoperative CT scans (unavailable for this study) would help identify patients who would benefit from early, as opposed to delayed, CEA.