A Systematic Review and Meta-analysis of Peri-Procedural Outcomes in Patients Undergoing Carotid Interventions Following Thrombolysis

Eur J Vasc Endovasc Surg. 2021 Sep;62(3):340-349. doi: 10.1016/j.ejvs.2021.06.003. Epub 2021 Jul 12.

Abstract

Objective: To evaluate the safety of carotid artery stenting (CAS) and carotid endarterectomy (CEA) after thrombolytic therapy (TT).

Data sources: Medline, Scopus, and Cochrane databases.

Review methods: Systematic review and meta-analysis of studies involving patients who underwent CEA/CAS after TT.

Results: In 25 studies (n = 147 810 patients), 2 557 underwent CEA (n = 2 076) or CAS (n = 481) following TT. After CEA, the pooled peri-procedural stroke/death rate was 5.2% (95% confidence interval [CI] 3.3 - 7.5) and intracranial haemorrhage (ICH) was 3.4% (95% CI 1.7 - 5.6). After CAS, the pooled peri-procedural stroke/death rate was 14.9% (95% CI 11.9 - 18.2) and ICH was 5.5% (95% CI 3.7 - 7.7). In case control studies comparing CEA outcomes in patients receiving TT vs. no TT, peri-procedural death/stroke was non-significantly higher after TT (4.3% vs. 1.5%; odds ratio [OR] 2.34, 95% CI 0.74 - 7.47), but ICH was significantly higher after TT (2.2% vs. 0.12%; OR 7.82, 95% CI 4.07 - 15.02), as was local haematoma formation (3.6% vs. 2.26%; OR 1.17, 95% CI 1.17 - 2.33). In case control studies comparing CAS outcomes in patients receiving TT vs. no TT, peri-procedural stroke/death was significantly higher after TT (5.2% vs. 1.5%; OR 8.49, 95% CI 2.12 - 33.95) as was ICH (5.4% vs. 0.7%; OR 7.48, 95% CI 4.69 - 11.92). Meta-regression analysis demonstrated an inverse association between the time interval from intravenous (IV) TT to undergoing CEA and the risk of peri-procedural stroke/death (p = .032). Peri-operative stroke/death was 13.0% when CEA was performed three days after TT and 10.6% when performed four days after TT, with the risk reducing to within the currently accepted 6% threshold after six-seven days had elapsed.

Conclusion: Peri-procedural ICH and local haematoma were significantly more frequent in patients undergoing CEA after TT (vs. no TT), although there were no randomised comparisons. Peri-procedural hazards were also significantly higher for CAS after TT. The inverse relationship between timing to CEA and peri-procedural stroke/death mandates careful patient selection and suggests that it may be safer to defer CEA for six-seven days after TT.

Keywords: Carotid artery stenting; Carotid endarterectomy; Stroke; Thrombolysis.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Blood Vessel Prosthesis
  • Blood Vessel Prosthesis Implantation* / instrumentation
  • Blood Vessel Prosthesis Implantation* / mortality
  • Carotid Stenosis / complications
  • Carotid Stenosis / mortality
  • Carotid Stenosis / surgery*
  • Combined Modality Therapy
  • Endarterectomy, Carotid* / mortality
  • Fibrinolytic Agents / therapeutic use
  • Hematoma / epidemiology
  • Hematoma / etiology
  • Humans
  • Incidence
  • Intracranial Hemorrhages / epidemiology
  • Intracranial Hemorrhages / etiology
  • Postoperative Complications / epidemiology
  • Postoperative Complications / etiology*
  • Recurrence
  • Risk Factors
  • Secondary Prevention / methods*
  • Stents
  • Stroke / drug therapy
  • Stroke / etiology*
  • Stroke / prevention & control
  • Thrombolytic Therapy*
  • Time Factors
  • Treatment Outcome

Substances

  • Fibrinolytic Agents