Timing of carotid intervention in symptomatic carotid artery stenosis: a topical review

INTRODUCTION: Criteria and optimal timing for carotid artery revascularization have been polarizing subjects for investigators and clinicians dedicated to carotid artery atherosclerotic disease. A topical review was performed with the purpose of 1) providing an overview of the evidence on the definition of index event and on the definition of delay of intervention; 2) summarizing the rationale for the current definition for the optimal timing for carotid intervention, and 3) drawing a sketch for future directions implementing the aspect of timing in daily clinical practice.

EVIDENCE ACQUISITION: A literature search was performed using the Medline database and the following query ("Endarterectomy, Carotid"[Mesh]) AND ("Stroke" [Mesh] OR Symptomatic) AND "Randomized Controlled Trial"). A comprehensive review of manuscripts addressing timing of intervention was also performed.

EVIDENCE SYNTHESIS: A total of eleven RCTs were identified and data on index event definition, timing of intervention and BMT were resumed. The definition of the index event can have a significant impact on the delay times but has (surprisingly) received little attention. Different definitions in itself may be correct, but in terms of stroke prevention, it is most important to understand and emphasize that the risk of recurrent stroke. The optimal timing of CEA after stroke remains an important but unresolved question. No prospective, randomized study has ever been undertaken to specifically determine which patients and when they might safely undergo expedited CEA after recent stroke.

CONCLUSIONS: Collecting data on events during waiting time to intervention and developing reporting standards for these waiting times seem to be the key for unraveling this controversy.