Closing the Loop: A 21-year Audit of Strategies for Preventing Stroke and Death Following Carotid Endarterectomy

• Published in: European journal of vascular and endovascular surgery 2013-08, Vol.46 (2), p.161-170
• Main Authors: Naylor, A.R, Sayers, R.D, McCarthy, M.J, Bown, M.J, Nasim, A, Dennis, M.J, London, N.J.M, Bell, P.R.F
• Format: Article
• Language: English
• Subjects: Angioscopy; Aspirin - administration & dosage; Carotid Artery Diseases - complications; Carotid Artery Diseases - diagnosis; Carotid Artery Diseases - mortality; Carotid Artery Diseases - physiopathology; Carotid Artery Diseases - surgery; Carotid endarterectomy; Clinical Protocols; Drug Therapy, Combination; Endarterectomy, Carotid - adverse effects; Endarterectomy, Carotid - mortality; Endarterectomy, Carotid - standards; Humans; Hypertension - etiology; Hypertension - mortality; Hypertension - prevention & control; Intracranial Embolism - etiology; Intracranial Embolism - mortality; Intracranial Embolism - prevention & control; Intracranial Hemorrhages - etiology; Intracranial Hemorrhages - mortality; Intracranial Hemorrhages - prevention & control; Intraoperative Care; Medical Audit; Monitoring; Peri-operative stroke; Platelet Aggregation Inhibitors - administration & dosage; Postoperative Care; Practice Guidelines as Topic; Predictive Value of Tests; Quality control; Quality of Health Care; Risk Factors; Stroke - diagnosis; Stroke - etiology; Stroke - mortality; Stroke - physiopathology; Stroke - prevention & control; Surgery; Ticlopidine - administration & dosage; Ticlopidine - analogs & derivatives; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Transcranial
• ISSN: 1078-5884; 1532-2165
• DOI: 10.1016/j.ejvs.2013.05.005

The objective of this review was to identify causes of stroke/death after carotid endarterectomy (CEA) and to develop transferable strategies for preventing stroke/death after CEA, via an overview of a 21-year series of themed research and audit projects. Three preventive strategies were identified: (i) intra-operative transcranial Doppler (TCD) ultrasound and completion angioscopy which virtually abolished intra-operative stroke, primarily through the removal of residual luminal thrombus prior to restoration of flow; (ii) dual antiplatelet therapy with a single 75-mg dose of clopidogrel the night before surgery in addition to regular 75 mg aspirin which virtually abolished post-operative thromboembolic stroke and may also have contributed towards a decline in stroke/death following major cardiac events; and (iii) the provision of written guidance for managing post-CEA hypertension which was associated with virtual abolition of intracranial haemorrhage and stroke as a result of hyperperfusion syndrome. The pathophysiology of peri-operative stroke is multifactorial and no single monitoring or therapeutic strategy will reduce its prevalence. Two of the preventive strategies developed during this 21-year project (peri-operative dual antiplatelet therapy, published guidance for managing post-CEA hypertension) are easily transferable to practices elsewhere.