key: cord-0867831-rvu3dtjn
authors: Hellegering, Joyce; van der Laan, Maarten J.; Heide, Erik-Jan de; Uyttenboogaart, Maarten; Zeebregts, Clark J.; Bokkers, Reinoud P.H.
title: Preventing stroke in symptomatic carotid artery disease during the COVID-19 pandemic
date: 2020-05-21
journal: J Vasc Surg
DOI: 10.1016/j.jvs.2020.04.476
sha: 290aa730b610849cf9c37a750c1674d44630d884
doc_id: 867831
cord_uid: rvu3dtjn

nan

Preventing stroke in symptomatic carotid artery disease during the COVID-19 pandemic As the coronavirus disease 2019 (COVID-19) pandemic is escalating, many countries are struggling to contain the virus and ensure appropriate care. Hospitals and their intensive care units have seen an overwhelming increase in the number of patients, which has had substantial effects on the care for all other patients.

For patients with symptomatic carotid artery disease, carotid endarterectomy (CEA) can prevent major stroke or death. 1,2 These semi-acute treatments are, however, likely to be cancelled or postponed because of the reallocation of resources, such as anesthesiology teams, ventilators, and operation room capacity. However, analyses of the pooled North American Symptomatic Carotid Endarterectomy Trial and European Carotid Surgery Trial data have shown that the benefit of surgery is considerable reduced when patients are treated more than 2 weeks after the presenting symptoms. 3 To ensure the care for patients with symptomatic carotid artery disease during the COVID-19 outbreak, we decided to temporarily switch our primary form of treatment from CEA to carotid artery stenting (CAS) because CAS does not require anesthetics or intensified care on a standard basis. The use of CAS can achieves long-term benefits similar to those with CEA but has been associated with an increased risk of periprocedural stroke or death. 4 Within our center, a tertiary referral center located in the northern region of The Netherlands, we evaluated the results for CEA and CAS for the past 2 years to assess the safety of CAS in daily practice. The primary endpoint was ischemic or hemorrhagic stroke within 90 days after the procedure. A total of 155 patients had been treated from January 2018 to December 2019 for symptomatic carotid artery disease. Of the 155 patients, 110 had undergone CEA and 44 had undergone CAS because severe comorbidities, a hostile neck, or a high cervical carotid bifurcation. Within the CAS group, 2 postprocedural hemorrhagic stroke events occurred (4.5%). One patient experienced intracerebral hemorrhage within 90 days of treatment. For that patient, clopidogrel was replaced by ticagrelor, in addition to aspirin, because of poor (0%) platelet aggregation inhibition with clopidogrel, as measured by P2Y12 platelet function testing. The second patient had had symptoms of a transient ischemic attack on the ward, with no new ischemic damage found on a computed tomography scan but an unexpected asymptomatic thalamic hemorrhage under triple anticoagulation regimen. Both patients recovered completely. One patient had developed amaurosis fugax 6 months after CAS because of in stent stenosis, with explantation of the stent performed, followed by formal endarterectomy.

Within the CEA cohort, 1 patient experienced a transient ischemic attack (0.9%), and 4 patients developed a postoperative neck hematoma for which repeat intervention was needed (3.6%). During follow-up, 3 patients (2.7%) developed symptomatic ipsilateral restenosis of the carotid artery, 2 of which within 90 days of CAS. These patients were all successfully treated with CAS. Complications such as myocardial infarction or cerebral hyperperfusion syndrome were not reported in the CAS and CEA groups.

With these results, we believe that a temporary CAS first approach within our center is a safe and reasonable approach. Primary treatment with CAS could reduce the burden of care within hospitals and ensure adequate and timely care for this patient group during a time of limited capacity.

Analysis of pooled data from the randomised controlled trials of endarterectomy for symptomatic carotid stenosis

Carotid endarterectomy for symptomatic carotid stenosis

Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery

Percutaneous transluminal balloon angioplasty and stenting for carotid artery stenosis