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Delays in Carotid Endarterectomy: The Process is the Problem

  • Dylan Blacquiere (a1), Michael Sharma (a2) and Prasad Jetty (a3)

Abstract:

Background:

Current recommendations for carotid endarterectomy (CEA) for symptomatic carotid stenosis state benefit is greatest when performed within two weeks of symptoms. However, only a minority of cases are operated on within this guideline, and no systematic examinations of reasons for these delays exist.

Methods:

All CEA cases performed at our institution by vascular surgery for symptomatic carotid stenosis after neurologist referral in 2008-2009 were reviewed. Dates of symptom onset, initial presentation, referral to and evaluation by neurology and vascular surgery, vascular imaging, and CEA were collected, and the length of time between each analysed. Reasons for delays were noted where available.

Results:

Of 36 included patients, 34 had CEA more than two weeks after symptom onset. Median time to CEA from onset was 76 days (IQR, 38-105 days). Longest intervals were between surgeon assessment and CEA (14 days; IQR, 9-21 days), neurology referral and neurologist assessment (9 days; IQR, 2-26 days), vascular imaging and referral to vascular surgery (9 days; IQR, 2-35 days) and vascular surgery referral and assessment (8 days; IQR, 6-15 days). Few patients (44.1%) had reasons for delays identified; of these, process-related delays were related to delayed vascular imaging, delayed referral by primary care physicians, or multiple conflicting referrals.

Conclusions:

There are significant delays between symptom onset and CEA in patients referred for CEA, with delay highest between specialist referral and evaluation. Strategies to reduce these delays may be effective in increasing the proportion of procedures performed within two weeks of symptom onset.

RÉsumÉ: Contexte:

Selon les recommandations actuelles pour l'endartérectomie carotidienne (EC) effectuée pour une sténose carotidienne symptomatique, on obtient les meilleurs résultats lorsque l'intervention est effectuée dans les deux semaines suivant l'apparition des symptômes. Cependant, seulement une minorité de patients sont opérés dans le délai recommandé par les lignes directrices et aucun examen systématique des raisons du délai n'a été effectué.

Méthode:

Nous avons revu les dossiers de tous les cas d'EC référés par un neurologue, qui ont subi une chirurgie vasculaire dans notre institution pour une sténose carotidienne symptomatique en 2008-2009. Les dates de début des symptômes, de la consultation initiale, de la demande de consultation en spécialité et de l'évaluation en neurologie et en chirurgie vasculaire, de l'imagerie vasculaire et de l'EC ont été colligées et le temps écoulé entre chacune de ces dates a été analysé. Les raisons expliquant les délais ont été notées quand elles étaient disponibles.

Résultats:

Parmi les 36 patients inclus dans l'étude, 34 ont subi une EC plus de deux semaines après le début des symptômes. Le temps médian écoulé entre le début des symptômes et l'EC était de 76 jours (écart interquartile (ÉIQ) 38-105 jours). Les intervalles les plus longs étaient entre l'évaluation par le chirurgien et l'EC (14 jours; ÉIQ 9-21), la demande de consultation en neurologie et l'évaluation par le neurologue (9 jours; ÉIQ 2-26 jours), l'imagerie vasculaire et la demande de consultation en chirurgie vasculaire (9 jours; ÉIQ 2-35 jours) et la demande de consultation en chirurgie vasculaire et l'évaluation par le chirurgien (8 jours; ÉIQ 6-15 jours). Les raisons des délais étaient identifiées chez moins de la moitié des patients (44,1%); parmi eux, des délais dans le processus étaient reliés à l'imagerie vasculaire, à la demande de consultation par le médecin de première ligne ou à plusieurs demandes de consultation conflictuelles.

Conclusions:

Il existe des délais significatifs entre le début des symptômes et l'EC chez les patients référés pour une EC et le délai le plus long se situe entre la demande de consultation au spécialiste et l'évaluation faite par celui-ci. Des stratégies pour diminuer ces délais seraient susceptibles d'augmenter la proportion d'interventions effectuées dans les deux semaines suivant le début des symptômes.

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Copyright

Corresponding author

Department of Medicine, Division of Neurology, The Ottawa Hospital, and the University of Ottawa, Civic Campus, 1053 Carling Avenue, Ottawa, Ontario, K1Z 5R7, Canada. Email: dblacquiere@toh.on.ca

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Canadian Journal of Neurological Sciences
  • ISSN: 0317-1671
  • EISSN: 2057-0155
  • URL: /core/journals/canadian-journal-of-neurological-sciences
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