Gianluca Faggioli (University of Bologna, Bologna, Italy) and Gert J de Borst (UMC Utrecht, Utrecht, The Netherlands) went head-to-head at the recent European Society for Vascular Surgery (ESVS) annual meeting (24–27 September, Kraków, Poland) to debate a motion that the two-week carotid endarterectomy (CEA) target for symptomatic patients is ‘outdated’ and that evidence-based treatment is now achievable.
Faggioli’s main argument, opening the debate, was that both clinical and anatomic factors should be used to determine the timing of intervention rather than a set threshold.
The presenter first addressed the origin of the two-week CEA target. “It’s come from the fact that the risk of recurrent stroke usually happens within 15 days,” he informed ESVS attendees.
Early intervention, Faggioli continued, is supported by a paper from Rantner et al, in which performing CEA within seven days is shown to reduce the risk of subsequent stroke.
However, Faggioli stressed that to fully answer the question at hand, it is important to understand that neurological symptoms in symptomatic patients are highly varied and must be categorised into stable and unstable, with stable symptoms being far more common.
Citing a review of the literature on patients with stable symptoms, Faggioli relayed that stroke and death rates among patients operated within 48 hours actually appear to be higher than those in patients operated later on, but not significantly so.
Regarding transient ischaemic attack (TIA), the presenter continued, the literature and the guidelines suggest ascertaining the cause of the TIA before intervening. “After that,” he said, “you can intervene without a significant recommendation regarding the timing of the intervention”.
Faggioli also noted that intervening within 48 hours after a stroke incurs a far greater risk of complication than intervening later on.
However, the presenter stressed that there is a wide variety of data on this topic, adding also that in patients with more severe strokes and extended ischaemic lesions, the risks associated with intervening quickly “are very much increased”.
“We have to consider not only the presence of the cerebral lesions but also their size and the clinical appearance of these strokes,” Faggioli emphasised.
Furthermore, the presenter noted that there is a “significant” difference in outcomes for patients with large ischaemic lesions treated before and after four weeks.
Finally, in patients with more significant ischaemic lesions, Faggioli continued, European guidelines recommend deferring carotid intervention, while the US guidelines advise against treating these patients.
“Symptomatic carotid patients can present with a variety of clinical and anatomical situations,” Faggioli said in his conclusion, emphasising that these must be central to any treatment decision. “Timing of revascularisation should be decided according to both clinical and anatomical factors.”
De Borst was in agreement that the two-week threshold is ‘outdated’. Where his argument differed from Faggioli’s related to the available evidence, with the presenter highlighting its heterogeneity.
“First of all,” de Borst began, “I think it’s crucial that we discuss stable symptoms—that’s where the greatest benefit can be achieved.”
With this in mind, the presenter gave an overview of the available literature, starting with the oldest. He highlighted a high natural-cause risk apparent here. “In the past,” he explained, “relatively early surgery was considered to be associated with very high perioperative risk, and that was why CEA was delayed on purpose—to six weeks or more.”
This changed with an analysis from Rothwell et al, de Borst noted. “Not everybody is aware where this 14-day threshold actually came from—it’s from this analysis,” he pointed out.
Here de Borst remarked: “If Rothwell would have chosen 10 days or 20 days, all of us would have been discussing that time frame.” On the two-week threshold, he continued: “It’s absolutely an arbitrary threshold.” De Borst commented that “it’s not bad to do a surgery at 15 days from symptoms—it’s only bad if you do surgery at 15 days and you have a very high perioperative stroke risk, and then you’re not providing any benefit to your patients”.
Since the Rothwell analysis, de Borst continued, a meta-analysis from Sweden of 12 studies including more than 230,000 patients—which the presenter noted “caused a lot of noise in our field”—revealed “very high and alarming” stroke and mortality rates resulting from operating within the first two days post-index operation. “This is astonishing, this should not be true,” he said. Following this meta-analysis, de Borst noted that several subsequent studies “showed a completely different picture”.
Referencing four randomised controlled trials on symptomatic patients, de Borst highlighted that stroke and death rates both within and beyond seven days show that surgery is safe in both time frames, while rates with stenting are “alarmingly high”.
Citing some of the most recent data, de Borst put forward a central component of his argument: “In my view, the most critical point is that within studies there’s a very heterogeneous definition of the index event—this should be standardised so we can speak the same language.”
Here he reiterated the “arbitrary” nature of the two-week cut-off, aligning with the view put forward by Faggioli, while going on to stress that “there’s still no strong evidence to change policy today”.
