Complications of Carotid Interventions for Symptomatic Lesions After Systemic Thrombolysis

Series detailing complications after carotid endarterectomy (CEA) and transfemoral carotid stenting (tfCAS) for patients presenting with neurologic symptoms that are treated with systemic thrombolysis (ST) are sparse. We sought to determine if treatment with ST was associated with a higher rate of postcarotid intervention complications. A multispecialty, institutional, prospectively maintained database was queried for symptomatic patients treated with CEA, tfCAS, or transcarotid artery revascularization (TCAR) from 2007 to 2019. Rate of bleeding complications (access/wound complications, hematuria. Intracranial hemorrhage, etc) and return to the operating room was compared between patients who were and were not treated with ST. The rates of stroke and death were also compared. Potential confounding variables were controlled for using inverse probability weighting. There were 1153 patients included (949 [82.3%] CEA, 190 [16.5%] tfCAS, and 14 [1.2%] TCAR). All treated lesions were symptomatic (550 [47.7%] stroke, 603 [52.3%] transient ischemic attack). Fifty-six patients (4.9%) were treated with ST. Fifteen of 56 patients also underwent catheter-based intervention for stroke. ST was administered 0 to 1 days preoperatively in 19 (33.9%) patients, 2 to 10 days, preoperatively, in 34 (64.2%) patients, and >10 days, preoperatively, in 3 (5.4%) patients. ST patients were more likely to present with stroke (92.8% vs 45.4%; P < .001) and have a higher mean preoperative Rankin score (2.7 ± 0.2 vs 1.1 ± 0.0; P < .001). Unadjusted rate of bleeding/return to operating room was 1.8% for ST group and 3.0% for non-ST group (P = .60). Unadjusted rate of stroke was 3.6% for ST group and 3.3% for non-ST group (P = .91), while perioperative mortality was 5.4% for ST group and 1.2% for non-ST group (P = .009). After adjusting for patient factors, preoperative antiplatelet/anticoagulation, and operative factors, ST was not associated with an increased odds of perioperative bleeding/return to operating room (odds ratio [OR], 0.10; 95% confidence interval [CI], 0.01-0.79; P = .03), stroke (OR, 1.01; 95% CI, 0.20-5.2; P = .98), or death (OR, 1.01; 95% CI, 0.28-3.6; P = .98). ST does not convey a higher risk of complications after CEA, tfCAS, or TCAR. After controlling for other factors, patients that received ST had similar rates of local complications, stroke, and death when compared to non-ST patients. Early carotid intervention is safe, and delays should be avoided in symptomatic patients given the high risk of recurrent stroke.