Reasons for Delayed Carotid Endarterectomy for Symptomatic Carotid Stenosis in Norway 2018–2019: A National Audit

Abstract

Objective

Symptomatic carotid stenosis is one of the main causes of amaurosis fugax, transient ischaemic attack (TIA), and stroke. National and international guidelines recommend treatment with carotid endarterectomy (CEA) within 14 days of the index event. In Norway, the proportion of patients operated on within 14 days increased from 65% in 2015 to 83% in 2020. A national clinical audit cross sectional study was performed to identify the reasons for delayed CEA that could be addressed by quality improvement.

Methods

Patients operated on by CEA for symptomatic stenosis more than 14 days after the index event in 2018 and 2019 were identified from the Norwegian Registry for Vascular Surgery. The local registrar assessed the reason for the delay, based on the medical record. Possible reasons for delay were categorised as medical reasons, doctor delay, patient delay, and other reasons.

Results

Fourteen units performed 686 CEA for symptomatic stenosis in Norway in the study period, of which 179 (26%) were delayed. Ten units participated in the audit, accounting for 120 of 179 (67%) delayed CEAs. The reason for delay was identified for all patients in the participating units. There was a medical reason for the delay in 23 patients. There was doctor delay in 54 cases, patient delay in 28 cases, and a combination of patient delay and doctor delay in 10 cases. The reason for the delay was travel abroad in five cases.

Conclusion

Delayed CEA for symptomatic stenosis is usually due to doctor delay or patient delay. Medical reasons account for 19% of delayed operations. This implies that quality improvement is feasible by addressing doctor and patient delay. Healthcare providers should implement strategies to decrease the proportion of delayed CEA for symptomatic stenosis. Patient delay should be addressed with regular information campaigns.