Early revascularization in symptomatic carotid artery disease leads to better outcomes: A 10-year multicenter cohort analysis.

Abstract

Objective: Randomized trials and meta-analyses have suggested that earlier intervention for symptomatic carotid artery disease may benefit patients, yet the optimal timing window remains debated. This study evaluated the impact of timing of revascularization on perioperative and long-term outcomes.

Methods: We conducted a retrospective review of 821 carotid revascularization procedures for carotid artery disease from 2016 to 2026, excluding patients with previous neck radiation. Procedures were stratified by time from symptom onset to intervention into urgent (0-2 days), early (3-14 days), and delayed (≥15 days) groups. Perioperative end points included 30-day mortality, ipsilateral stroke, transient ischemic attack (TIA), myocardial infarction (MI), and a composite of these events. Long-term outcome end points included all-cause mortality, ipsilateral stroke, TIA, MI, restenosis, and reintervention. Univariable and multivariable Cox proportional hazards regression analyses were performed to identify independent predictors of the 30-day composite outcome and long-term reintervention. Sensitivity analyses were also included excluding patients who underwent thrombolysis or thrombectomy to adjust for factors related to adjunct procedures at the time of initial neurovascular event presentation.

Results: The study cohort had a median age of 74.2 years (interquartile range, 66.7-80.5) and was predominantly composed of male patients (69.4%), with high rates of hypertension (86.1%), hyperlipidemia (84.4%), and coronary artery disease (35.6%). The most common presentation was stroke (48.4%), followed by TIA (31.8%) and amaurosis fugax (19.9%). The 30-day composite outcome of stroke, TIA, MI, or death was significantly lower in the early group (2.8%) than in the delayed (4.0%) and urgent (8.0%) groups (P = .03). Thirty-day mortality was significantly higher in the urgent group (2.9%) than in the early (0.3%) and delayed (0.3%) groups (P = .01). On multivariable Cox regression, urgent timing [hazard ratio (HR), 2.50; 95% confidence interval, 1.02-6.12; P = .044] and absence of preoperative antithrombotic therapy (HR, 3.75; 95% confidence interval, 1.46-9.64; P = .006) were independent predictors of the 30-day composite outcome. At a median follow-up of 2.8 years (interquartile range, 1.1-5.3), all-cause mortality was comparable across groups (urgent, 20.4% vs early, 18.5% vs delayed, 16.5%; P = .57). Long-term MI was more frequent in the early group (4.7%) than in the urgent (1.5%) and delayed (1.6%) groups (P = .03), confined entirely to those initially presenting with TIA on subgroup analysis. Long-term restenosis was highest in the urgent group (9.5%), followed by delayed (5.3%) and early groups (3.9%; P = .05). Reintervention rates followed the same pattern (urgent, 6.6% vs delayed, 3.1% vs early, 1.1%; P < .01), with a 3-year reintervention-free survival of 97.9% for early, 76.3% for urgent, and 74.6% for delayed (log-rank P = .009). On multivariable Cox regression, both urgent (HR, 4.13; P = .018) and delayed (HR, 5.63; P = .003) timing were independently associated with higher reintervention risk compared with early revascularization. In both sensitivity analysis excluding patients who underwent thrombolysis and thrombectomy, 30-day composite outcomes remained significantly higher for the urgent group, as did restenosis and reinterventions outcomes.

Conclusions: Early carotid revascularization between 3 and 14 days after neurovascular symptoms have most favorable perioperative and long-term outcomes compared with both urgent and delayed intervention. Urgent revascularization carries significantly higher perioperative risk, whereas delayed intervention beyond 14 days reduces the potential preventive benefit of timely revascularization and is associated with higher long-term reintervention rates. These findings support consideration of revascularization within a 3- to 14-day window as the optimal strategy for symptomatic patients.