Emergent Endovascular Intervention for Acute Neurological Deficits Post-Carotid Endarterectomy: A Single-Institutional Analysis and Systematic Review of the Literature

Abstract

Objective: Carotid endarterectomy (CEA) is a standard treatment for atherosclerotic carotid stenosis. Perioperative symptomatic restenosis or reocclusion of the carotid artery following CEA is a rare but serious complication that typically necessitates intervention. The efficacy and safety profile of emergent endovascular therapy (EVT) as an alternative to repeat CEA in the treatment of acute perioperative neurological decline remain unknown.

Methods: All patients undergoing CEA in the Department of Neurosurgery at a single comprehensive stroke center from 2015 to 2024 were reviewed. Patients who underwent EVT for acute perioperative neurological deficits were included in our series. A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify articles relevant to the endovascular management of acute neurological deficits following CEA.

Results: Four patients from our institutional cohort met the inclusion criteria. An additional 39 patients were identified from the literature review in 11 source articles, which yielded a total of 43 patients. CEA was performed for symptomatic lesions in 28 (28/32, 87.5%) patients. Abnormal angiographic findings were reported for all patients. Thrombus accumulation in or distal to the operated internal carotid artery (ICA) (26/43, 60.5%) and dissection flaps (15/43, 34.9%) were the most common findings. Five (11.6%) patients had tandem cervical ICA and intracranial occlusions, of which thrombectomy of the intracranial lesion was successfully performed on 3 patients. All patients except for 1 (42/43, 97.6%) underwent technically successful endovascular stenting. Following EVT, 76.7% (33/43) of patients had no persisting neurological deficits. Nine (20.9%) patients were found to have new cerebral infarcts on post-EVT imaging. In-hospital mortality was reported for 6 patients (14%), 4 of whom were found to have tandem cervical ICA and intracranial occlusions.

Conclusion: EVT is likely a technically viable alternative treatment for patients with perioperative acute neurologic deficits after CEA. However, most of the literature available comes from case series, thereby limiting the quality of evidence. Improved reporting of standard stroke outcome measures may help to inform the implementation of EVT and repeat CEA for acute ischemic symptoms after CEA.

Introduction

Approximately 20% of cases of acute ischemic stroke are attributable to atherosclerotic carotid artery stenosis.¹⁾ Carotid endarterectomy (CEA) remains a mainstay of surgical intervention for carotid artery stenosis alongside minimally invasive endovascular therapies (EVT).^2,3) Restenosis of the carotid arteries following CEA occurs in up to 37% of patients, typically within the first 3 years due to intimal hyperplasia or plaque reaccumulation.⁴⁾ Historically, recurrent lesions have been managed with repeat CEA, though reoperation is made challenging by scarring of the surgical site and carries a 3-fold increase in the risk of stroke and a 2-fold increased mortality rate compared to primary CEA.^5,6) More recently, carotid artery stenting (CAS) and transcarotid artery revascularization have become preferable in treating restenosis to avoid disruption of scar tissue.^7,8)

In rare cases, patients develop acute ischemic symptoms in the perioperative period, likely due to symptomatic narrowing of the carotid artery. Emergent operative reintervention in these cases carries high morbidity and mortality rates due to reopening of the surgical site, potential damage to surrounding structures, and repeated need for clamping the carotid artery for a period of time.^9,10) In addition, urgent repeat CEA may potentiate permanent neurological damage in cases of perioperative intracranial thromboemboli. Tandem intracranial occlusions need to be addressed promptly, and undergoing repeat CEA could delay endovascular treatment.^9,10) One must also consider that clamping the carotid during this time may potentially compromise collateral flow to the hemisphere, thereby increasing the risk of infarction. While CAS has been shown to be comparably safe and effective relative to repeat CEA in the setting of chronic carotid restenosis, it has not been explored as an alternative to open reoperation in the perioperative period.^11,12) We present a systematic review, including our own institutional cohort, of patients undergoing emergent EVT in the immediate perioperative period following CEA to better delineate the indications for and risks of post-CEA EVT for acute neurological deficits following CEA.

Materials and Methods

Single institution review

A retrospective review of all patients undergoing CEA by the Department of Neurosurgery at a single comprehensive stroke center from May 1, 2015 through October 1, 2024 was conducted. Inclusion criteria were age greater than 18 years old, successful CEA as observed by intraoperative indocyanine green (ICG) and Doppler demonstrating internal carotid artery (ICA) patency prior to closure, impedance of blood flow through the operated carotid artery on CT angiogram within 72 hours of CEA causing globally altered mental status or isolated neurologic deficits, and attempted EVT within 72 hours of CEA. Patients with asymptomatic lesions following CEA were not included, as these patients are typically managed with aggressive medical management and observation, if they are identified, due to the risk of thrombus embolization with intervention. Review of the electronic medical records was performed to collect relevant patient data, including demographics, indication for CEA, symptoms at the time of acute neurological change, angiographic details and interventions, and outcomes. Descriptive statistics were calculated. The local patient cohort was combined with the literature-derived cohort for pooled analyses. The research within our submission has been approved by the Institutional Review Board of Brown University Health.

Systematic review of the literature

A systematic review of PubMed was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. All relevant cases and studies between January 1967 and June 2022 were reviewed. The search terms “carotid endarterectomy,” “thrombosis,” “stroke,” “ischemia,” “angiography,” “endo-vascular,” and “thrombectomy” were used in the following combination to find relevant articles:

(“endarterectomy, carotid” [mesh] OR “CEA” OR “Carotid endarterectomy”) AND (“thrombosis” [mesh] OR “thrombosis” OR “stroke” [mesh] OR “stroke” OR “occlu*” OR “ischemia” [mesh] OR “ischemia” OR “Carotid Artery Injuries” [mesh] or “dissection”) AND (“after” OR “following” OR “rescue” OR “complication” OR “reoperation” [mesh]) AND (“percutaneous” OR “angioplasty” OR “angioplasty” [mesh] OR “angiogr*” OR “angiography” [mesh] OR “endovascular” OR “Endovascular Procedures” [mesh] OR “stents” [mesh] OR “stent” OR “thrombectomy” OR “thrombectomy” [mesh]).

Sources were screened for relevance following the PRISMA guidelines (Fig. 1). Exclusion criteria were book reviews, poster abstracts, studies involving preclinical (nonhuman) subjects, reviews without case reports, studies about unrelated topics, studies without available full texts, and papers that are not available in English. Sources reporting pooled data with patients not meeting inclusion criteria were also excluded. Titles and abstracts were screened for full-text review by 2 reviewers (C.M.P. and R.A.S.) and required unanimous agreement for inclusion. Discrepancies in screening results were resolved through joint adjudication by the reviewers. Full-text review for final study inclusion was carried out by the same reviewers and required unanimous agreement, or joint adjudication was conducted. All relevant information, including the number of relevant patients, demographics, presenting symptoms, angiographic findings, and outcomes, was manually extracted by the reviewers if available. Reviewers collected data independently. Data were obtained at the patient level from included studies to allow for detailed description of the patients, treatments, and outcomes. Included studies were evaluated using the Joanna Briggs Institute Critical Appraisal of Cohort Studies tool for assessment of evidence quality.¹³⁾

Fig. 1 Algorithm by which relevant articles from a literature search were reviewed.

Statistical analysis

Continuous variables were described with means and standard deviations. Ordinal variables were described with medians and interquartile ranges (IQRs). Categorical variables were described with frequencies and percentages. As the data included in each source article were different, missing data were common, and all statistics were calculated using only available data. Data imputation was not performed. Due to the small number of patients included from the single-center review (local patients), data from these patients were presented in a combined fashion with patient data obtained from the systematic review. As patients may have demonstrated more than 1 symptom to prompt CEA or post-CEA angiography and EVT, the total number of patients described as demonstrating various symptoms was greater than the number of patients included in the cohort.

Primary outcomes included the rate of technically successful stent placement and the rate of in-hospital mortality. Secondary outcomes included determination of the proportion of patients with persistent neurological deficits, new infarction on post-EVT imaging, and post-EVT neck hematoma development.

Results

Single institution review

Among 315 patients treated with CEA for symptomatic carotid stenosis, 3 patients (0.9%) were identified who underwent emergent endovascular treatment for acute neurological deficits. One other patient was transferred from an outside hospital with acute neurological deficits following CEA and underwent EVT, and this patient was included in this study.

Systematic review of the literature

After removal of duplicate titles, 2499 articles were initially screened for inclusion. Thirty-three articles underwent full-text review, and 11 articles were determined to meet inclusion criteria (Fig. 1).^10,14–23) Thirty-nine patients were identified from the 11 source articles (Table 1). In combination with local patients, 43 patients in total were included in the final analyses. Of the 11 included articles, 6 were case studies and 5 were case series (Table 2), and therefore carry a high risk of selection and publication biases and independently provide a low level of evidence (class 4C and 4D).

Table 1 Relevant cases reported in the literature

Reference	Number of patients	Average age in years (SD)	Gender (%)	Patients who were symptomatic before CEA (%)	Reasons for post-CEA angiogram	Angiogram findings	Number of patients successfully stented (%)	Post-endovascular repair deficits	Mortality in immediate postoperative period (%)
Anzuini et al., 200114)	13	65 (5)	10 males (76.9) 3 females (23.1)	13 (100)	Perioperative stroke (n = 13, 100%)	Thrombus (n = 8, 61.5%) Dissection (n = 5, 38.5%)	13 (100)	Major neurological deficit (n = 1, 7.7%)	1 (7.7)
Attigah et al., 200918)	1	67	1 male (100)	1 (100)	Completion angiography (n = 1, 100%)	Dissection (n = 1, 100%)	1 (100)	None	0 (0)
Benitez et al., 199823)	1	55	1 male (100)	1 (100)	Right-sided hemiparesis and aphasia (n = 1, 100%)	High-grade stenosis (n = 1, 100%)	1 (100)	None	0 (0)
Doss et al., 201417)	1	67	1 male (100)	1 (100)	Left-sided hemiplegia (n = 1, 100%)	Dissection (n = 1, 100%)	1 (100)	None	0 (0)
Kim et al., 200421)	1	43	1 male (100)	0 (0)	Left-sided hemiplegia (n = 1, 100%)	Dissection (n = 1, 100%)	1 (100)	Persistent neurological deficit (n = 1, 100%)	0 (0)
Ko et al., 201619)	1	Not reported	1 male (100)	0 (0)	Left-sided amaurosis fugax and dysarthria (n = 1, 100%)	Dissection (n = 1, 100%)	1 (100)	None	0 (0)
Marone et al., 201015)	7	65 (7)	3 male (42.8), 4 females (57.2)	7 (100)	Hemiparesis (n = 7, 100)	Thrombus (n = 4, 57.2%) Dissection (n = 2, 28.6%), spasm (n = 1, 14.3%)	7 (100)	Persistent neurologic deficits (n = 5, 71.4%)	0 (0)
Melissano et al., 199922)	1	Not reported	Not reported	Not reported	Transient ischemic attack (n = 1, 100%)	Dissection (n = 1, 100%)	1 (100)	None	0 (0)
Schulte et al., 200816)	2	Not reported	2 males (100)	Not reported	Completion angiography (n = 1, 50%) Transient ischemic attack and Horner syndrome (n = 1, 50%)	Dissection (n = 2, 100%)	2 (100)	None	0 (0)
Spiotta et al., 201510)	10	70.6 (8.1)	9 males (90) 1 female (10)	7 (70)	Completion duplex ultrasound (n = 1, 10%) Stroke symptoms (n = 9, 90%)	Thrombotic stenosis (n = 9, 90%) Dissection (n = 1, 10%)	10 (100)	Persistent deficits (n = 4, 40%)	2 (20)
Takahashi et al., 202120)	1	78	1 male (100)	1 (100)	Completion angiography (n = 1, 100%)	Hematoma compression of the carotid (n = 1, 100%)	1 (100)	Hoarseness and Horner syndrome that spontaneously resolved (n = 1, 100%)	0 (0)

CEA, carotid endarterectomy; SD, standard deviation

Table 2 Briggs scores for included articles

Reference	Number of patients	Score
Anzuini et al., 200114)	13	4c
Attigah et al., 200918)	1	4d
Benitez et al., 199823)	1	4c
Doss et al., 201417)	1	4d
Kim et al., 200421)	1	4d
Ko et al., 201619)	1	4d
Marone et al., 201015)	7	4c
Melissano et al., 199922)	1	4d
Schulte et al., 200816)	2	4c
Spiotta et al., 201510)	10	4c
Takahashi et al., 202120)	1	4d

Combined cohort analysis

Age was known for all except 1 patient found in the literature search (41/42, 97.6%), and the average age of all patients was 66.8 ± 8.0 years. Sex was reported in all 43 patients, and females represented 25.6% (11/43) of the cohort. Symptomatic versus asymptomatic status prior to CEA was known for 32 patients, with 28 (87.5%) patients being symptomatic. The symptoms prompting CEA were recorded for only 6 patients; symptoms included hemiplegia (4/6, 66.7%), dysarthria (2/6, 33.3%), amaurosis fugax (1/6, 16.7%), and expressive aphasia (1/6, 16.7%). The use of an intraoperative shunt was reported in 2 (2/43, 4.6%) cases, and the use of a patch closure was reported in 1 (1/43, 2.3%) patient. The anesthetic regimen used for CEA was known for 28 patients; local anesthesia or a cervical block was used for 21 (75.0%), and general endotracheal anesthesia was used for 7 (25.0%).

Deficits prompting angiographic evaluation and EVT were reported for all patients. The most common symptoms were hemiparesis (14/43, 32.5%), followed by middle cerebral artery syndrome (9/43, 20.9%), and aphasia (4/43, 9.3%). Horner syndrome, amaurosis fugax, and delayed emergence from general anesthesia prompted angiography and EVT in 1 patient each. Lastly, 13 patients (30.2%) underwent angiography and EVT for stroke symptoms that were not further specified by the original authors. Angiographic findings were reported for all patients. Findings included thrombus accumulation in or distal to the operated ICA (26/43, 60.5%) and dissection flaps (15/43, 34.9%). One patient was described as having vasospasm of the ICA distal to the originally operated site, and 1 patient was reported to demonstrate contrast extravasation from the vessel with adjacent hematoma resulting in vascular compression. One patient was found to have focal stenosis of the ICA that was refractory to stenting and balloon angioplasty without an identifiable cause. All patients were appropriately anticoagulated for EVT. No patients received a preoperative antiplatelet regimen, though an intraoperative antiplatelet load of aspirin, clopidogrel, abciximab, or cangrelor was described for 28 (28/43, 65.1%) patients.^10,14,17) Technically successful stenting was reported for all other patients (42/43, 97.7%).

Concomitant cervical ICA and intracranial occlusions were reported in 5 (5/43, 11.6%) patients, and thrombectomy of the intracranial lesion was successfully performed on 3 of these 5 patients. A modified thrombolysis in cerebral infarction (TICI) score of 2c was achieved in the patient treated at our institution, while TICI scores were not reported for all other patients.¹⁰⁾ Thrombectomy was not attempted in 1 patient due to multiple distal occlusions of the M3 segments of the middle cerebral artery and was not attempted in 1 other patient due to poor clinical condition. One local patient underwent successful stenting of the ICA and thrombectomy of an ipsilateral M2 occlusion, though an occlusion of a fetal-remnant P4 segment of the posterior cerebral artery was refractory to thrombectomy.

In the perioperative period following EVT, 11 (11/43, 25.6%) patients had persistent neurological deficits. Two patients were noted to have post-EVT stenosis of the carotid stent, 1 within the perioperative period and one 2 years later. Nine (20.9%) patients had new cerebral infarcts on post-EVT imaging. One patient was noted to have hoarseness and ipsilateral Horner syndrome after emergence from anesthesia, though all symptoms spontaneously resolved over time. New neck hematomas after CEA but before EVT were reported in 3 patients, and 2 required surgical evacuation. Neck hematoma developing after EVT was reported in 1 patient and resolved without surgical intervention.

A post-EVT antiplatelet regimen was described for all except 1 patient; 25 (25/43, 58.1%) patients were prescribed a dual-antiplatelet therapy (DAPT) regimen of aspirin and clopidogrel, 14 (32.5%) were prescribed aspirin and ticlopidine, 3 (7.0%) were prescribed aspirin and ticagrelor, 1 (2.3%) was prescribed an unspecified antiplatelet regimen, and 1 (2.3%) patient was prescribed anticoagulation without an antiplatelet regimen for prior aortic valve replacement surgery.

In-hospital mortality was reported for 6 patients (6/43, 13.9%), 4 of whom had tandem cervical ICA and intracranial occlusions. Eight of the 11 (72.7%) source articles reported 100% survival (Fig. 2). Of patients who died in the hospital, 2 patients from the local cohort died due to non-neurologic causes, including an inferior wall myocardial infarction and hospital-acquired pneumonia in a patient on an immunosuppressive regimen for multiple myeloma treatment.

Fig. 2 Histogram of the percentage of survivors within each source article. Eight of the 11 source articles reported 100% survival rates.

Discussion

Acute ischemic symptoms caused by a defect in the carotid artery in the perioperative period after CEA are a rare neurological emergency that requires rapid correction. This single-center and systematic review of the literature demonstrates that EVT is likely a technically viable alternative to urgent reoperation. To our knowledge, this is the largest cohort of patients managed with EVT for this indication reported in the literature. These analyses establish a baseline estimate of the technical success of emergent stenting post-CEA and define a reasonable DAPT regimen. However, this cohort was collected from evidence of class 4C and 4D, as patients were presented in case reports and case series. Additionally, reporting of nearly universal successful stenting and survival suggests significant publication bias. Despite heterogeneity in patient selection criteria and treatment methodologies, these results improve generalizability and suggest that EVT can be successfully performed for post-CEA neurological compromise. Standardized reporting of outcomes is needed to better delineate the comparative efficacy of EVT and repeat CEA.

Acute neurologic decline requiring reintervention occurred in 0.9% of patients in this institutional cohort, consistent with prior estimates of 0.6%–3.9%.^14,15,24) Source articles reported varying EVT techniques and stent options, though discussions of differences in technique between standard and emergent CAS were not included. In the authors’ institutional practice, aspiration thrombectomy of the CEA site was more common during reintervention due to suspected acute thrombus formation, though otherwise there were no consistent differences between emergent and standard EVT approaches. EVT achieved technically successful stenting in 97.7% of patients, with 75% surviving without persistent neurological deficits. In addition, EVT resulted in a 14% in-hospital mortality rate. The morbidity and mortality rates associated with EVT were comparable to those reported in prior analyses of repeat perioperative CEA. A previously published cohort of 15 patients undergoing urgent operative reintervention reported that only 33% of their patients remained alive without neurological deficit at hospital discharge.²⁵⁾ Other reports cite acceptable clinical outcomes in 42%–55% of patients.^24,26) A subgroup analysis of The North American Symptomatic Carotid Endarterectomy Trial similarly found that urgent reoperation did not benefit any patients with perioperative stroke, including 2 symptomatic patients found not to have defects at the operative site.²⁷⁾ However, no studies directly comparing repeat perioperative CEA to EVT are available, though this study supports EVT as a technically feasible alternative to repeat CEA for EVT-trained practitioners, particularly if there is imaging evidence of a target lesion.

In the patient cohort collected here, all patients underwent emergent EVT following CEA due to acute neurologic deficits prompting repeat imaging demonstrating a putative target lesion, including carotid dissection, stenosis, thrombus, and/or intracranial thrombus. Clear selection criteria for emergent EVT remain undefined, though disabling neurological deficits appear to warrant intervention, particularly with a possible target lesion identified on noninvasive imaging. Although routine postoperative imaging, if practiced, may detect carotid artery lesions in asymptomatic patients, they are unlikely to benefit from EVT due to the risk of intracranial embolization.^10,14,24) In such cases, maximal medical management and observation may be favored, reserving EVT for new or progressive symptoms. The risks of emergent EVT for symptomatic patients must also be considered, though criteria for patients at high risk from EVT remain elusive due to the lack of reporting of unsuccessful cases. We hypothesize that the primary risks revolve around initiation of DAPT with a concomitant risk of hemorrhagic conversion of large or newly infarcted territories, development of a neck hematoma within the operative bed, or carotid angioplasty resulting in avulsion or dehiscence of the recent operative site. Though this latter complication is not directly reported, we propose caution with aggressive angioplasty in the setting of a recalcitrant lesion, as was the reason for procedural abortion and failed stenting in our cohort given concern for carotid dehiscence in the setting of a lesion that was believed to be mechanical rather than atheroembolic in nature.

On the whole, EVT was associated with a small number of minor complications, including neck hematoma requiring no intervention, Horner syndrome, and perioperative carotid restenosis, each of which occurred in 1 patient, but importantly, no patients developed symptomatic intracerebral hemorrhage or cranial nerve injury after EVT. A large retrospective analysis of patients treated with acute repeat CEA reported 2% of patients developing rapidly expanding neck hematomas due to patch disruption during reoperation, and 10% of patients developing symptomatic intracranial hemorrhage.²⁵⁾ Other small analyses of repeat CEA did not report instances of neck hematoma formation or symptomatic intracranial hemorrhage, making the complication profiles of EVT versus repeat CEA difficult to compare. However, our pooled cohort demonstrated a rate of hemorrhagic complications with EVT that was comparable to repeat CEA despite all patients being administered DAPT after EVT. No patients were reported to have received preoperative antiplatelet therapy, while 65% received intraoperative antiplatelet loading. New ischemic infarct rates of up to 60% after repeat CEA have been reported in the literature, which is higher than the 20% rate found in our cohort.^24–26) While it may be challenging to differentiate whether poor neurologic outcomes are due to infarcts that developed prior to initial CEA versus after repeat CEA or EVT, patients who undergo EVT may benefit from lower stroke burden due to aggressive antiplatelet therapy and the ability to intervene upon intracranial occlusions.

Of the 5 patients with tandem cervical carotid and intracranial occlusions, 3 survived without significant neurologic deficits. Previous literature regarding patients with tandem occlusions managed with EVT has found concurrent CAS and intracranial thrombectomy result in favorable outcomes when compared to either treatment alone.^28,29) CT angiography of the head and neck is critical in patients with acute neurologic deficits after CEA, as it can reveal intracranial lesions inaccessible through a cervical incision. However, outcomes for patients with tandem occlusions remain poor overall, and it is unclear whether thrombectomy alone for the intracranial occlusion with delayed carotid reoperation or concurrent management of the carotid and intracranial lesions results in superior neurologic outcomes or a more favorable safety profile.³⁰⁾ One study of 56 patients undergoing EVT for intervention of tandem occlusions reported positive outcomes in 64% of patients, while a separate study of 62 patients reported positive outcomes in 61% of patients.^28,29) Survival without severe neurologic deficits in 60% of the patients with tandem occlusions in our cohort is comparable to these literature standards, though it is important to recognize that comparison between patients with and without a history of recent CEA is difficult given the differences in underlying pathophysiology—such as the more typical atherosclerotic carotid occlusion in tandem occlusion cases—and that this may change decision-making when considering carotid intervention. Despite these limitations, EVT as an alternative to reoperation has the potential to save time in the diagnosis of intracranial occlusions and allow for simultaneous intervention.

Despite these promising findings, meaningful assessment of neurological recovery was hampered by limited standardized outcome reporting. The National Institutes of Health Stroke Scale (NIHSS) prior to EVT was reported in 2 of 11 source articles and was recorded for only 2 of 4 local patients. Post-EVT NIHSS was not available for any patient, making an objective determination of neurologic improvement impossible. Additionally, an objective outcome measure at a standardized follow-up interval, such as modified Rankin Scale at 90 days postdischarge, was not reported in any patient. Objective outcome comparisons are necessary, as there are several possible reasons why EVT may be selected over repeat CEA, including the ability to detect and intervene upon intracranial occlusions, as well as improved ability to evaluate the entire carotid artery lumen by angiography as compared to only a short segment in CEA.¹⁴⁾ Additionally, EVT may reduce ischemic time, as it can generally be performed rapidly and does not require ICA clamping. Improved patient assessment and reporting will be necessary in future studies to better understand the outcomes of EVT for acute carotid reocclusion.

This review has several limitations. Primarily, as this is a rare complication, the included cohort is small and a control group for comparison of outcomes was not available, thereby limiting generalizability. Second, a lack of standardized outcome measures reporting limits comparisons of EVT to repeat CEA. Third, the source articles that met inclusion criteria were case reports or case series, thereby limiting the quality of the evidence (Table 2). Fourth, publication bias was likely present, as the rates of favorable neurologic outcomes and survival strongly clustered around 100%. There was also likely substantial variability in patient selection criteria and angiographic techniques utilized, many of which were unreported. Fifth, as post-EVT imaging was rarely reported, further investigation will be necessary to determine the embolization risk of acute post-CEA EVT. Finally, while this review utilized broad search criteria, relevant cases may have been missed or excluded as only full-text sources written in English were considered.

Conclusion

Typical management of symptomatic acute ischemic symptoms following CEA has historically been emergent open operative repair despite poor reported outcomes. With the emergence of EVT in the treatment of acute ischemic stroke, this analysis of an institutional cohort plus a systematic review of the literature provides evidence for technical viability as well as comparable morbidity and mortality rates of EVT when compared to urgent repeat CEA outcomes reported in the literature. The implementation of endovascular techniques as an alternative to CEA may reduce the risk of blood loss and damage to adjacent structures while allowing for simultaneous management of tandem carotid and intracranial occlusions. While endovascular management of acute neurological deficits caused by carotid artery reocclusion may be reasonable for select patients, additional data more rigorously comparing endovascular to open approaches and using standardized stroke outcome measures remain necessary.

Disclosure Statement

The authors declare that they have no conflicts of interest.

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