Early Revascularization in Symptomatic Carotid Artery Disease Leads to Better Outcomes: A Ten-Year Multi-Center Cohort Analysis.

Objective

Randomized trials and meta-analyses have suggested that earlier intervention for symptomatic carotid artery disease (CAD) 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 CAD from 2016 to 2026, excluding patients with prior 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 endpoints included 30-day mortality, ipsilateral stroke, transient ischemic attack (TIA), myocardial infarction (MI), and a composite of these events. Long-term outcome endpoints 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 (IQR 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%) compared to delayed (4.0%) and urgent (8.0%) groups (P=0.03). Thirty-day mortality was significantly higher in the urgent group (2.9%) than in the early (0.3%) and delayed (0.3%) groups (P=0.01). On multivariable Cox regression, urgent timing (HR 2.50; 95% CI 1.02-6.12; P=0.044) and absence of preoperative antithrombotic therapy (HR 3.75; 95% CI 1.46-9.64; P=0.006) were independent predictors of the 30-day composite outcome. At a median follow-up of 2.8 years (IQR 1.1-5.3), all-cause mortality was comparable across groups (20.4% urgent vs. 18.5% early vs. 16.5% delayed; P=0.57). Long-term MI was more frequent in the early group (4.7%) than in the urgent (1.5%) and delayed (1.6%) groups (P=0.03), 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=0.05). Reintervention rates followed the same pattern (urgent 6.6% vs. delayed 3.1% vs. early 1.1%; P<0.01), with a 3-year reintervention-free survival of 97.9% for early, 76.3% for urgent, and 74.6% for delayed (log-rank P=0.009). On multivariable Cox regression, both urgent (HR 4.13; P=0.018) and delayed (HR 5.63; P=0.003) timing were independently associated with higher reintervention risk compared to early revascularization. In both sensitivity analysis excluding thrombolysis and thrombectomy patients, 30-day composite outcomes remained significantly higher for the urgent group; as were the 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 to both urgent and delayed intervention. Urgent revascularization carries significantly higher perioperative risk, while 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 revascularization within a 3-to-14-day window as the optimal strategy for symptomatic patients.