Intended for healthcare professionals


Access to stroke prevention surgery varies widely in UK

BMJ 2011; 342 doi: (Published 21 June 2011) Cite this as: BMJ 2011;342:d3882

Re: Access to stroke prevention surgery varies widely in UK. Wise, et al. BMJ 2011;342:(Published 25 June 2011)

Dear editor,

The Author comments on the third report from the United Kingdom Audit
of Vascular Surgical Services and Carotid Endarterectomy (CEA)[1] and
highlights concerns that many suitable patients are not being offered
timely stroke prevention surgery. There is robust evidence that patients
with acute ischaemic stroke or TIA, in the presence of an ipsilateral
moderate or severe carotid stenosis, benefit from early carotid
endarterectomy to reduce the risk of recurrent ipsilateral stroke[2,3].
National Clinical Guidelines on Stroke, published in 2009[4], advised that
patients with suspected non-disabling CVA/TIA should undergo carotid
imaging within 1 week of onset of symptoms, and those with confirmed non-
disabling CVA/TIA and stable neurological symptoms if appropriate should
undergo surgery within a maximum of 2 weeks of onset symptom. Indeed the
governments National Stroke Strategy[5] has set a target of 48 hours from
symptoms to surgery to be achieved by 2017, which will represent a major
challenge for clinicians managing stroke.

As a high-volume unit conducting carotid revascularisation we
conducted a clinical audit of our practice between 2009 and 2011 to
monitor progress towards meeting these targets and identify persistent
factors causing delay between symptoms and surgery. We found significant
improvement in the total median number of days from symptoms to surgery,
from 56 days (in 2009) to 34.5 days (in 2010), p<0.01. Particular
improvement was noted in timeframe from referral to surgery, factors which
can be controlled by the vascular surgery team, with time from referral to
surgery reducing from 24.5 days (in 2009) to 12 days (in 2010), p<0.05.
Of those patients who still did not meet the recommended 14 day timeframe
in 2010, the majority (71%) of delays could not be directly controlled by
the vascular surgical team, of these the commonest causes of delay were:
delayed referral (31%); patient initiated delays (35%), due to postponed
or cancelled appointments.

Whilst we continue to improve timeframes from referral to surgery it
is important that all clinicians managing stroke and indeed the public at
large fully engage in the campaign to raise awareness of the signs of
stroke and ensure that that prompt emergency treatment reduces the risk of
death and disability[6].

1. Prepared on behalf of The Clinical Standards Department Royal
College of Physicians of London. UK Audit of Vascular Surgical Services
& Carotid Endarterectomy. April 2011 Public Report.

2. Rothwell PM, Eliasziw M, Gutnikov SA et al for the Carotid
Endarterectomy Trialists' Collaboration. Analysis of pooled data from the
randomised controlled trials of endarterectomy for symptomatic carotid
stenosis. Lancet 2003; 361: 107-116.

3. Rothwell PM, Giles MF, Chandratheva A et al. Effect of urgent
treatment of transient ischaemic attack and minor stroke on early
recurrent stroke (EXPRESS Study): a prospective population-based
sequential comparison. Lancet 2007; 370: 1432-42.

4. National Clinical Guidelines 2009 Stroke: The diagnosis and acute
management of stroke and transient ischaemic attacks by the National
Institute for Health and Clinical Excellence

5. Department of Health. National Stroke Strategy London 2007.

6. Stroke: act F.A.S.T. awareness campaign.

Competing interests: No competing interests

28 June 2011
Denis W. Harkin
Honorary Senior Lecturer & Consultant Vascular Surgeon
Julia A. Street, Claire Jones, and Stephen A. Badger
Royal victoria Hospital, Belfast Health & Social Care Trust