Carotid endarterectomy without angiography does not compromise operative outcome (original) (raw)
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New duplex ultrasound scan criteria for managing symptomatic 50% or greater carotid stenosis
Journal of Vascular Surgery, 1999
The North American Symptomatic Carotid Endarterectomy Trial (NASCET) showed that selected patients benefited from surgery when their carotid artery was 50% or more stenosed. This study assessed the accuracy of color-flow duplex ultrasound scanning (DUS) parameters to detect 50% or greater carotid artery stenosis and to determine the situations in which carotid endarterectomy (CEA) without angiography could be justified. Methods: From March 1, 1995, to December 1, 1995, all patients considered for CEA were studied with DUS and carotid angiography. Results of the two tests were blindly compared. DUS measurements of internal carotid artery (ICA) peak systolic velocity (PSV), end diastolic velocity, and ratio of the ICA to common carotid artery PSV (ICA/CCA) were subjected to receiver operator characteristic curve analysis to determine the most accurate criterion predicting 50% or greater angiographic stenosis. The criterion for identifying patients for CEA without angiography was selected from criteria with a high positive predictive value (PPV) and sensitivity. Results: A total of 188 carotid bifurcations were available for comparison. A PSV (ICA/CCA) of 2 or higher was the most accurate criterion for detection of 50% or greater stenosis, with an accuracy rate of 93% (sensitivity, 96%; specificity, 89%; PPV, 92%). A PSV (ICA/CCA) of 3.6 or higher was the best criterion for identifying candidates for CEA who had not undergone earlier angiography, with PPV, sensitivity, specificity, and accuracy rates of 98%, 77%, 98%, and 86%, respectively. Conclusion: These redefined criteria detect the NASCET-defined threshold level of 50% or greater ICA stenosis, above which CEA results in stroke reduction. A management algorithm based on these criteria should help to minimize both angiography and unnecessary intervention.
Intraoperative duplex scanning and late carotid artery stenosis
Journal of Vascular Surgery, 1994
Purpose: The purpose of this study was to assess the effect of intraoperative duplex scanning on early and late results after carotid endarterectomy. Methods: We reviewed 316 carotid arteries in 283 patients who underwent operation since 1986. The results of intraoperative ultrasonography were normal in 254 (80.4%) and abnormal in 62 (19.6%). We did not reexplore 53 (85.5%) of the abnormalities because the defect was minor, 2 to 3 mm or less. These defects were retained atheroma in the common carotid artery (n = 35), internal carotid artery (leA) (n = 5), external carotid artery (n = 2), small frond in the bulb (n = 2), thickened wall of the vein patch (n = 2), and leA kink (n = 7), two of which were associated with retained atheroma. Nine defects (14.5%) were reexplored and repaired; there were seven flaps, one residual plaque, and one case with turbulent flow alone. Results: Patients with a normal examination result had an early leA occlusion rate of 0.79% (n = 2), an early stroke rate of 1.6% (n = 4), and one death (0.4%). In the unrepaired group these rates were 1.9% (n = 1) and 1.9% (n = 1), respectively. No occlusion occurred in the repaired group, but one preexisting cerebrovascular accident worsened immediately after operation. Frequency analysis and B-mode imaging were performed after operation and every 6 to 12 months in all patients (mean 21.6 months). A greater than 75% area stenosis was found in nine (17%) of the 53 unrepaired carotid arteries, but in only four (4.3%) of the 254 carotid arteries lacking defects and in one of the reopened group (p < 0.001). There have been no late strokes, and only three late transient ischemic attacks overall. Conclusions: A normal intraoperative scanning result obtained after carotid endarterectomy is associated with improved late patency rates. Even small defects appear to be associated with an increased incidence of late restenosis, reemphasizing the importance of technical perfection. a VASe SURG
Can duplex ultrasonography select appropriate patients for carotid endarterectomy?
European Journal of Vascular and Endovascular Surgery, 1997
Objectives: This study investigated the reliability of carotid duplex ultrasound (DUS) to identify appropriate candidates for carotid endarterectomy (CEA) according to a panel of vascular specialists. Design: Prospective study. Material: 102 patients with 145 carotid bifurcation stenosis or occlusions. Methods: All patients who required a carotid angiogram were evaluated using DUS followed by carotid angiography. A blinded panel of four vascular specialists individually decided whether CEA would be appropriate for each patient based on pre-angiographic information. Angiograms were then shown to panelists to see if their management decision was altered by the angiogram. Results: For stenosis >_ 80% on DUS (n = 60), panelists unanimously agreed on CEA without angiography in 57 lesions. In 50 lesions (87.7%), angiography showed >_ 70% stenosis and the management plan remained unchanged. For the other seven lesions, intracranial aneurysms (n = 2), tandem intracranial lesion (n = 1), unsuspected proximal common carotid lesion (n=l), a 40% stenotic lesion (n=l), and high carotid bifurcations (n=2) were seen. In lesions with 50-79% stenosis on DUS (n = 66), none of the panelists recommended CEA without prior angiography. Eighteen (27%) of these lesions were >_ 70% stenosed on angiogram. Complications of angiograms included one stroke, one haematoma, and one severe allergic reaction. Conclusion: Carotid duplex ultrasonography without angiography can reliably select lesions appropriate for surgery only when critical stenosis >_ 80% is chosen. Routine angiography is recommended for carotid stenosis of 50-79% when CEA is considered.
Colour duplex scanning versus angiography: a retrospective assessment of carotid stenosis
Cardiovascular Surgery, 1995
A retrospective study was performed to investigate the reliability of colour duplex scanning as a screening method in detecting carotid artery disease. The results of this technique and digital subtraction arteriography of 100 carotid bifurcations in SO patients undergoing carotid endarterectomy were compared. In accordance with suggested standard reports dealing with cerebrovascular disease, the diameter reduction was classified in one of five categories: < 20 ZO-59%, 60-79%. 80-99% and total occlusion. In 78% the gradings determined using dig&a! subtraction arteriography and duplex scanning correlated perfectly, and in 99% of the studied bifurcations the difference was not more than one grade. The sensitivity and specificity of colour duplex scanning in detecting a stenosis with a diameter reduction of more than 60% was 98% and 87.7%, respectively. The best non-invasive method to identify carotid bifurcation disease is duplex scanning. Although the role of duplex scanning as an alternatlve to angiography is currently evolving, the authors still advocate carotid angiography when surgery is considered.
Journal of Vascular Surgery, 2000
Purpose: The purpose of this study was to evaluate the accuracy of magnetic resonance angiography (MRA) for categorizing the severity of carotid disease relative to duplex ultrasound scan and cerebral contrast arteriography (CA) to determine if MRA imaging could replace the need for cerebral angiography in cases of indeterminate or inadequate duplex scan imaging. Methods: Seventy-four carotid bifurcations in 40 patients undergoing 45 carotid endarterectomies from 1996 to 1998 were imaged with duplex ultrasound scan; MRA (two-dimensional neck and three-dimensional intracranial, time-of-flight technique); and biplanar, digital subtraction cerebral arteriography. Studies were blindly reviewed by one reader who used established threshold velocity criteria for the duplex scan and the North American Symptomatic Carotid Endarterectomy Trial method for MRA and CA to determine the percentage of diameter reduction of the internal carotid artery (ICA). Disease severity was grouped into four categories (< 50%, 50%-74%, 75%-99% stenosis and occlusion), and the results of MRA and duplex ultrasound scan were compared with CA. Results: Sensitivity, specificity, positive predictive value, and negative predictive value for detection of > 50% ICA stenosis were 100%, 96%, 98%, and 100% for MRA and 100%, 72%, 88%, and 100% for duplex ultrasound scan, respectively; similarly, for detection of > 75% ICA stenosis values were 100%, 77%, 76%, and 100% for MRA and 90%, 74%, 72%, and 91% for duplex ultrasound scan, respectively. Both MRA and duplex ultrasound scan accurately differentiated all cases of > 95% stenosis (n = 7) from occlusion (n = 4). Short length ICA flow gaps were present on MRA in all cases of 75% to 99% stenosis and one half of cases of CA-defined 50% to 74% stenosis. In patients with 50% to 74% stenosis, the mean angiographic stenosis was significantly greater when a flow gap was present on MRA (64% ± 6%) versus no flow gap (57% ± 7%) (P = .04). There was overall agreement among duplex ultrasound scan, MRA, and CA in 73% of carotids imaged. Of the 24% discordant results between MRA and duplex ultrasound scan, MRA correctly predicted disease severity in all cases, and inaccurate duplex ultrasound scan results were due to overestimation in 83% of cases. The operative plan was altered by CA findings in only one patient (2%) after duplex ultrasound scan and MRA. Conclusions: MRA can accurately categorize the severity of carotid occlusive disease. Duplex ultrasound scan facilitates patient selection for carotid endarterectomy in most cases, but adjunct use of MRA improves diagnostic accuracy for > 75% stenoses and may obviate the need for cerebral arteriography when duplex scan results are inconclusive or demonstrate borderline disease severity. (J Vasc Surg 2000;32:429-40.)
Prospective evaluation of new duplex criteria to identify 70% internal carotid artery stenosis
Journal of Vascular Surgery, 1996
Purpose: Large multicenter trials (North American Symptomatic Carotid Endarterectomy Trial, European Carotid Surgery Trial) have documented the benefits of carotid endarterectomy for treating symptomatic patients with > 70% stenosis of the internal carotid artery. Although color-flow duplex scanning has become the preferred method for noninvasive assessment of internal carotid artery disease, no criteria have been generally accepted to identify this subset of patients. We previously reported a retrospective series to establish such criteria. This study details our results when these criteria were applied prospectively.
Is duplex scanning sufficient evaluation before carotid endarterectomy?
Journal of Vascular Surgery, 1989
Recent reports have suggested that cerebral angiography may not be necessary before carotid endarterectomy is performed in selected patients. To determine ff arteriography provides additional information that might influence the decision to operate or the conduct of the operation, a retrospective review was performed of 100 consecutive patients undergoing cerebral angiography and carotid duplex scanning. Eighty of the 100 patients subsequently underwent carotid endarterectomy for neurologic symptoms or asymptomatic stenosis greater than 80%. Among the 20 patients not operated on, three would have undergone unnecessary surgery for mistaken diagnoses had the arteriogram not been obtained. Two other patients in this group of 20 would have had carotid endarterectomy for asymptomatic stenosis in the presence of an equally stenotic tandem lesion. Among the 80 patients operated on, an additional three had the operative procedure altered because arteriographic studies revealed pathologic findings outside the area of duplex scan examination. Thus the use of arteriography altered the management of eight (8%) patients in this group of 100. (J VAsc SURG 1989;9:193-201.) 193 194 Geuder et al.