The value and economic analysis of routine postoperative carotid duplex ultrasound surveillance after carotid endarterectomy

Introduction We reviewed the literature for preoperative computed tomography carotid angiography and/or carotid duplex to determine their respective sensitivity and specificity in assessing the degree of carotid stenosis. We aimed to identify whether one imaging modality can accurately identify critical stenosis in patients presenting with transient ischaemic attack or symptoms of a cerebrovascular accident requiring carotid endarterectomy. Methods Systematic search of MEDLINE, Embase, Cochrane database of systematic reviews, all Evidence-Based Medicine Reviews (Cochrane Database of Systematic Reviews, ACP Journal club, Database of Abstracts of Reviews of Effects, Cochrane Clinical Answers, Cochrane Controlled Trials Register, Cochrane Methodology Register, Health Technology Assessment and NHS Economic Evaluation Database) for primary studies relating to computed tomography carotid angiography (CTA) and/or carotid duplex ultrasound (CDU). Studies included were published between 1990 and 2018 and focused on practice in the UK, Europe and North America. Results The sensitivity and specificity of CTA and CDU are comparable. CDU is safe and readily available in the clinical environment hence its use in the initial preoperative assessment of carotid stenosis. CDU is an adequate imaging modality for determining stenosis greater than 70%; sensitivity and specificity are improved when the criteria for determining greater than 70% stenosis are adjusted. Vascular laboratories opting to use duplex as their sole imaging modality should assess the sensitivity and specificity of their own duplex procedure before altering practice to preoperative single imaging for patients. Conclusions The sensitivity and specificity of CTA (90.6% and 93%, respectively) and CDU (92.3% and 89%, respectively) are comparable. Both are dependent on criteria used in vascular laboratories. CDU sensitivity and specificity was improved to 98.7% and 94.1%, respectively, where peak systolic velocity and end diastolic velocity were assessed. Either modality can be used to determine greater than 70% stenosis, although a secondary imaging modality may be required for cases of greater than 50% stenosis.

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Is routine duplex ultrasound surveillance after carotid endarterectomy cost-effective?

Surgery ◽

10.1016/s0039-6060(98)70140-0 ◽

1998 ◽

Vol 124 (2) ◽

pp. 343-352 ◽

Cited By ~ 31

Author(s):

Sheela T. Patel ◽

Karen M. Kuntz ◽

K.Craig Kent

Keyword(s):

Carotid Endarterectomy ◽

Duplex Ultrasound ◽

Cost Effective ◽

Ultrasound Surveillance

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Duplex Ultrasound Surveillance After Carotid Endarterectomy

Noninvasive Vascular Diagnosis ◽

10.1007/978-3-030-49616-6_66-1 ◽

2021 ◽

pp. 1-6

Author(s):

Efthymios D. Avgerinos ◽

Rabih A. Chaer

Keyword(s):

Carotid Endarterectomy ◽

Duplex Ultrasound ◽

Ultrasound Surveillance

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Carotid Duplex Ultrasound Performed Immediately Post Carotid Endarterectomy Predicts Outcome at Two Years

European Journal of Vascular and Endovascular Surgery ◽

10.1016/j.ejvs.2015.06.106 ◽

2015 ◽

Vol 50 (3) ◽

pp. e28-e29

Author(s):

E. Mc Partland ◽

C.O. McDonnell ◽

K. O'Malley ◽

M.K. O'Donohoe ◽

S.A. Badger ◽

...

Keyword(s):

Carotid Endarterectomy ◽

Duplex Ultrasound ◽

Carotid Duplex

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Optimization of duplex velocity criteria for diagnosis of internal carotid artery (ICA) stenosis: A report of the Intersocietal Accreditation Commission (IAC) Vascular Testing Division Carotid Diagnostic Criteria Committee

Vascular Medicine ◽

10.1177/1358863x211011253 ◽

2021 ◽

pp. 1358863X2110112

Author(s):

Heather L Gornik ◽

Tatjana Rundek ◽

Hannah Gardener ◽

James F Benenati ◽

Nirvikar Dahiya ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Diagnostic Criteria ◽

Internal Carotid ◽

Peak Systolic Velocity ◽

Duplex Ultrasound ◽

Additional Parameter ◽

Characteristic Analysis ◽

Carotid Duplex ◽

Ica Stenosis

Diagnostic criteria to classify severity of internal carotid artery (ICA) stenosis vary across vascular laboratories. Consensus-based criteria, proposed by the Society of Radiologists in Ultrasound in 2003 (SRUCC), have been broadly implemented but have not been adequately validated. We conducted a multicentered, retrospective correlative imaging study of duplex ultrasound versus catheter angiography for evaluation of severity of ICA stenosis. Velocity data were abstracted from bilateral duplex studies performed between 1/1/2009 and 12/31/2015 and studies were interpreted using SRUCC. Percentage ICA stenosis was determined using North American Symptomatic Carotid Endarterectomy Trial (NASCET) methodology. Receiver operating characteristic analysis evaluated the performance of SRUCC parameters compared with angiography. Of 448 ICA sides (from 224 patients), 299 ICA sides (from 167 patients) were included. Agreement between duplex ultrasound and angiography was moderate (κ = 0.42), with overestimation of degree of stenosis for both moderate (50–69%) and severe (⩾ 70%) ICA lesions. The primary SRUCC parameter for ⩾ 50% ICA stenosis of peak-systolic velocity (PSV) of ⩾ 125 cm/sec did not meet prespecified thresholds for adequate sensitivity, specificity, and accuracy (sensitivity 97.8%, specificity 64.2%, accuracy 74.5%). Test performance was improved by raising the PSV threshold to ⩾ 180 cm/sec (sensitivity 93.3%, specificity 81.6%, accuracy 85.2%) or by adding the additional parameter of ICA/common carotid artery (CCA) PSV ratio ⩾ 2.0 (sensitivity 94.3%, specificity 84.3%, accuracy 87.4%). For ⩾ 70% ICA stenosis, analysis was limited by a low number of cases with angiographically severe disease. Interpretation of carotid duplex examinations using SRUCC resulted in significant overestimation of severity of ICA stenosis when compared with angiography; raising the PSV threshold for ⩾ 50% ICA stenosis to ⩾ 180 cm/sec as a single parameter or requiring the ICA/CCA PSV ratio ⩾ 2.0 in addition to PSV of ⩾ 125 cm/sec for laboratories using the SRUCC is recommended to improve the accuracy of carotid duplex examinations.

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