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A Methodological Approach to Non-invasive Assessments of Vascular Function and Morphology
Published on: February 7, 2015
Clinical benefit of carotid endarterectomy based on duplex ultrasonography
Gregory C Kasper1, Joann M Lohr, Richard E Welling
1John J. Cranley Vascular Laboratory, Good Samaritan Hospital, Cincinnati, OH, USA.
Insights
Duplex ultrasonography alone is sufficient for preoperative evaluation before carotid endarterectomy, avoiding complications and high costs associated with catheter angiography. This approach maintains low stroke and morbidity rates.
Area of Science:
- Vascular Surgery
- Diagnostic Imaging
- Health Economics
Background:
- Carotid endarterectomy is a key procedure for reducing stroke risk in patients with carotid artery stenosis.
- Optimizing this procedure involves minimizing morbidity and costs without compromising patient safety.
- Preoperative imaging plays a crucial role in patient selection and procedural planning.
Purpose of the Study:
- To compare the outcomes, complications, and costs of carotid endarterectomy using duplex ultrasonography alone versus duplex ultrasonography combined with catheter angiography for preoperative evaluation.
- To determine if the addition of catheter angiography provides significant clinical benefit to justify its associated risks and expenses.
Main Methods:
- Prospective collection of data from 123 carotid endarterectomies at a community teaching hospital.
- All patients underwent duplex ultrasonography; a subset also had catheter angiography.
- Comparison of mortality, morbidity, complications, and costs between the two imaging groups.
Main Results:
- Carotid endarterectomy demonstrated low rates: 0% mortality, 6.5% morbidity, and 0.8% stroke.
- Catheter angiography, used in 23% of cases, had a 21% complication rate (e.g., hematoma, pseudoaneurysm) and added $4,200 in costs per patient.
- No significant differences in intraoperative assessment, morbidity, mortality, or stroke rates were observed between the groups.
Conclusions:
- Preoperative duplex ultrasonography alone is a safe and cost-effective method for evaluating patients for carotid endarterectomy.
- The routine addition of catheter angiography increases morbidity and healthcare costs without improving patient outcomes.
- Reliance on duplex ultrasonography alone for preoperative assessment is recommended to enhance the overall benefit of carotid endarterectomy.
Abstract:
Carotid endarterectomy has been shown to significantly reduce the risk of stroke caused by carotid artery stenosis in selected patients. Limiting the morbidity and costs of this process without increasing the risks should further improve the benefits of this procedure. Results were prospectively collected from 123 consecutive carotid endarterectomies performed at a community teaching hospital. All patients underwent duplex ultrasonography for preoperative evaluation. Catheter angiography was used on a selective basis. Preferential use of regional anesthetic and selective use of the intensive care unit were applied. The mortality, morbidity, complications, and costs were then compared for the group receiving only preoperative duplex ultrasonography with those undergoing catheter angiography preoperatively. Age, comorbid risk factors, indications for carotid endarterectomy, and incidence of stroke were similar in both patient groups. The rates of mortality, morbidity, and stroke for carotid endarterectomy were low (mortality 0%, morbidity 6.5%, stroke 0.8%). For preoperative evaluation all patients underwent duplex ultrasonography (100%) and 28 (23%) underwent preoperative catheter angiography in addition to duplex ultrasonography. The complication rate associated with catheter angiography was 6/28 (21%). Complications included groin hematoma (7%), pseudoaneurysm (3.6%), bradycardia (7%), and unstable angina (3.6%). Costs for duplex ultrasonography averaged 165 US dollars and additional costs incurred by the use of catheter angiography averaged 4,200 US dollars. Intraoperative assessment of the carotid endarterectomy site did not change based on the use of preoperative catheter angiography. Morbidity, mortality, and stroke rates were the same for the 2 groups. The preoperative use of duplex ultrasonography for the sole evaluation in carotid endarterectomy is well established. The use of preoperative catheter angiography is still preferred by a subset of surgeons. The use of catheter angiography is associated with significant morbidity and additional costs when compared to performing carotid endarterectomy based solely on preoperative duplex ultrasonography. The added costs and morbidity of angiography increase the societal cost of this procedure without significant clinical improvement in patient outcome.
