Mandatory diagnostic angiography for carotid artery stenosis prior to carotid artery intervention
Amgad N Makaryus1, Lawrence M Phillips, Paul Wright
1North Shore University Hospital, Manhasset, New York, New York 11030, USA.
Insights
Noninvasive imaging for carotid stenosis overestimates disease severity, leading to unnecessary interventions. Angiography is crucial before carotid revascularization to confirm stenosis and avoid unindicated procedures.
Area of Science:
- Vascular Surgery
- Neurology
- Radiology
Background:
- Revascularization is key for stroke risk reduction in severe carotid atherosclerosis.
- Noninvasive imaging like MRA and ultrasound often overestimate carotid stenosis.
- Current practice may lead to unindicated interventions due to imaging limitations.
Purpose of the Study:
- To evaluate the sufficiency of noninvasive imaging for carotid intervention referral.
- To determine if noninvasive tests accurately identify patients needing carotid revascularization.
Main Methods:
- Analysis of 101 patients referred for carotid artery stenting (CAS).
- Prior evaluation included carotid ultrasound and Magnetic Resonance Angiography (MRA).
- Comparison of noninvasive findings with angiography results to assess intervention necessity.
Main Results:
- 36% of referred patients had <70% stenosis and did not require intervention.
- Of those needing intervention, 75% underwent CAS and 23% underwent Carotid Endarterectomy (CEA).
- No major adverse events (stroke, MI, death) occurred during follow-up.
Conclusions:
- Noninvasive imaging frequently leads to referral for unnecessary carotid interventions.
- Angiography is essential for accurate stenosis assessment prior to carotid intervention.
- This highlights the need for confirmatory angiography to guide revascularization decisions.
Introduction:
Revascularization is an important strategy for reducing stroke risk in patients with severe carotid atherosclerosis. Magnetic resonance angiography (MRA) and/or carotid ultrasound have traditionally been used as the only diagnostic modalities prior to revascularization. Patients undergoing CEA frequently have no further assessments of carotid anatomy prior to surgery. Evaluation with carotid ultrasound and MRA can often overestimate the degree of stenosis. We sought to determine if noninvasive imaging was sufficient for determining whether a patient should be referred for carotid intervention.
Methods:
We performed an analysis of 101 patients referred for carotid artery stenting (CAS). All patients had previously been evaluated with carotid ultrasound and 94% had undergone MRA as well. We sought to determine if noninvasive diagnostic imaging for carotid stenosis was sufficient to determine the necessity for endovascular intervention.
Results:
Of the 101 patients referred for carotid intervention, 36 (36%) were shown to have <70% stenoses and did not require intervention. Of those who had significant disease, 49 (75%) underwent successful CAS, 15 (23%) underwent CEA, and 1 patient was treated medically for a total occlusion. Three of the 36 patients not requiring carotid intervention were found to have subclavian stenosis. Two (4%) of the patients undergoing CAS and 4 (27%) of the patients undergoing CEA had minor complications. No patients suffered a major stroke, MI, or death at follow-up.
Conclusion:
This analysis demonstrates that 36% of patients referred for endovascular intervention based on noninvasive imaging did not meet criteria by angiography. This emphasizes the need for carotid angiography prior to carotid intervention.
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