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Who needs surveillance of the contralateral carotid artery?
M D Iafrati1, H Salamipour, C Young
1Department of Surgery, New England Medical Center, Boston, Massachusetts 02111, USA.
Insights
Carotid endarterectomy patients show disease progression in the contralateral artery. Tailoring duplex surveillance intensity by age and initial stenosis may improve cost-effectiveness for stroke prevention.
Area of Science:
- Vascular Surgery
- Neurology
- Medical Economics
Background:
- Carotid endarterectomy is a proven procedure, but postoperative surveillance strategies are debated.
- Understanding contralateral carotid artery disease progression is crucial for optimizing patient care.
- Assessing the economic impact of stroke prevention in the contralateral carotid artery is important.
Purpose of the Study:
- To determine the natural history of contralateral carotid artery disease progression using duplex surveillance.
- To evaluate the cost-effectiveness of stroke prevention strategies for the contralateral carotid artery.
Main Methods:
- Retrospective review of vascular laboratory records for carotid endarterectomy patients with at least two duplex studies (1984-1995).
- Definition of critical stenosis as >= 75% area reduction.
- Duplex scan follow-up ranging from 1 month to 11 years (mean 30.3 months).
Main Results:
- Age and initial stenosis were significant predictors of contralateral carotid artery stenosis progression.
- Overall, 19.5% of patients progressed to critical stenosis within 5 years.
- High-risk groups (age > 65 or initial stenosis >= 50%) showed progression rates of 27% and 39%, respectively.
- Cost per stroke prevented ranged from $143,500 to $418,200, varying with initial stenosis.
Conclusions:
- Patients undergoing carotid endarterectomy are prone to developing stenosis in the contralateral carotid artery.
- The cost-benefit ratio of surveillance can be enhanced by adjusting duplex surveillance intensity based on patient age and initial stenosis degree.
- Personalized surveillance protocols may optimize resource allocation for stroke prevention.
Background:
Although the value of carotid endarterectomy has been proven, postoperative surveillance remains controversial. The purpose of this study was to determine the natural history of disease progression in the contralateral carotid artery by duplex surveillance, and to assess the cost of stroke prevention on this contralateral side.
Methods:
Vascular laboratory records were reviewed to identify carotid endarterectomy patients who had two or more duplex studies between 1984 and 1995. Critical stenosis was defined as > or = 75% area reduction.
Results:
In all, 324 patients were followed up with duplex scans for 1 month to 11 years (mean 30.3 months). The only factors that correlated with progression to critical stenosis were age and initial stenosis. Overall, 19.5% of patients progressed to critical stenosis within 5 years while the high-risk groups with age > 65 years or initial stenosis > or = 50% progressed to critical disease in 27% and 39%, respectively (P < or = 0.05). The cost per stroke prevented ranged from $143,500 to $418,200 when stratified by initial stenosis.
Conclusion:
Patients who have undergone a carotid endarterectomy demonstrate a propensity for progression of carotid stenosis in the unoperated (contralateral) artery. The cost/benefit ratio may be improved by varying the intensity of duplex surveillance of the contralateral carotid based on the patient's age and initial degree of stenosis.
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