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Clinical follow-up rather than duplex surveillance after carotid endarterectomy
J Golledge1, R Cuming, M Ellis
1Department of Surgery, Charing Cross and Westminster Medical School, London, United Kingdom.
Insights
Long-term duplex surveillance after carotid endarterectomy offers no proven benefit for detecting restenosis or contralateral disease. Selective clinical follow-up for high-grade contralateral stenoses is recommended.
Area of Science:
- Vascular Surgery
- Neurology
- Diagnostic Imaging
Background:
- Carotid endarterectomy is a common procedure to prevent stroke.
- Post-operative surveillance is crucial to monitor for complications like restenosis and contralateral disease progression.
Purpose of the Study:
- To evaluate the efficacy of duplex surveillance after carotid endarterectomy.
- To assess the significance of contralateral carotid disease in patients who underwent ipsilateral endarterectomy.
Main Methods:
- Prospective observation of 305 patients for a median of 36 months post-carotid endarterectomy.
- Duplex surveillance performed at regular intervals: 1 day, 1 week, 3, 6, 9, 12 months, and annually thereafter.
Main Results:
- Ipsilateral symptoms (stroke/TIA) occurred in 10% of patients, with no significant difference based on restenosis severity.
- Contralateral symptoms (stroke/TIA) developed in 8% of patients, significantly associated with higher-grade contralateral stenoses (p < 0.01).
- Progression of contralateral disease was linked to increased TIA risk (p < 0.01), but not contralateral stroke.
Conclusions:
- Symptomatic restenosis after carotid endarterectomy is uncommon.
- Contralateral stroke is rare and not significantly associated with progressive contralateral disease.
- Long-term duplex surveillance provides no demonstrable benefit; selective clinical follow-up for high-grade contralateral stenoses is more appropriate.
Purpose:
The value of duplex surveillance and the significance of contralateral carotid disease after endarterectomy have been assessed.
Methods:
Three hundred five patients were observed prospectively after carotid endarterectomy for a median time of 36 months (range, 6 to 96 months), with duplex surveillance performed at 1 day; 1 week; 3, 6, 9, and 12 months; and then each year after endarterectomy.
Results:
Thirty patients (10%) had ipsilateral symptoms (13 strokes, 17 transient ischemic attacks [TIAs]) at a median time of 6 months (range, 0 to 60 months). Life table analysis demonstrated that ipsilateral stroke was equally common for patients who had > or = 50% restenosis (3% at 36 months) and those who did not (6% at 36 months, p > 0.5). Twenty-three patients (8%) developed symptoms (stroke 5, TIA 14) attributable to the contralateral carotid artery at a median time of 9 months (range, 0 to 36 months) after endarterectomy. By life table analysis, 40% of patients with 70% to 99%, 6% with 50% to 69%, 1% with < 50% contralateral internal carotid stenosis, and 5% with contralateral carotid occlusion at the time of endarterectomy had a contralateral TIA in the 36 months after endarterectomy (p < 0.01). However, contralateral stroke was not significantly more common for patients with severe contralateral internal carotid stenosis demonstrated at the time of endarterectomy (< 50% stenosis, 0%; 50% to 69%, 3%; 70% to 99%, 7%; occlusion, 6% stroke rate at 36 months). Seven of the 32 patients who developed progression of contralateral disease had a TIA, compared with 11 of 227 patients who did not develop progression of contralateral disease (p < 0.01). None of the 12 patients who progressed from a < 70% to a 70% to 99% contralateral stenosis had a stroke.
Conclusions:
After carotid endarterectomy restenosis is rarely associated with symptoms; contralateral stroke is rare and is not associated with progressive internal carotid artery disease suitable for endarterectomy. This study has shown no benefit from long-term duplex surveillance after carotid endarterectomy. Selective clinical follow-up of patients who have high-grade contralateral stenoses would appear more appropriate.