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Aortic arch angiography prior to carotid endarterectomy. Is its continued use justified?
A M Kadwa1, J V Robbs, A T Abdool-Carrim
1Metropolitan Vascular Service, University of Natal, Durban, South Africa.
Insights
Aortic arch angiography is often unnecessary for patients evaluated for carotid endarterectomy. Non-invasive tests and clinical exams effectively detect aortic arch branch lesions, reducing the need for invasive procedures.
Area of Science:
- Vascular Surgery
- Diagnostic Imaging
- Cardiovascular Medicine
Background:
- Traditional evaluation for carotid endarterectomy involves four-vessel aortic arch angiography.
- The development of non-invasive vascular laboratory techniques prompts a re-evaluation of this diagnostic approach.
Purpose of the Study:
- To determine the diagnostic yield of aortic arch angiography in patients with carotid bifurcation stenosis.
- To assess the influence of angiography findings on surgical management decisions.
- To evaluate the accuracy of clinical examination and non-invasive vascular testing in identifying aortic arch branch lesions.
Main Methods:
- Prospective study of 129 patients undergoing evaluation for carotid endarterectomy.
- Clinical assessment included pulses, blood pressure, and bruits.
- Duplex scan evaluated proximal arterial inflow.
- Four-vessel aortic arch angiography was performed for comparison.
Main Results:
- 14.7% of patients (19/129) had angiographic evidence of aortic arch branch disease.
- All detected lesions were identified through non-invasive methods (clinical exam or duplex scan).
- 5.4% of patients (7/129) required additional surgery for these lesions.
Conclusions:
- Aortic arch angiography is largely unnecessary for patients with significant carotid bifurcation stenosis.
- Non-invasive vascular assessment is accurate in detecting relevant aortic arch branch lesions.
- Angiography is reserved for select cases with abnormal non-invasive findings.
Unlabelled:
Patients with significant stenosis at the carotid bifurcation are traditionally subjected to four vessel aortic arch angiography prior to consideration for carotid endarterectomy. The advent of the non-invasive vascular laboratory has necessitated a reappraisal of this approach.
Aims:
1. Determine the yield from aortic arch angiography and its influence on surgical management. 2. Evaluate the accuracy of clinical examination and the non-invasive vascular laboratory in the detection of aortic arch branch lesions.
Methods:
One hundred and twenty-nine consecutive patients undergoing evaluation for carotid endarterectomy were prospectively enrolled into the study. The protocol entailed: 1. Clinical recording of upper limb pulses, blood pressure and supraclavicular bruits. 2. Duplex scan examination to evaluate proximal inflow into the carotid arteries. 3. Four vessel aortic arch angiography to detect aortic branch lesions. Data from the non-invasive tests were compared to angiography. Patients with aortic arch branch lesions were further evaluated to determine the proportion requiring additional surgery.
Results:
Nineteen patients had angiographic evidence of aortic branch disease (14.7%); six involved the common carotid artery, three the innominate artery and 10 the subclavian artery. All of these lesions were detected by the combination of unequal blood pressure, pulse deficit, bruit or duplex scan. Seven patients underwent additional surgery (5.4%) which included carotid-subclavian bypass (five), aortoinnominate bypass (one) and innominate endarterectomy (one).
Conclusion:
In patients with significant stenosis at the carotid bifurcation undergoing evaluation for carotid endarterectomy, aortic arch angiography is unnecessary except in a small percentage of patients with abnormal clinical and non-invasive findings.