Can duplex ultrasonography select appropriate patients for carotid endarterectomy?

This study investigated the reliability of carotid duplex ultrasound (DUS) to identify appropriate candidates for carotid endarterectomy (CEA) according to a panel of vascular specialists.

Prospective study.

102 patients with 145 carotid bifurcation stenosis or occlusions.

All patients who required a carotid angiogram were evaluated using DUS followed by carotid angiography. A blinded panel of four vascular specialists individually decided whether CEA would be appropriate for each patient based on pre-angiographic information. Angiograms were then shown to panelists to see if their management decision was altered by the angiogram.

For stenosis > or = 80% on DUS (n = 60), panelists unanimously agreed on CEA without angiography in 57 lesions. In 50 lesions (87.7%), angiography showed > or = 70% stenosis and the management plan remained unchanged. For the other seven lesions, intracranial aneurysms (n = 2), tandem intracranial lesion (n = 1), unsuspected proximal common carotid lesion (n = 1), a 40% stenotic lesion (n = 1), and high carotid bifurcations (n = 2) were seen. In lesions with 50-79% stenosis on DUS (n = 66), none of the panelists recommended CEA without prior angiography. Eighteen (27%) of these lesions were > or = 70% stenosed on angiogram. Complications of angiograms included one stroke, one haematoma, and one severe allergic reaction.

Carotid duplex ultrasonography without angiography can reliably select lesions appropriate for surgery only when critical stenosis > or = 80% is chosen. Routine angiography is recommended for carotid stenosis of 50-79% when CEA is considered.