The value and economic analysis of routine postoperative carotid duplex ultrasound surveillance after carotid endarterectomy

Abstract

Background Several studies have reported on the role of postoperative duplex ultrasound surveillance after carotid endarterectomy (CEA) with varying results. Most of these studies had a small sample size or did not analyze cost-effectiveness. Methods We analyzed 489 of 501 CEA patients with patch closure. All patients had immediate postoperative duplex ultrasound examination and were routinely followed up both clinically and with duplex ultrasound at regular intervals of 1 month, 6 months, 12 months, and every 12 months thereafter. A Kaplan-Meier analysis was used to estimate the rate of ≥50% and ≥80% post-CEA restenosis over time and the time frame of progression from normal to ≥50% or ≥80% restenosis. The cost of post-CEA duplex surveillance was also estimated. Results Overall, 489 patients with a mean age of 68.5 years were analyzed. Ten of these had residual postoperative ≥50% stenosis, and 37 did not undergo a second duplex ultrasound examination and therefore were not included in the final analysis. The mean follow-up was 20.4 months (range, 1-63 months), with a mean number of duplex ultrasound examinations of 3.6 (range, 1-7). Eleven of 397 patients (2.8%) with a normal finding on immediate postoperative duplex ultrasound vs 4 of 45 (8.9%) with mild stenosis on immediate postoperative duplex ultrasound progressed to ≥50% restenosis (P = .055). Overall, 15 patients (3.1%) had ≥50% restenosis, 9 with 50% to <80% and 4 with 80% to 99% (2 of these had carotid artery stenting reintervention), and 2 had late carotid occlusion. All of these were asymptomatic, except for one who had a transient ischemic attack. The mean time to ≥50% to <80% restenosis was 14.7 months vs 19.8 months for ≥80% restenosis after the CEA. Freedom from restenosis rates were 98%, 96%, 94%, 94%, and 94% for ≥50% restenosis and 99%, 98%, 97%, 97%, and 97% for ≥80% restenosis at 1 year, 2 years, 3 years, 4 years, and 5 years, respectively. Freedom from myocardial infarction, stroke, and deaths was not significantly different between patients with and without restenosis (100%, 93%, 83%, and 83% vs 94%, 91%, 86%, and 79% at 1 year, 2 years, 3 years, and 4 years, respectively; P = .951). The estimated charge of this surveillance was 3.6 × 489 (number of CEAs) × $800 (charge for carotid duplex ultrasound), which equals $1,408,320, to detect only four patients with ≥80% to 99% restenosis who may have been potential candidates for reintervention. Conclusions This study shows that the value of routine postoperative duplex ultrasound surveillance after CEA with patch closure may be limited, particularly if the finding on immediate postoperative duplex ultrasound is normal or shows minimal disease.

The Influence of the Metabolic Syndrome on the Short- and Long-Term Outcome After Carotid Endarterectomy

“…Moreover, the value of duplex after CEA for stroke prevention is still a subject of discussion and a customized follow-up in low-risk patients seems justified. 22,23 Third, hypertension was based on either the blood pressure at the outpatient clinic, as measured by the anesthesiologist preoperatively or by the use of medications. We acknowledge that a limited number of measurements is insufficient to properly diagnose patients for hypertension.…”

Carotid artery disease progression and related neurologic events after carotid endarterectomy

“…Under this prism and if cost-effectiveness is in demand, policies of duplex scan surveillance at 1 month and then at 1-to 2-year intervals should be implemented. 40,41 Such long intervals should be counterbalanced against the benefits of encouraging more frequent patient follow-up, including careful reassessment of risk factors and medical treatment optimization.…”

“…This surveillance protocol detected only four patients with $80% restenosis, raising concerns about the unrealistic overuse of surveillance ultrasound assessments. 41 We are currently implementing surveillance at 1 month and annually thereafter.…”

The Society for Vascular Surgery implementation document for management of extracranial cerebrovascular disease

“…This notion, however, is increasingly challenged because of the decreasing and selective role for intervention in otherwise asymptomatic patients. 462,590,[594][595][596] A surveillance protocol is meaningful when anticipated results are likely to alter a medical or interventional treatment plan in a cost-effective manner.…”

“…The authors challenged the need for surveillance as not cost-effective and suggested decision making based on severity of the contralateral carotid. 596…”