The Value of a Carotid Duplex Surveillance Program for Stroke Prevention

Srivastava

Journal of Vascular Surgery

et al. 2015

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.

Section: Discussionsupporting

confidence: 91%

“…1-5 Advancements in medical treatment and the current emphasis on cost-effectiveness have questioned the value of performing routine carotid ultrasound scanning after CEA.…”

mentioning

confidence: 99%

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

Srivastava

Journal of Vascular Surgery

et al. 2015

Journal of Vascular Surgery

“…DUS accurately visualizes the carotid bifurcation and allows development of restenosis in the operated-on carotid artery and progression of disease in the contralateral carotid artery to be assessed. 1 Nonrandomized studies have reported mixed results regarding the timing and value of postoperative DUS surveillance, but no consensus has been reached. 2,3 Significant restenoses is generally thought to occur within the first 3 months after CEA and is the rationale most centers use to perform an early DUS scan.…”

mentioning

confidence: 99%

Duplex ultrasound surveillance after carotid artery endarterectomy

Shakarchi

Lowry

Nath

et al. 2016

“…Carotid stenosis progression has been suggested to be a better predictor of subsequent TIA/ stroke than a single measurement. 10 Although general carotid sonography surveillance may not be cost-effective, 11 this situation may well be different for a subgroup of patients with a higher risk for stenosis progression. It is conceivable that MR imaging-PH is also an indicator of disease progression 12 and, therefore, may be useful in this regard.…”

mentioning

confidence: 99%

MR Imaging–Detected Carotid Plaque Hemorrhage Is Stable for 2 Years and a Marker for Stenosis Progression

Simpson¹,

Akwei²,

Hosseini³

et al. 2015

AJNR Am J Neuroradiol

BACKGROUND AND PURPOSE: MR imaging-detected carotid plaque hemorrhage is associated with an increased risk of recurrent ischemic cerebrovascular events and could be an indicator of disease progression; however, there are limited data regarding the dynamics of the MR imaging-detected carotid plaque hemorrhage signal. We assessed the temporal change of this signal and its impact on carotid disease progression.