Routine early postoperative duplex scanning is unnecessary following uncomplicated carotid endarterectomy

Surveillance duplex ultrasound prompted interventions after carotid endarterectomy

OBJECTIVE

Current societal guidelines recommend duplex ultrasound (DUS) surveillance beyond 30 days after carotid endarterectomy (CEA) for patients with risk factors for restenosis or who underwent primary closure. However, the appropriate duration of this surveillance has not yet been identified, and the rate at which DUS surveillance prompts intervention is unknown. Multiple calls for decreasing health care spending that does not provide value, including unnecessary testing, have been made. The purpose of this study was to examine the rate of intervention prompted by surveillance DUS on the ipsilateral or contralateral carotid artery after CEA and determine the value of continued surveillance by determining the rate of DUS-prompted intervention.

METHODS

A single-center, retrospective chart review of all patients older than 18 years who had undergone CEA from August 2009 to July 2022 was performed. Patients with at least one postoperative duplex in our Intersocietal Accreditation Council-accredited ultrasound lab were included. Exclusion criteria were patients with incomplete medical charts or patients who underwent a concomitant procedure. The primary end point was return to the operating room for subsequent intervention based on abnormal surveillance DUS findings. Secondary end points were the number of postoperative surveillance duplexes, duration of surveillance, and incidence of perioperative stroke. The study participant data were queried for patients who had a diagnosis of stroke that occurred following their procedure.

RESULTS

A total 767 patients, accounting for 771 procedures, were included in this study, which resulted in 2145 ultrasound scans. A total of 40 (5.2%) patients required 44 subsequent interventions that were prompted by DUS surveillance scans. The average number of ultrasound scans per patient was 2.8 (range: 0-14), and the average duration of surveillance was 26.4 months (range: 0-155 months). Of the 767 patients, 669 (87.2%) had a unilateral CEA. A total of 62 of 767 (8.1%) patients had planned endarterectomies on the contralateral side based on initial imaging, not prompted by interval DUS surveillance scans. Of 767 patients, 28 (3.7%) patients who underwent CEA had a subsequent procedure for progression of contralateral disease, which was prompted by duplex surveillance scans. The average duration between index CEA and intervention on contralateral carotid was 29.57 months (range: 3-81 months). A total of 11 patients, accounting for 12 procedures, underwent a subsequent procedure for restenosis of their ipsilateral carotid, prompted by duplex surveillance scans. The average duration between index CEA and reintervention on the ipsilateral carotid was 17.9 months (range: 4-70 months). Three of 767 (0.4%) patients in total were identified as having a perioperative stroke.

CONCLUSIONS

The overall rate of ipsilateral reintervention after CEA is low. A small percentage of patients will progress their contralateral disease, ultimately requiring surgical intervention. These data suggest that regular duplex surveillance after CEA is warranted for patients with at least moderate contralateral disease; however, the yield is low for ipsilateral restenosis after 36 months based on this single institution study. Further study is needed to better delineate which patients need follow-up to decrease unnecessary testing while still targeting patients most at risk of restenosis or contralateral progression of disease.

Management of postoperative internal carotid artery intimal flap after carotid endarterectomy: a cohort study and systematic review

OBJECTIVE

Postoperative internal carotid artery (ICA) intimal flap (IF) is a potential complication after carotid endarterectomy (CEA) for carotid artery stenosis. There are no clear recommendations in the current literature on the management of this condition due to sparse evidence. Some authors advocate carotid stent placement or reoperation, while others suggest watchful waiting. The aim of this study was to analyze incidence and management strategies of postoperative ICA-IF, and moreover, to put these findings into context with a systematic literature review.

METHODS

The authors retrospectively reviewed all consecutive CEA cases performed at the University Hospital of Bern over a decade (January 2008 to December 2018). The incidence of postoperative ICA-IF, risk factors, management strategies, and outcomes were analyzed. These results were put into context with a systematic review following the PRISMA guidelines.

RESULTS

A total of 725 CEAs were performed between January 2008 and December 2018. Postoperative ICA-IF was detected by routine duplex neurovascular ultrasound (NVUS) in 13 patients, corresponding to an incidence rate of 1.8% (95% CI 1.0%-3.1%). There were no associated intraluminal thrombi on the detected IF. Intraoperative shunt placement was used in 5.6% and one or more intima tack sutures were performed in 42.5% of the 725 cases. There was no significant association between intraoperative shunt placement and the occurrence of an IF (p > 0.99). Two patients (15.4%) with IF experienced a transient postoperative neurological deficit (transient ischemic attack). In these cases, the symptoms resolved spontaneously without any interventions or change in the antiplatelet regimen. All other cases (84.6%) with IF were asymptomatic. In 1 patient (7.7%) with IF, the antiplatelet treatment was switched from a mono- to a dual-antiaggregating regimen because the IF led to a stenosis > 70%; this patient remained asymptomatic. All cases of IFs were managed conservatively with close radiological follow-up evaluations, without reoperation or stenting of the ICA. All 13 IFs vanished spontaneously after a mean duration of 6.9 months (median 1.5 months, range 0.5-48 months). A systematic literature review revealed a postoperative ICA-IF incidence of 3.0% (95% CI 2.1%-4.1%) with relatively heterogenous management strategies.

CONCLUSIONS

Postoperative ICA-IF is a rare finding after CEA. Conservative therapy with close NVUS follow-up evaluations appears to be an acceptable and safe management strategy for asymptomatic IFs without associated intraluminal thrombi.

Asymptomatic dissecting intimal lesions of common carotid arteries after carotid endarterectomy

PURPOSE

Carotid endarterectomy is a standard treatment for symptomatic high-degree internal carotid artery stenosis. The aim of this article is to present possible intimal lesions after carotid endarterectomy. These lesions could be manifested as intimal flaps, intimal steps or dissections with or without occlusion or stenosis of the artery.

METHODS

The evaluation of the frequency and characteristics of the asymptomatic dissecting intimal lesions of the common carotid arteries was performed in a sample of 100 patients who underwent endarterectomy for symptomatic high-grade stenosis of the internal carotid artery.

RESULTS

We found five patients with asymptomatic dissecting intimal lesions of the common carotid arteries.

CONCLUSION

The most common causes of these intimal lesions were shunting and prolongation of the clamping time. Routine carotid ultrasound follow-up exams are necessary because of the potential need for a change in the antithrombotic therapy or due to a need to perform an endovascular treatment.

The value of a carotid duplex surveillance program for stroke prevention

BACKGROUND

Although duplex ultrasonography (DU) can readily identify progression of carotid stenosis, controversy regarding the natural history of asymptomatic carotid stenosis as well as the need and appropriate interval for carotid DU surveillance still exists. Furthermore, consensus has not yet been made in the surgical literature regarding the usefulness, cost-effectiveness, or timing of DU surveillance after carotid endarterectomy (CEA). The purpose of this study was to determine how often DU surveillance for asymptomatic carotid disease or postintervention stenosis resulted in any change in the patient's clinical management, how many strokes were prevented by DU surveillance, and the cost of such a DU surveillance program per stroke prevented.

METHODS

We reviewed a 9-year vascular surgical database to identify all patients enrolled in a carotid DU surveillance program for asymptomatic carotid stenosis or following CEA between January 1, 2000, and December 31, 2008. The number of duplex scans and CEAs performed in those patients through March 2010 was also determined. The results of the Asymptomatic Carotid Atherosclerosis Study were then used to estimate the number of strokes prevented by CEA in the study population. Reimbursement data were assessed to calculate the average cost of each DU and the cost of the DU surveillance program for each stroke prevented.

RESULTS

During the study period, there were 11,531 carotid duplex scans performed on 3,003 patients (mean: 3.84 scans per patient) who had been enrolled in the DU surveillance program. CEA for asymptomatic carotid stenosis was performed on 225 (7.5%) patients. The DU surveillance program prevented approximately 13 strokes (871 carotid duplex scans per stroke prevented). The mean cost of each duplex scan was $332 ± 170. The total cost of the DU surveillance program was approximately $3,830,000 or $290,000 per stroke prevented.

CONCLUSIONS

Although a carotid DU surveillance program generates substantial revenue for a vascular surgery practice, it is costly and inefficient. A reappraisal of the "value" of carotid DU surveillance in stroke prevention is warranted. Consideration should be given to eliminating routine surveillance of postendarterectomy carotids in the absence of contralateral disease and limiting the number of DU surveillance studies for asymptomatic carotid disease.

[Role of duplex ultrasound for lower limb artery, abdominal aorta, and carotid artery surgery follow-up]

Long-term post-surgery follow-up is an essential part of the surgical and medical care for vascular surgery patients with peripheral arterial disease. Close collaboration with the patient's primary care physician is essential. In addition to close surveillance of the outcome after vascular surgery, follow-up includes an assessment and appropriate treatment of cardiovascular risk factors. Duplex ultrasound is a safe and noninvasive surveillance method, which should be performed by an experimented physician. We summarize the specific features of duplex ultrasound examinations after arterial surgery of the carotid arteries, the abdominal aorta and the lower limbs, and propose a surveillance schedule.

Risk factors for restenosis after carotid artery angioplasty and stenting

OBJECTIVES

With carotid artery stenting (CAS) becoming an ever-increasing procedure, we sought to determine risk factors for in-stent restenosis after CAS.

METHODS

Consecutive patients undergoing CAS between January 2002 and October 2004 at a tertiary care hospital were retrospectively reviewed. Patient, filter, and stent selection were left to the discretion of the attending surgeon. High-risk patients were defined by significant comorbidities or a hostile neck (prior surgery or radiation, or both), and risk factor analysis was performed. In-stent restenosis was defined as >60%, and selective angiography was performed on patients with an in-stent restenosis >80% by duplex ultrasound imaging.

RESULTS

Reviewed were 101 patients (55 men, 46 women) who underwent 109 CAS procedures. Comorbidities were typical for patients with atherosclerosis. In addition, 38% (n = 41) of procedures were performed in patients who had prior neck surgery, of which 29% (n = 32) had previous ipsilateral carotid endarterectomy. Seventeen patients (16%) had a history of neck cancer, and all had prior neck radiation. Median follow-up was 5 months (range, 0 to 30 months). Neurologic complications included three transient ischemic attacks (2.8%) and one nondisabling stroke (0.9%). There were two myocardial infarctions (1.9%) and no periprocedural deaths (30 days), for a combined stroke, myocardial infarction, and death rate of 2.9%. Asymptomatic in-stent restenosis developed in 12 carotids (11%), five of which required endovascular intervention, with a mean of 6 months to restenosis. Univariate Cox proportional hazard regression models were used to determine risk factors for the development of restenosis. Prior stroke, transient ischemic attack, amaurosis fugax, and prior neck cancer were all significant risk factors. When these significant risk factors from univariate analysis were put into multivariate analysis, however, the only marginally significant risk factor was prior neck cancer (P = .06). Kaplan-Meier analysis revealed a cumulative freedom from in-stent restenosis at 24 months of 88% +/- 6% in patients without neck cancer compared with 27% +/- 17% (P = .02) in patients with neck cancer.

CONCLUSIONS

CAS has been shown to be safe and effective in high-risk patients, with minimal adverse events.

Recurrent Carotid Artery Stenosis Following Endarterectomy: Natural History and Risk Factors

OBJECTIVES

To establish the incidence of restenosis (RES) following carotid endarterectomy (CEA) and evaluate clinical and technical factors related to its development.

DESIGN

Prospective non-randomised cohort study.

PATIENTS AND METHODS

Two hundred and twenty-four patients with 243 CEA between May 1998 and December 2002, were subjected to clinical and haemodynamic follow-up, median follow-up 23 months (1-56). There was selective use of a shunt (17.3%) and patch (61.7%). RES (> or =50%) and severe restenosis, > or =70%, (sRES) were defined as peak systolic velocities of > or =150 and > or =300cm/s (or > or =250cm/s with diastolic velocity >100cm/s), respectively. Rates of RES, symptom development and mortality were analysed using Kaplan-Meier curves. Cox's regression model (hazards ratio/95% CI) was used to evaluate prognostic factors.

RESULTS

We detected 13 sRES (5.3%) (median time 6.1 months) and 30 (12.3%) moderate stenosis (mRES) (median time 3.7 months). Cumulative freedom from sRES at 23 months was 94.2%. Five sRES detected in the first 45 days after the procedure were deemed to be residual restenosis (rRES). Five (38.4%) sRES were symptomatic, 15.3% progressed to occlusion. Patient survival was 98.0 and 96.4% at 12 and 24 months, respectively. Independent risk factors for sRES: female sex (HR: 3.3, 95% CI 1.1-10 p=0.04) and diabetes (HR: 4.5, 95% CI 1.4-13.9 p=0.008).

CONCLUSIONS

Carotid restenosis appears early, is usually low-grade and mostly asymptomatic. Although few stenoses progress to occlusion, women and diabetic patients were at highest risk.

Operative intervention for recurrent stenosis after carotid stent angioplasty: a report

Carotid artery angioplasty and stenting is gaining popularity, yet the natural history and optimal treatment for recurrent stenoses within stents are not known. Recurrent stenosis rates are not well characterized, with rates between 0 and 33% reported within the first year. Treatment of these lesions with repeat angioplasty may not be feasible or desirable, leading to operative interventions. We present two cases of asymptomatic high-grade in-stent restenosis treated successfully with carotid artery bypass using PTFE.