Discrepancies in recommended criteria for grading of carotid stenosis with ultrasound

Jogestrand, Tomas; Fredén-Lindqvist, Johan; Lindqvist, M.; Lundgren, Susanne; Tillman, Ann-Sofie; Zachrisson, Helene

doi:10.1111/cpf.12236

Cited by 4 publications

(5 citation statements)

References 19 publications

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“…As expected, the agreement between diameter‐based and velocity‐based grading was not perfect. At least partly, this moderate degree of agreement depends on sources of error included in both kinds of grading procedures (Jogestrand et al., 2016). Other factors include different hemodynamic situations with reduced or accelerated blood flow in native main stems or collateral vessels, which will influence the blood flow velocities but not the diameters (Zachrisson et al., 2012).…”

Section: Discussionmentioning

confidence: 99%

“…Each case was also classified by V max in the stenotic segment of ICA according to both NASCET and ECST standards using locally recommended flow velocity cut-offs (Jogestrand et al, 2002(Jogestrand et al, , 2016Nowak & Jogestrand, 2007). For NASCET: 1.3-2.2 m/s implies 20%-49% stenosis (ECST 50%-69%), 2.3-3.1 m/s implies 50%-69% stenosis (ECST 70%-79%), and ≥3.2 m/s implies 70%-99% stenosis (ECST 80%-99%).…”

Section: Ultrasoundmentioning

confidence: 99%

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Diameter‐based measurements of the degree of carotid artery stenosis using ultrasonography

Larsson¹,

Rosfors

2020

Clin Physio Funct Imaging

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Flow velocity measurement by duplex ultrasonography (DUS) is widely accepted as a preoperative method for grading carotid stenoses. Diameter-based grading is used for angiographic methods, but so far the experience is limited regarding diameter-based grading using DUS. In 101 cases with different degrees of carotid stenoses, we compared diameter-and velocity-based grading using DUS and evaluated variability and reproducibility for diameter measurements in 38 of the stenoses. In 18% of the cases, suboptimal image quality with calcifications and acoustic shadowing precluded diameter measurements. In the remaining 83 cases, the agreement between velocity-based and diameter-based grading for distinction between significant and non-significant stenosis was 69% with a kappa value of 0.40. Repeated measurements of diameters showed a coefficient of variation of 10% and intraclass coefficients of correlation of 0.9. We conclude that diameter measurement with DUS can be performed with high reproducibility in most patients with carotid stenosis. These measurements can then be used for calculations of the degree of stenosis, to supplement velocity-based grading. The moderate agreement between diameter-based and flow velocity-based grading cannot easily be explained. Discrepancies probably constitute a mixture of methodological errors and hemodynamic factors and need further evaluation.

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Section: Discussionmentioning

confidence: 99%

Section: Ultrasoundmentioning

confidence: 99%

Diameter‐based measurements of the degree of carotid artery stenosis using ultrasonography

Larsson¹,

Rosfors

2020

Clin Physio Funct Imaging

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“…These estimations expose the high clinical impact CDUS diagnostic criteria variations across testing centers may have. The main source of variation in CDUS criteria arises from the exponential relation between the angiographic degree of stenosis (considered the gold standard) and the PSV on spectral Doppler originally described by Spencer and Reid (61,62). The steep graph leads to a significant change in velocity despite minimal changes in the angiographic degree of stenosis, particularly in the range of highest clinical relevance (60% to 90%).…”

Section: Diagnostic Criteria For Extracranial Carotid Artery Stenosismentioning

confidence: 99%

Why are we still debating criteria for carotid artery stenosis?

Brutto¹,

Gornik²,

Rundek³

2020

Ann Transl Med

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The risk of new or recurrent stroke is high among patients with extracranial carotid artery stenosis and the benefit of carotid revascularization is associated to the degree of luminal stenosis. Catheterbased digital subtraction angiography (DSA) as the diagnostic gold-standard for carotid stenosis (CS) has been replaced by non-invasive techniques including duplex ultrasound, computed-tomography angiography, and magnetic resonance angiography (MRA). Duplex ultrasound is the primary noninvasive diagnostic tool for detecting, grading and monitoring of carotid artery stenosis due to its low cost, high resolution, and widespread availability. However, as discussed in this review, there is a wide range of practice patterns in use of ultrasound diagnostic criteria for carotid artery stenosis. To date, there is no internationally accepted standard for the gradation of CS. Discrepancies in ultrasound criteria may result in clinically relevant misclassification of disease severity leading to inappropriate referral, or lack of it, to revascularization procedures, and potential for consequential adverse outcome. The Society of Radiologists in Ultrasound (SRU), either as originally outlined or in a modified form, are the most common criteria applied. However, such criteria have received criticism for relying primarily on peak systolic velocities, a parameter that when used in isolation could be misleading. Recent proposals rely on a multiparametric approach in which the hemodynamic consequences of carotid narrowing beyond velocity augmentation are considered for an accurate stenosis classification. Consensus criteria would provide standardized parameters for the diagnosis of CS and considerably improve quality of care. Accrediting bodies around the world have called for consensus on unified criteria for diagnosis of CS. A healthy debate between professionals caring for patients with CS regarding optimal CS criteria still continues.

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“…It has been clear for some time now that discrepancies may exist between the different techniques of carotid stenosis severity determination [ 22 , 27 – 29 ]; this issue, however, has not been systematically investigated.…”

Section: Introductionmentioning

confidence: 99%

Imaging modality-dependent carotid stenosis severity variations against intravascular ultrasound as a reference: Carotid Artery intravasculaR Ultrasound Study (CARUS)

Tekieli,

Kablak-Ziembicka,

Dabrowski

et al. 2023

Int J Cardiovasc Imaging

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Purpose Different non-invasive and invasive imaging modalities are used to determine carotid artery stenosis severity that remains a principal parameter in clinical decision-making. We compared stenosis degree obtained with different modalities against vascular imaging gold standard, intravascular ultrasound, IVUS. Methods 300 consecutive patients (age 47–83 years, 192 men, 64% asymptomatic) with carotid artery stenosis of “ ≥ 50%” referred for potential revascularization received as per study protocol (i) duplex ultrasound (DUS), (ii) computed tomography angiography (CTA), (iii) intraarterial quantitative angiography (iQA) and (iv) and (iv) IVUS. Correlation of measurements with IVUS (r), proportion of those concordant (within 10%) and proportion of under/overestimated were calculated along with recipient-operating-characteristics (ROC). Results For IVUS area stenosis (AS) and IVUS minimal lumen area (MLA), there was only a moderate correlation with DUS velocities (peak-systolic, PSV; end-diastolic, EDV; r values of 0.42–0.51, p < 0.001 for all). CTA systematically underestimated both reference area and MLA (80.4% and 92.3% cases) but CTA error was lesser for AS (proportion concordant-57.4%; CTA under/overestimation-12.5%/30.1%). iQA diameter stenosis (DS) was found concordant with IVUS in 41.1% measurements (iQA under/overestimation 7.9%/51.0%). By univariate model, PSV (ROC area-under-the-curve, AUC, 0.77, cutoff 2.6 m/s), EDV (AUC 0.72, cutoff 0.71 m/s) and CTA-DS (AUC 0.83, cutoff 59.6%) were predictors of ≥ 50% DS by IVUS (p < 0.001 for all). Best predictor, however, of ≥ 50% DS by IVUS was stenosis severity evaluation by automated contrast column density measurement on iQA (AUC 0.87, cutoff 68%, p < 0.001). Regarding non-invasive techniques, CTA was the only independent diagnostic modality against IVUS on multivariate model (p = 0.008). Conclusion IVUS validation shows significant imaging modality-dependent variations in carotid stenosis severity determination.

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Discrepancies in recommended criteria for grading of carotid stenosis with ultrasound

Cited by 4 publications

References 19 publications

Diameter‐based measurements of the degree of carotid artery stenosis using ultrasonography

Diameter‐based measurements of the degree of carotid artery stenosis using ultrasonography

Why are we still debating criteria for carotid artery stenosis?

Imaging modality-dependent carotid stenosis severity variations against intravascular ultrasound as a reference: Carotid Artery intravasculaR Ultrasound Study (CARUS)

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