Intraoperative duplex scanning for carotid endarterectomy

Steinmetz, Oren K.; MacKenzie, Kent S.; Nault, Patrice; Singher, F.; Dumaine, J.

doi:10.1016/s1078-5884(98)80158-5

Cited by 21 publications

(24 citation statements)

References 26 publications

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“…1-10 Proponents argue that completion imaging allows surgeons to identify causes of and avert early complications, as well as to ensure good long-term outcomes by avoiding restenosis. 1-8,11,12 Completion imaging with arteriography 3,4,9,10 and duplex ultra-sound 1-13 have been studied extensively and have excellent sensitivity (97% to 100%) and specificity (100%) 5,14 for the intraoperative detection of technical errors during CEA.…”

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confidence: 99%

“…9,15 It is unclear if completion imaging is routinely necessary, which abnormalities require re-exploration, and what effect completion imaging has on outcomes such as 30-day stroke/death or restenosis. 4,7-9,15 Studies attempting to answer these questions have largely consisted of small, single-center series, 1-8,11,12 or were not adequately powered to detect differences in outcomes. 2-7,11,12 …”

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confidence: 99%

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Completion imaging after carotid endarterectomy in the Vascular Study Group of New England

Wallaert

Goodney

Vignati

et al. 2011

Journal of Vascular Surgery

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Objectives We studied surgeons’ practice patterns in the use of completion imaging (duplex or arteriography), and their association with 30-day stroke/death and 1-year restenosis after carotid endarterectomy (CEA). Methods Using a retrospective analysis of 6115 CEAs, we categorized surgeons based on use of completion imaging as rarely (<5% of CEAs), selective (5% to 90%), or routine (>90%). Crude and risk-adjusted 30-day stroke/death and 1-year restenosis rates were examined across surgeon practice patterns. Finally, we audited 90 operative reports of patients who underwent re-exploration and characterized findings and interventions. We analyzed the effect of re-exploration on outcomes. Results Practice patterns in completion imaging varied: 51% of surgeons performed completion imaging rarely, 22% selectively, and 27% routinely. Crude 30-day stroke/death rates were highest among surgeons who routinely used completion imaging (rarely: 1.7%; selectively: 1.2%, routinely: 2.4%; P = .05). However, after adjusting for patient characteristics predictive of stroke/death, the effect of surgeon practice pattern was not statistically significant (odds ratio [OR] for routine-use surgeons, 1.42; 95% CI, 0.93-2.17; P = .10; selective-use surgeons, 0.75; 95% CI, 0.40-1.41; P = .366). Stenosis >70% at 1 year showed a trend toward lowest rates for surgeons who performed completion imaging (rarely: 2.8%, selectively: 1.1%, and routinely: 1.1%; P = .09). This effect became statistically significant for selective-use surgeons after adjustment (hazard risk [HR] for selective-use surgeons, 0.52; 95% CI, 0.29-0.92; P = .02). Overall, 178 patients (2.9%) underwent operative re-exploration. Routine-use surgeons were most likely to perform re-exploration (7.6% routine, 0.8% selective, 0.9% rare; P < .001). An audit of 90 re-explored patients demonstrated technical problems, the most common being flap, debris, and plaque. Rates of stroke/death were higher among patients who underwent re-exploration (3.9% vs 1.7%; P = .03); however, this affect was attenuated after adjustment (OR, 2.1; 95% CI, 0.9-5.0; P = .08). Conclusions The use of completion imaging during CEA varies widely across our region. There is little evidence that surgeons who use completion imaging have lower rates of 30-day stroke/death, although selective use of completion imaging is associated with a small but a significant reduction in stenosis 1 year after surgery. We also demonstrate an association between re-exploration and higher risk of 30-day stroke/death, although this effect was attenuated after adjustment for patient-level predictors of stroke/death. Future work is needed to direct the selective use of completion imaging to prevent stroke, rather than cause unnecessary re-exploration.

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confidence: 99%

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confidence: 99%

Completion imaging after carotid endarterectomy in the Vascular Study Group of New England

Wallaert

Goodney

Vignati

et al. 2011

Journal of Vascular Surgery

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“…1,2 Many of them have also reexamined their own results by means of retrospective studies. 10,11 Nault et al 12 showed that the rate of CEAs in Quebec was similar to that in Ontario during the 1990s, 12 but no province-wide audit of outcomes and appropriateness has been performed. Because the benefit of CEA also depends on how the results of these clinical trials (defining the efficacy) are applied to actual clinical practice (the effectiveness of the procedure), the effectiveness of CEA in Quebec has not been demonstrated.…”

Section: Discussionmentioning

confidence: 99%

Modification of outcomes by lowering ischemic events after reconstruction of extracranial vessels (MOLIERE): An internet-based prospective study to evaluate and improve the effectiveness of carotid endarterectomy

Nault

Elkouri

Daniel

et al. 2008

Journal of Vascular Surgery

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MOLIERE is the first Canadian online prospective registry allowing surgeons to audit CEA results. The SDRs for participating surgeons were valid and within standards. Scientific vascular societies played a key role in supporting this project. Such audits allow surgeons and medical stroke experts to examine the appropriateness and results of CEAs in their institutions to improve them. The future of MOLIERE is in validation of its concept, increased participation by surgeons, and integration of a multidisciplinary approach.

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“…Many authors have suggested that intraoperative duplex scanning with B-mode imaging (CDU) and hemodynamic assessment of the CEA could be less invasive than completion angiography and as useful to lower the risk of stroke in this group of patients. 10,13,14 The problem with CDU in our practice was the availability of the technologist even if CDU seems to be more cost-effective than completion angiography. 21 Using CDU with small 10 or 15 MHz hockey stick probes, Asher et al 14 found in a series of 650 consecutive cases 2.3% of CEA (n ¼ 15) requiring a surgical revision.…”

Section: Completion Duplex Ultrasonographymentioning

confidence: 99%

Part One: For the Motion. Completion Angiography Should be Used Routinely Following Carotid Endarterectomy

Ricco

Schneider

2013

European Journal of Vascular and Endovascular Surgery

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Intraoperative duplex scanning for carotid endarterectomy

Abstract: Intraoperative carotid duplex scanning can be used to assess the immediate technical adequacy of carotid endarterectomy. B-mode image and Doppler flow abnormalities which are reversible can be distinguished from those which require immediate revision.

Cited by 21 publications

References 26 publications

Completion imaging after carotid endarterectomy in the Vascular Study Group of New England

Completion imaging after carotid endarterectomy in the Vascular Study Group of New England

Modification of outcomes by lowering ischemic events after reconstruction of extracranial vessels (MOLIERE): An internet-based prospective study to evaluate and improve the effectiveness of carotid endarterectomy

Part One: For the Motion. Completion Angiography Should be Used Routinely Following Carotid Endarterectomy

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