CAROTID ENDARTERECTOMY BASED ON PREOPERATIVE DUPLEX ULTRASOUND

Recent studies have suggested that carotid endarterectomy can be perfo rmed safely based solely on the noninvasive duplex ultrasound evaluati on in selected patients. We have prospectively evaluated 60 consecutiv e patients who underwent 65 carotid endarterectomies, 48 patients with out preoperative angiography and 12 with angiography. Forty-two patien ts were operated on for symptomatic disease, and 23 procedures were do ne for critical, asymptomatic stenoses. Long term followup consisted o f physical examination and serial duplex scans every 3-6 months postop eratively over a mean followup period of 2.4 years. Clinical managemen t indicated by duplex ultrasound was altered in only one of the 12 pat ients who had preoperative angiography, a change in the timing of the endarterectomy in a symptomatic patient with an ulcerated lesion seen at angiography. At operation the severity of disease predicted by dupl ex ultrasound was confirmed in all cases (100 per cent sensitivity), i ncluding one >80% diameter stenosis interpreted by angiography as occl uded; no unsuspected anatomic anomalies were found at surgery. The dup lex scan also correlated well with intraoperative findings of surface ulceration and gross intraplaque hemorrhage. There was one intraoperat ive stroke with good recovery in a patient with preoperative angiograp hy; and there were no deaths, for a combined morbidity and mortality o f 1.6 per cent. During long term followup, 97 per cent of patients hav e remained symptom-free. We conclude that clinical assessment with a p reoperative duplex ultrasound scan of good technical quality and inter preted in collaboration with the vascular surgeon provides appropriate information on which to base carotid endarterectomy and allows a safe alternative to the routine use of preoperative angiography. The minor ity of patients for whom angiography is indicated can be identified by technically inadequate or equivocal duplex scans or minimal disease s een by the duplex examination in a symptomatic patient.