THE ROLE OF DUPLEX SCANNING AND ARTERIOGRAPHY BEFORE CAROTID ENDARTERECTOMY - A PROSPECTIVE-STUDY

Purpose: This study examines the current role of diagnostic tests done before carotid endarterectomy and the need for routine arteriography. Methods: We prospectively studied vascular surgeons' decision-making over a 29-month period during which 111 carotid arteries in 103 patien ts were considered for endarterectomy. For each case the surgeon's man agement plan was recorded after clinical evaluation and review of the duplex scan findings, but before arteriography. This plan was later co mpared with the patient's ultimate clinical management. Results: Of 11 1 total cases in this period, 17 were excluded from analysis because a rteriography was not done or it was performed before the surgeon's eva luation. Carotid duplex scans were diagnostic in 87 (93%) of the remai ning 94 cases. The carotid lesion was incompletely assessed by duplex scanning in seven patients because the disease was not limited to the distal common or proximal internal carotid artery (n = 4); anatomic or pathologic features of the carotid artery interfered with imaging or accurate Doppler assessment (n = 1); or an internal carotid artery occ lusion could not be distinguished from a high-grade stenosis (n = 2). When a technically adequate duplex scan showed significant disease of the carotid bifurcation, arteriography contributed information that af fected clinical management in only a single case (1%). This patient ha d a middle cerebral artery occlusion distal to a high-grade carotid bi furcation stenosis. Conclusions: Clinical assessment and duplex scanni ng were sufficient for the preoperative evaluation of 93% of the candi dates for carotid endarterectomy. Clinical circumstances or atypical d uplex scan findings can be used to identify the minority of patients f or whom arteriography is necessary. On the basis of this experience, w e have developed practical guidelines for the selective use of arterio graphy before carotid endarterectomy.