Carotid endarterectomy without angiography: Can clinical evaluation and duplex ultrasonographic scanning alone replace traditional arteriography for carotid surgery workup? A prospective study

Background. The aim of this study, was to determine whether clinical evalua tion and duplex ultrasonography (DUS) alone can replace contrast cerebral a rteriography (CA) for the detection of patients suitable for surgery at our institution. Methods. During an 18-month period, 100 patients underwent DUS and CA durin g evaluation for carotid endarterectomy (CEA). All patients were studied pr ospectively; in each case an initial decision for or against CEA on the bas is of DUS evaluation of the the internal carotid arteries (ICAs) was subseq uently compared with the surgeon's final management plan after CA. Of the 2 00 ICAs evaluated, 113 were considered for CEA but 14 were excluded from th e study because the patient could not be evaluated before and after CA. Thi s left 99 ICAs (86 patients) available for comparative analysis. Results. The outcome of the 2 diagnostic modalities was perfectly consisten t in 95.3% of the ICAs (kappa = 0.969). The clinical management decision wa s altered by the CA findings in only 2 cases (2%). Of the 99 ICAs considere d suitable, 97 underwent CEA. No arteriographic complications occurred amon g the 100 patients undergoing CA. The perioperative stroke risk and mortali ty rates were 0%. Conclusions. Ninety-eight percent of the ICAs considered for surgery would have received appropriate clinical treatment on the strength of the patient s' neurologic history and the outcome of DUS alone. Our results indicate th at DUS is sufficient to establish the need for surgery in symptomatic and a symptomatic patients being considered for CEA and can replace CA in most cl inical circumstances.