Carotid endarterectomy based on duplex ultrasonography: A safe approach associated with long-term stroke prevention

To evaluate the short-term and long-term safety of carotid endarterectomy ( CEA) based on duplex ultrasound without confirmatory diagnostic arteriograp hy. A 4-year retrospective review off CEA based on duplex ultrasound alone (n = 653) or with confirmatory arteriography (n = 118) was performed in 244 wom en and 458 men whose ages ranged from 39 to 92 years (mean, 70 years). Prac tice patterns, perioperative morbidity, and stroke rate (life-table analysi s) of a community-based and university-based vascular surgical practice wer e analyzed and compared. Surgical intervention based on duplex ultrasound was judged possible in 85% of the patients (community, 93%; university, 55%). Indications for arterio graphy included: testing completed prior to surgical consultation (44%), no nfocal extracranial carotid stenosis (23%), nonhemispheric symptoms (13%), and prior stroke (9%). This approach was safe (with a combined operative mo rtality and neurologic morbidity of 1.8%), associated with long-term stroke prevention (a 95% stroke-free survival at 4 years), and yielded results si milar to CEA with arteriography (operative morbidity, 2.6%; 91% stroke-free survival). The incidence and nature of late neurologic deficits were simil ar after CEA with and without arteriography. Twenty-three (4%) of the patie nts who underwent CEA based on duplex ultrasound developed late neurologic symptoms including 9 contralateral and 4 ipsilateral strokes; and 4 ipsilat eral and 4 contralateral transient ischemic attacks (TIAs). Cardiac embolis m from atrial fibrillation accounted for 6 strokes, lacunar infarct associa ted with hypertension (3 strokes), intracranial atherosclerosis (3 strokes) , and contralateral internal carotid artery (ICA) occlusion (1 stroke). For ty patients (6.8%) died predominantly from cardiac events. After CEA with a rteriography 6 (5%) of the patients died. Six late strokes (4 contralateral , and 2 ipsilateral hemisphere) occurred as a result of progressive, untrea ted ICA stenosis (n = 3), and lacunar infarct (n = 3). Overall, 11% of the patients underwent contralateral CEA for progressive ICA stenosis. CEA, based on duplex scanning, is safe and applicable for the majority of p atients undergoing surgical evaluation. Short-term and long-term outcomes w ere similar to outcomes in patients having CEA based on diagnostic arteriog raphy.