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 arteriography. A 4-year retrospective review of CEA based on duplex ultrasound alone (n = 653) or with confirmatory arteriography (n = 118) was performed in 244 women and 458 men whose ages ranged from 39 to 92 years (mean, 70 years). Practice patterns, perioperative morbidity, and stroke rate (life-table analysis) of a community-based and university- based vascular surgical practice were analyzed and compared. Surgical intervention based on duplex ultrasound was judged possible in 85% of the patients (community, 93%; university, 55%). Indications for arteriography included: testing completed prior to surgical consultation (44%), nonfocal extracranial carotid stenosis (23%), nonhemispheric symptoms (13%), and prior stroke (9%). This approach was safe (with a combined operative mortality and neurologic morbidity of 1.8%), asso ciated with long-term stroke prevention (a 95% stroke-free survival at 4 years), and yielded results similar to CEA with arteriography (operative morbidity, 2.6%; 91% stroke- free survival). The incidence and nature of late neurologic deficits were similar after CEA with and without arteriography. Twenty-three (4%) of the patients who underwent CEA based on duplex ultrasound developed late neurologic symptoms including 9 contralat eral and 4 ipsilateral strokes; and 4 ipsilateral and 4 contralateral transient ischemic attacks (TIAs). Cardiac embolism from atrial fibrillation accounted for 6 strokes, lacunar infarct associated with hypertension (3 strokes), intracranial atherosclerosis (3 strokes), and contralateral internal carotid artery (ICA) occlusion (1 stroke). Forty patients (6.8%) died predominantly from cardiac events. After CEA with arteriography 6 (5%) of the patients died. Six late strokes (4 contralateral, and 2 ipsilateral hemisphere) occurred as a result of progressive, untreated 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 patients undergoing surgical evaluation. Short-term and long-term outcomes were similar to outcomes in patients having CEA based on diagnostic arteriography.