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For Referring Physicians Apirl 1998 Carotid Endarterectomy - without Angiography As we all know, stroke is the third leading cause of death in the United States, with a mortality of the first stroke reaching 20%. Sixty percent of survivors of the first stroke will have a recurrent stroke within two years, with a five year mortality rate of 60%. Carotid endarterectomy reduces the stroke risk to about 2% per year. Inrra-arterial contrast arteriography continues to be the "gold standard" for the pre-operative evaluation of cerebrovascular disease. There are two important reasons for omitting arteriography from the work-up of patients being considered for carotid endarterectomy. First, arteriograpy adds to the cost of the patient's care, and second, because of the risks associated with arteriography. Cost remains a prominent issue since there are approximately 80 - 100,000 carotid endarterectomis performed each year in the U.S. Arteriography is expensive with an average cost of $2500 - $4000. If you add in other associated hospital charges, the true figure will be significantly higher. The morbidity of arteriography should be added to the operative complication rate when considering the overall treatment of cerebrovascular disease. There was a 1.2% stroke rate for patients undergoing arteriography in the Asymptomatic Carotid Atherosclerosis Study (ACAS). There was combined perioperative stroke and death rate of 2.3%; arteriography accounted for almost half the neurologic morbidity. Radiographic contrast media can also cause severe anaphylactic reactions in less than 2%. Contrast related nephrotoxicity is another problem especially for patients with pre-existing renal disease, diabetes mellitus, heart failure, and patients over 70 years of age. Acute renal dysfunction continues to occur despite the use of non-ionic contrast agents. The method of evaluation can vary, however the duplex scan of the carotid artery seems to be the most reliable and cost effective approach. Atherosclerotic lesions tend to be localized near the carotid bifurcation. Duplex scanning can provide complete assessment of this segment. The diagnostic questions - "is there atherosclerotic disease involving the carotid bifurcation?", and "what is the severity of the stenosis?" - are answered by duplex ultrasound scanning. It is unnecessary to routinely evaluate the aortic arch, its proximal branches, and the distal intracranial circulation with arteriogrphy before planning a carotid endarterectomy. Apple Hill Surgical Associates has been routinely performing carotid endarterectomies without contrast arteriography for three years. This has evolved due to emphasis on performing the most complete and accurately documented carotid duplex ultrasound study. Quality assurance standards were analyzed over the past four years comparing carotid duplex results with arteriography, MRA, and/or surgical specimen. These results were submitted to the Intersocietal Commission for the Accreditation of Vascular Laboratories (ICAVL) for review and the carotid duplex exam consistently showed an overall accuracy rate greater than 95%. Carotid endarterectomy without routine pre-operative arteriography is an acceptable approach when the cost and potential morbidity of invasive diagnostic studies are considered. The diagnostic evaluation is tailored to each individual patient's situation. The use of duplex ultrasound scanning as a definitive pre-operative study requires the examination be performed by skilled and experienced technologist in a validated vascular laboratory. For any additional information on this subject matter, please contact
us at Apple Hill Surgical Associates - Vascular Division. Thank you for your continued support! |
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