Surveillance Duplex Ultrasound Prompted Interventions After Carotid Endarterectomy.

OBJECTIVES: Current societal guidelines recommend duplex ultrasound surveillance beyond 30-days after carotid endarterectomy (CEA) for patients with risk factors for restenosis or who underwent primary closure. However, the appropriate duration of this surveillance has not yet been identified and the rate at which duplex ultrasound (DUS) surveillance prompts intervention is unknown. Multiple calls for decreasing healthcare spending that does not provide value, including unnecessary testing, have been made. The purpose of this study was to examine the rate of intervention prompted by surveillance DUS on the ipsilateral or contralateral carotid artery after CEA and determine the value of continued surveillance by determining the rate of DUS-prompted intervention.

METHODS: A single center retrospective chart review of all patients greater than 18 years of age who had undergone CEA from August 2009 to July 2022 was performed. Patients with at least one postoperative duplex in our Intersocietal Accreditation Council accredited ultrasound lab were included. Exclusion criteria were patients with incomplete medical charts or patients undergoing a concomitant procedure. The primary endpoint was return to the operating room for subsequent intervention based on abnormal surveillance DUS findings. Secondary endpoints were number of post-operative surveillance duplexes, duration of surveillance, and incidence of perioperative stroke. The study participant data was queried for patients who had a diagnosis of stroke that occurred following their procedure.

RESULTS: A total 767 patients, accounting for 771 procedures were included in this study which resulted in 2,145 ultrasounds. A total of 40 (5.2%) patients required 44 subsequent interventions that were prompted by DUS surveillance. The average number of ultrasounds per patient was 2.8 (range 0-14), and the average duration of surveillance was 26.4 months (range 0-155). Of the 767 patients, 669 (87.2%) patients had a unilateral carotid endarterectomy. A total of 62 out of 767 (8.1%) patients had planned endarterectomies on the contralateral side based on initial imaging, not prompted by interval DUS surveillance. Twenty eight out of 767 patients (3.7%) who underwent carotid endarterectomy had a subsequent procedure for progression of contralateral disease which was prompted by duplex surveillance. The average duration between index carotid endarterectomy and intervention on contralateral carotid was 29.57 months (range 3-81). A total of 11 patients, accounting for 12 procedures, underwent a subsequent procedure for re-stenosis of their ipsilateral carotid, prompted by duplex surveillance. The average duration between index carotid endarterectomy and re-intervention on the ipsilateral carotid was 17.9 months (range 4-70). Three out of 767 (0.4%) patients in total were identified as having a perioperative stroke.

CONCLUSIONS: The overall rate of ipsilateral reintervention after CEA is low. A small percentage of patients will progress their contralateral disease, ultimately requiring surgical intervention. These data suggest regular duplex surveillance following CEA is warranted for patients with at least moderate contralateral disease, however, the yield is low for ipsilateral restenosis after 36 months based on this single institution study. Further study is needed to better delineate which patients need follow up to decrease unnecessary testing while still targeting patients most at risk of restenosis or contralateral progression of disease.