title: Carotid endarterectomy without angiography: is color-flow duplex scanning sufficient?
abstract: BACKGROUND
  This study was designed to determine whether clinical evaluation and color-flow duplex scanning (CFS) alone provide enough information for patients to undergo carotid endarterectomy (CEA) safely without preoperative cerebral angiography and to assess the appropriate role of CFS in the evaluation of extracranial carotid artery disease.
  
  
  METHODS
  During a 31-month period 167 patients (114 symptomatic and 53 asymptomatic) underwent CFS and angiography during evaluation for CEA. One hundred fifty-three patients were studied retrospectively, and 14 were studied prospectively. Data were reviewed to determine whether cerebral angiography added information not provided by duplex findings and, if so, did the results alter clinical management.
  
  
  RESULTS
  Of the 167 patients studied, 149 underwent CEA and 18 were treated medically. Results of the two diagnostic modalities agreed perfectly in 82% of the patients, with 99% of the stenoses estimated by CFS being classified within one category of those measured with angiography. The sensitivity of CFS for detecting greater than 50% diameter-reducing stenoses of the internal carotid artery was 98%, and the positive predictive value was 99%. For detecting greater than 80% stenoses, CFS had a sensitivity of 84% and a positive predictive value of 95%. Clinical management was altered by angiographic findings in only seven patients (4%). False-positive results (n = 5) were due to poor scanning technique or interpreter error (n = 2), anatomic variations (n = 2), and unknown cause (n = 1). All false-negative results (n = 2) were due to poor scanning technique.
  
  
  CONCLUSIONS
  Ninety-six percent of the patients in this study would have received appropriate clinical management based on neurologic history and the results of CFS alone. Our results indicate that CFS is sufficient for determining the need for surgery in patients being considered for CEA and can supplant cerebral angiography in nearly all clinical circumstances.
authors.affiliation: Southern Illinois University School of Medicine, Department of Surgery, Springfield 62794-9230.
authors.forename: M A
authors.initials: MA
authors.lastname: Mattos
authors.forename: K J
authors.initials: KJ
authors.lastname: Hodgson
authors.forename: W E
authors.initials: WE
authors.lastname: Faught
authors.forename: A
authors.initials: A
authors.lastname: Mansour
authors.forename: L D
authors.initials: LD
authors.lastname: Barkmeier
authors.forename: D E
authors.initials: DE
authors.lastname: Ramsey
authors.forename: D S
authors.initials: DS
authors.lastname: Sumner
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D016893:Carotid Stenosis / Q000175:diagnosis*; D002533:Cerebral Angiography; D016894:Endarterectomy, Carotid; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged