title: Changes over time in optimal duplex threshold for the identification of patients eligible for carotid endarterectomy.
abstract: OBJECTIVE
  Two surgical trials established that carotid endarterectomy is beneficial to symptomatic patients who have a severe internal carotid artery (ICA) stenosis on angiograms. Duplex ultrasonography-derived hemodynamic parameters show a good correlation with angiography and are often used for detecting severe ICA stenoses. However, duplex performance is ultrasound machine and operator dependent. Over time both may change, possibly affecting duplex performance. We compared duplex performance of 2 time periods in 1 specific vascular laboratory using angiography as the gold standard.
  
  
  METHODS
  Consecutive patients who underwent both angiography and duplex examinations of the ICA were evaluated (first period, 60 patients; second period, 61 patients). Peak systolic velocity and several other hemodynamic parameters and ratios were analyzed by receiver operating characteristic curves in their ability to detect severe ICA stenoses. The optimal parameter and threshold were determined for each period. Subsequently, duplex test characteristics were compared after the optimal thresholds of both the first and the second periods were applied in the second period.
  
  
  RESULTS
  In both periods peak systolic velocity of the ICA was the best test parameter; areas under the receiver operating characteristic curve were similar (0.957 and 0.954, respectively). However, the optimal threshold was different. The optimal threshold in the second period was 270 cm/s. When the optimal threshold of 210 cm/s of the first period was applied in the second period, test characteristics changed significantly. Sensitivity increased from 98% to 100%, and specificity decreased from 85% to 71% (P=0.004).
  
  
  CONCLUSIONS
  The optimal threshold for detecting severe ICA stenoses with duplex ultrasonography in our laboratory changed over time. Individual laboratories should assess duplex accuracy regularly and adjust adopted criteria if necessary to keep diagnostic performance optimal.
authors.affiliation: Department of Radiology, the Department of Vascular Surgery, and the Julius Center for Patient Oriented Research University Hospital Utrecht, The Netherlands. oelgersm@azul.azu.nl
authors.forename: O E
authors.initials: OE
authors.lastname: Elgersma
authors.forename: M
authors.initials: M
authors.lastname: van Leersum
authors.forename: P C
authors.initials: PC
authors.lastname: Buijs
authors.forename: M S
authors.initials: MS
authors.lastname: van Leeuwen
authors.forename: Y T
authors.initials: YT
authors.lastname: van de Schouw
authors.forename: B C
authors.initials: BC
authors.lastname: Eikelboom
authors.forename: Y
authors.initials: Y
authors.lastname: van der Graaf
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015901:Angiography, Digital Subtraction; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging / Q000601:surgery; D016893:Carotid Stenosis / Q000000981:diagnostic imaging* / Q000601:surgery*; D004608:Eligibility Determination; D016894:Endarterectomy, Carotid; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D013997:Time Factors; D018616:Ultrasonography, Doppler, Duplex