Intraoperative imaging: does it really improve perioperative outcomes of carotid endarterectomy?
A variety of intraoperative imaging and assessment techniques can be used during carotid endarterectomy (CEA) to evaluate the technical results of the arterial repair. However, the necessity of utilizing these techniques routinely in every case, and the actual ability of these studies to improve the outcomes of the operation, remain areas of controversy. The most commonly used intraoperative assessment techniques include arteriography, duplex ultrasonography, and use of a hand-held continuous-wave Doppler probe. While surgeons who advocate intraoperative imaging presume that it will ultimately improve the technical "perfection" of the operation by allowing the intraoperative identification and immediate revision of occult technical defects that would likely predispose toward perioperative stroke, there is little comparative data in the literature to support this premise. Proponents of routine intraoperative assessment argue that the identification of technical imperfections will allow their immediate correction prior to a perioperative stroke resulting from thromboembolization. In addition, surgeons who use these techniques believe that the presumed reduction in rate of serious technical errors will also result in a lower rate of recurrent carotid stenosis. However, many experienced vascular surgeons who perform CEA do not routinely utilize any of these intraoperative assessment techniques, and report equally excellent results using meticulous technique alone and clinical inspection of the endarterectomy site and arterial repair. Potential issues that may arise when performing routine intraoperative assessment can include: making a determination of which type of "imperfections" actually require immediate revision of the arterial repair, and potential vascular injuries or cerebral ischemia associated with reclamping of the artery in order to perform an immediate revision. In an analysis of a large, population-based cohort study of CEAs, the authors have found no compelling evidence that routine use of these imaging techniques confers any advantage in terms of the perioperative outcomes of carotid endarterectomy.


CONCLUSIONS
the majority of surgeons who perform carotid endarterectomy do not routinely utilize any formal intraoperative completion imaging or assessment technique during CEA, other than clinical inspection of the arterial repair. However, even among vascular surgeons, less than 50% are routinely using intraoperative imaging or assessment. The routine use of intraoperative imaging studies did not appear to significantly improve perioperative outcomes with regard to ipsilateral perioperative stroke, and stroke/death. Considering the increased time and cost of performing these procedures, routine use of intraoperative imaging and assessment techniques during CEA is of questionable value. Selective use of these imaging or assessment techniques when the surgeon has a specific concern regarding the technical outcomes of the operation appears to be a reasonable alternative.
Rockman
Caron B
CB
Division of Vascular Surgery, New York University Medical Center, New York, NY 10016, USA. caron.rockman@nyumc.org
Halm
Ethan A
EA
D000368:Aged; D000369:Aged, 80 and over; D000792:Angiography; D002340:Carotid Artery Diseases / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D003952:Diagnostic Imaging / Q000379:methods* / Q000706:statistics & numerical data; D016894:Endarterectomy, Carotid / Q000009:adverse effects*; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D007430:Intraoperative Care; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D020521:Stroke / Q000209:etiology / Q000401:mortality / Q000473:pathology / Q000517:prevention & control*; D016896:Treatment Outcome; D018608:Ultrasonography, Doppler; D018616:Ultrasonography, Doppler, Duplex