title: Ultrasound criteria for severe in-stent restenosis following carotid artery stenting.
abstract: OBJECTIVE
  In-stent restenosis (ISR) is a known complication following carotid artery stenting (CAS). However, ultrasound criteria determining ISR are not well established. We evaluated alternative ultrasound velocity criteria for >70% ISR in our institution.
  
  
  METHODS
  Clinical records of 256 patients undergoing 282 consecutive CAS procedures over a 42-month period were reviewed. Follow-up ultrasounds were available for analysis in 237 patients. Selective angiograms and repeat interventions were performed for >70% ISR. Ultrasound criteria including peak systolic velocity (PSV), end diastolic velocity (EDV), and internal carotid to common carotid artery ratios (ICA/CCA) were examined. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for PSV (200, 250, 300, 350, and 400 cm/s), EDV (70, 80, 90, 100 cm/s), and CCA/ICA (3, 3.5, 4, 4.5, 5).
  
  
  RESULTS
  Twenty-two carotid angiograms were performed and 18 lesions had confirmations of >70% ISR in 11 patients including prior CEA in five patients and neck irradiation in two patients. Receiver operator characteristics (ROC) was analyzed for PSV, EDV, and CCA/ICA ratio. For 70% or greater angiographic ISR, PSV > 300 cm/s correlated to a 94% sensitivity, 50% specificity, 90% positive predictive value (PPV), and 67% negative predictive value (NPV); EDV > 90 cm/s correlated to an 89% sensitivity, 100% specificity, 100% PPV, and 67% NPV; and ICA/CCA > 4 had a 94.4% sensitivity, 75% specificity, 94% PPV, and 75% NPV. A significant color flow disturbance was detected in one patient who did not meet the aforementioned ultrasound velocity criteria. Further statistical analysis showed that an EDV of 90 cm/s provided the best discriminant value.
  
  
  CONCLUSIONS
  Our study demonstrated that PSV > 300 cm/s, EDV > 90 cm/s, and ICA/CCA > 4 correlated well with >70% ISR. Although still rudimentary, these velocity criteria combined with color flow patterns can reliably predict severe ISR in our vascular laboratory. However, due to the relatively infrequent cases of severe ISR following CAS, a multicentered study is warranted to establish standard post-CAS ultrasound surveillance criteria for severe ISR.
authors.affiliation: Division of Vascular and Endovascular Surgery, Department of Surgery, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA. weizhou@stanford.edu
authors.forename: Wei
authors.initials: W
authors.lastname: Zhou
authors.forename: Deborah D
authors.initials: DD
authors.lastname: Felkai
authors.forename: Mark
authors.initials: M
authors.lastname: Evans
authors.forename: Sally A
authors.initials: SA
authors.lastname: McCoy
authors.forename: Peter H
authors.initials: PH
authors.lastname: Lin
authors.forename: Panagiotos
authors.initials: P
authors.lastname: Kougias
authors.forename: Hosam F
authors.initials: HF
authors.lastname: El-Sayed
authors.forename: Alan B
authors.initials: AB
authors.lastname: Lumsden
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001783:Blood Flow Velocity; D016893:Carotid Stenosis / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012372:ROC Curve; D011859:Radiography; D012008:Recurrence; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D015607:Stents; D013997:Time Factors; D016896:Treatment Outcome; D018615:Ultrasonography, Doppler, Color; D018616:Ultrasonography, Doppler, Duplex; D014656:Vascular Surgical Procedures / Q000295:instrumentation*