title: Completion imaging after carotid endarterectomy in the Vascular Study Group of New England.
abstract: OBJECTIVE
  We studied surgeons' practice patterns in the use of completion imaging (duplex or arteriography), and their association with 30-day stroke/death and 1-year restenosis after carotid endarterectomy (CEA).
  
  
  METHODS
  Using a retrospective analysis of 6115 CEAs, we categorized surgeons based on use of completion imaging as rarely (<5% of CEAs), selective (5% to 90%), or routine (≥90%). Crude and risk-adjusted 30-day stroke/death and 1-year restenosis rates were examined across surgeon practice patterns. Finally, we audited 90 operative reports of patients who underwent re-exploration and characterized findings and interventions. We analyzed the effect of re-exploration on outcomes.
  
  
  RESULTS
  Practice patterns in completion imaging varied: 51% of surgeons performed completion imaging rarely, 22% selectively, and 27% routinely. Crude 30-day stroke/death rates were highest among surgeons who routinely used completion imaging (rarely: 1.7%; selectively: 1.2%, routinely: 2.4%; P = .05). However, after adjusting for patient characteristics predictive of stroke/death, the effect of surgeon practice pattern was not statistically significant (odds ratio [OR] for routine-use surgeons, 1.42; 95% CI, 0.93-2.17; P = .10; selective-use surgeons, 0.75; 95% CI, 0.40-1.41; P = .366). Stenosis >70% at 1 year showed a trend toward lowest rates for surgeons who performed completion imaging (rarely: 2.8%, selectively: 1.1%, and routinely: 1.1%; P = .09). This effect became statistically significant for selective-use surgeons after adjustment (hazard risk [HR] for selective-use surgeons, 0.52; 95% CI, 0.29-0.92; P = .02). Overall, 178 patients (2.9%) underwent operative re-exploration. Routine-use surgeons were most likely to perform re-exploration (7.6% routine, 0.8% selective, 0.9% rare; P < .001). An audit of 90 re-explored patients demonstrated technical problems, the most common being flap, debris, and plaque. Rates of stroke/death were higher among patients who underwent re-exploration (3.9% vs 1.7%; P = .03); however, this affect was attenuated after adjustment (OR, 2.1; 95% CI, 0.9-5.0; P = .08).
  
  
  CONCLUSIONS
  The use of completion imaging during CEA varies widely across our region. There is little evidence that surgeons who use completion imaging have lower rates of 30-day stroke/death, although selective use of completion imaging is associated with a small but a significant reduction in stenosis 1 year after surgery. We also demonstrate an association between re-exploration and higher risk of 30-day stroke/death, although this effect was attenuated after adjustment for patient-level predictors of stroke/death. Future work is needed to direct the selective use of completion imaging to prevent stroke, rather than cause unnecessary re-exploration.
authors: Dartmouth Hitchcock Medical Center, Lebanon, NH, USA. jessica.wallaert@hitchcock.org
authors: Jessica B
authors: JB
authors: Wallaert
authors: Philip P
authors: PP
authors: Goodney
authors: John J
authors: JJ
authors: Vignati
authors: David H
authors: DH
authors: Stone
authors: Brian W
authors: BW
authors: Nolan
authors: Daniel J
authors: DJ
authors: Bertges
authors: Daniel B
authors: DB
authors: Walsh
authors: Jack L
authors: JL
authors: Cronenwett
mesh_terms: D000792:Angiography / Q000706:statistics & numerical data*; D016893:Carotid Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D016009:Chi-Square Distribution; D016894:Endarterectomy, Carotid / Q000009:adverse effects / Q000401:mortality; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008485:Medical Audit; D009511:New England; D016017:Odds Ratio; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D020521:Stroke / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery; D013997:Time Factors; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex / Q000706:statistics & numerical data*