title: Clinical utility of carotid duplex ultrasound prior to cardiac surgery.
abstract: OBJECTIVE
  Clinical utility and cost-effectiveness of carotid duplex examination prior to cardiac surgery have been questioned by the multidisciplinary committee creating the 2012 Appropriate Use Criteria for Peripheral Vascular Laboratory Testing. We report the clinical outcomes and postoperative neurologic symptoms in patients who underwent carotid duplex ultrasound prior to open heart surgery at a tertiary institution.
  
  
  METHODS
  Using the combined databases from our clinical vascular laboratory and the Society of Thoracic Surgery, a retrospective analysis of all patients who underwent carotid duplex ultrasound within 13 months prior to open heart surgery from March 2005 to March 2013 was performed. The outcomes between those who underwent carotid duplex scanning (group A) and those who did not (group B) were compared.
  
  
  RESULTS
  Among 3233 patients in the cohort who underwent cardiac surgery, 515 (15.9%) patients underwent a carotid duplex ultrasound preoperatively, and 2718 patients did not (84.1%). Among the patients who underwent carotid screening vs no screening, there was no statistically significant difference in the risk factors of cerebrovascular disease (10.9% vs 12.7%; P = .26), prior stroke (8.2% vs 7.2%; P = .41), and prior transient ischemic attack (2.9% vs 3.3%; P = .24). For those undergoing isolated coronary artery bypass grafting (CABG), 306 (17.8%) of 1723 patients underwent preoperative carotid duplex ultrasound. Among patients who had carotid screening prior to CABG, the incidence of carotid disease was low: 249 (81.4%) had minimal or mild stenosis (<50%); 25 (8.2%) had unilateral moderate stenosis (50%-69%); 10 (3.3%) had bilateral moderate stenosis; 9 (2.9%) had unilateral severe stenosis (70%-99%); 5 (1.6%) had contralateral moderate stenosis; 2 (0.7%) had bilateral severe stenosis; 4 (1.3%) had unilateral occluded with contralateral less than 50% stenosis, 1 (0.3%) had unilateral occluded with contralateral (70%-99%) stenosis; and 1 had bilateral occluded carotid arteries. Primary outcomes of patients who underwent isolated CABG showed no difference in the perioperative mortality (2.9% vs 4.3%; P = .27) and stroke (2.9% vs 2.6%; P = .70) between patients undergoing preoperative duplex scanning and those who did not. Primary outcomes of patients who underwent open heart surgery also showed no difference in the perioperative mortality (5.1% vs 6.9%; P = .14) and stroke (2.6% vs 2.4%; P = .85) between patients undergoing preoperative duplex scanning and those who did not. Operative intervention of severe carotid stenosis prior to isolated CABG occurred in 2 of the 17 patients (11.8%) identified who underwent carotid endarterectomy with CABG.
  
  
  CONCLUSIONS
  In this study, the correlation between preoperative duplex-documented high-grade carotid stenosis and postoperative stroke was low. Prudent use of preoperative carotid duplex ultrasound should be based on the presence of cerebrovascular symptoms and the type of open heart surgery.
authors.affiliation: Division of Vascular Surgery, Edith and Benson Ford Heart and Vascular Institute, Henry Ford Health System, Detroit, Mich. Electronic address: jlin1@hfhs.org.
authors.forename: Judith C
authors.initials: JC
authors.lastname: Lin
authors.affiliation: Division of Vascular Surgery, Edith and Benson Ford Heart and Vascular Institute, Henry Ford Health System, Detroit, Mich.
authors.forename: Loay S
authors.initials: LS
authors.lastname: Kabbani
authors.affiliation: Department of Public Health, Henry Ford Health System, Detroit, Mich.
authors.forename: Edward L
authors.initials: EL
authors.lastname: Peterson
authors.affiliation: Division of Vascular Surgery, Edith and Benson Ford Heart and Vascular Institute, Henry Ford Health System, Detroit, Mich.
authors.forename: Khalil
authors.initials: K
authors.lastname: Masabni
authors.affiliation: Division of Cardiothoracic Surgery, Edith and Benson Ford Heart and Vascular Institute, Henry Ford Health System, Detroit, Mich.
authors.forename: Jeffrey A
authors.initials: JA
authors.lastname: Morgan
authors.affiliation: Division of Vascular Surgery, Edith and Benson Ford Heart and Vascular Institute, Henry Ford Health System, Detroit, Mich.
authors.forename: Sara
authors.initials: S
authors.lastname: Brooks
authors.affiliation: Division of Cardiothoracic Surgery, Edith and Benson Ford Heart and Vascular Institute, Henry Ford Health System, Detroit, Mich.
authors.forename: Kathleen P
authors.initials: KP
authors.lastname: Wertella
authors.affiliation: Division of Cardiothoracic Surgery, Edith and Benson Ford Heart and Vascular Institute, Henry Ford Health System, Detroit, Mich.
authors.forename: Gaetano
authors.initials: G
authors.lastname: Paone
mesh_terms: D000368:Aged; D002339:Carotid Arteries / Q000000981:diagnostic imaging* / Q000601:surgery; D016893:Carotid Stenosis / Q000150:complications / Q000000981:diagnostic imaging* / Q000401:mortality / Q000601:surgery; D002561:Cerebrovascular Disorders / Q000209:etiology; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000401:mortality; D016208:Databases, Factual; D016894:Endarterectomy, Carotid; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011237:Predictive Value of Tests; D011300:Preoperative Care; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D062606:Tertiary Care Centers; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex