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Importance of the imaging modality in decision making about carotid endarterectomy

From the Departments of Clinical Neurosciences (Drs. Kennedy and Feasby), Medicine (Dr. Ghali), and Community Health Sciences (Drs. Quan and Ghali), University of Calgary, Alberta, and Division of Neurology (Dr. Feasby), Department of Medicine, Capital Health and University of Alberta, Edmonton, Canada.

Objective: To determine the influence of all possible imaging strategies on the appropriateness ratings for carotid endarterectomy, because less accurate noninvasive techniques are replacing contrast angiography, which was used in the major efficacy trials.

Methods: An expert panel, using appropriateness methodology, rated 203 scenarios where endarterectomy might be performed. Each scenario was rated where internal carotid artery stenosis was determined using five different imaging sources: 1) conventional angiography, 2) ultrasound carotid Doppler only, 3) CT (CTA) or MR (MRA) angiography only, 4) concordant results from two noninvasive carotid imaging studies, and 5) discordant results from two noninvasive studies. The scenarios deemed appropriate by conventional angiography were identified. The effect of the other imaging modalities on these results was examined.

Results: Thirty-three scenarios were identified as being appropriate. Concordant imaging results had no effect on appropriateness ratings in symptomatic carotid artery disease when compared with conventional angiography. Single noninvasive imaging techniques were deemed appropriate for investigation only in the presence of severe symptomatic stenosis. In all other scenarios, single noninvasive imaging and discordant results reduced the appropriateness rating of scenarios to either uncertain benefit or inappropriateness. The single appropriate scenario for asymptomatic carotid artery stenosis was where severe stenosis was determined by concordant noninvasive imaging or by CTA or MRA alone.

Conclusion: It is important to take into account both the clinical scenario and the imaging modalities utilized to determine the degree of internal carotid artery stenosis in the clinical decision making surrounding carotid endarterectomy.

Received September 29, 2003. Accepted in final form November 20, 2003.

Additional material related to this article can be found on the Neurology Web site. Go to www.neurology.org and scroll down the Table of Contents for the March 23 issue to find the title link for this article.

This article has been cited by other articles:

				H. R. Tahmasebpour, A. R. Buckley, P. L. Cooperberg, and C. H. Fix Sonographic Examination of the Carotid Arteries RadioGraphics, November 1, 2005; 25(6): 1561 - 1575. [Abstract] [Full Text] [PDF]

				N. Hoggard, T. E. Feasby, J. Kennedy, H. Quan, and W. A. Ghali Importance of the imaging modality in decision making about carotid endarterectomy Neurology, October 12, 2004; 63(7): 1340 - 1341. [Full Text] [PDF]

				T. E. Feasby and J. M. Findlay CT angiography for the assessment of carotid stenosis Neurology, August 10, 2004; 63(3): 412 - 413. [Full Text] [PDF]

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