Surveillance Duplex Ultrasound Prompted Interventions After Carotid Endarterectomy
Abigail Clark, Katherine K McMackin, Kristen Knapp, Mark Zemela, Bruce Tjaden, Jr., Philip Batista, Jeffrey Carpenter, Joseph Lombardi
Cooper University Hospital, Camden, NJ
IntroductionCurrent societal guidelines recommend duplex ultrasound surveillance beyond 30-days after carotid endarterectomy for patients with risk factors for restenosis or who underwent primary closure. However, the appropriate length for this surveillance has not yet been identified and the rate at which surveillance prompts intervention is unknown. Multiple calls for decreasing healthcare spending that does not provide value, including unnecessary testing, have been made. The purpose of this study was to examine the rate of intervention prompted by surveillance duplex ultrasound on the ipsilateral or contralateral carotid artery after carotid endarterectomy.MethodsA single center retrospective review of all patients undergoing carotid endarterectomy from August 2009 to July 2022 was performed. Inclusion criteria was at least one post-operative duplex in our Intersocietal Accreditation Council accredited ultrasound lab. Those with incomplete medical charts were excluded. The primary outcome was duplex initiated intervention on the ipsilateral or contralateral side. Secondary outcomes were number of post operative duplex ultrasounds, subsequent carotid interventions not prompted by duplex ultrasound, and duration of follow up. ResultsA total of 794 patients undergoing carotid endarterectomy met inclusion criteria. These patients had a total of 2,146 post-operative carotid duplex ultrasounds, range 1-15 duplexes, mean 2.72. The average duration of surveillance was 26 months (range 1-155). Fifty-nine patients (7.4%) underwent an additional carotid intervention after initial endarterectomy. Most subsequent carotid interventions, 44 of 59, were planned endarterectomies on the contralateral side based on initial duplex imaging, not prompted by interval duplex surveillance. Fourteen patients (1.8%) had surveillance duplex that prompted subsequent carotid interventions. Twelve of these patients had progression of disease on the contralateral side leading to carotid endarterectomy. The initial level of contralateral carotid stenosis in these patients were: one with mild (20-49%), seven with moderate (50-69%), and four with severe (>70%). The average time between the initial carotid and subsequent contralateral carotid was 37.5 months (Figure 1). Four patients (0.5%) underwent subsequent ipsilateral interventions for restenosis (Table 1). One of those four had bilateral carotid interventions. Two patients of the four subsequent ipsilateral interventions also had a contralateral progression of disease requiring intervention. One patient who was lost to follow-up had a contralateral stroke requiring intervention.ConclusionsThe overall rate of ipsilateral reintervention after carotid endarterectomy is low. A small percentage of patients will progress their contralateral disease, ultimately requiring surgical intervention. These data suggest regular duplex surveillance post endarterectomy is warranted for patients with at least moderate contralateral disease, however, the yield is low for ipsilateral restenosis after one year. Further study is needed to better delineate which patients need follow up to decrease unnecessary testing while still targeting patients most at risk of restenosis or contralateral progression of disease. 
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