When Should Carotid Endarterectomy be Performed on the Basis of Carotid Noninvasive Examination Alone?

Abstract

Recent randomized prospective trials have defined more clearly the role of carotid endarterectomy (CEA) in both symptomatic and asymptomatic patients.^1-4 Simultaneously, technical refinements in the use of carotid noninvasive (CNIE) examination for diagnosing and categorizing carotid artery disease have changed the role of CNIE in the eyes of many vascular surgeons. Once seen primarily as a screening tool for selecting patients for more accurate invasive testing, CNIE now has the capability, in some situations, to serve as the sole diagnostic study, by supplying the information needed to make treatment decisions in patients with known or suspected carotid disease. For the last decade reports have appeared in the literature suggesting that under certain circumstances, relying on CNIE as the sole diagnostic study for selecting patients for CEA was not only feasible, but beneficial in terms of morbidity and cost.⁵ Simultaneously, evolution in the technical aspects of CNIE have both improved its accuracy and made earlier reports describing its role in the evaluation of these patients somewhat outdated.

This article will briefly review some of the recent developments of CNIE technology and vascular laboratory regulation and then examine the current arguments for and against the use of CNIE as the sole diagnostic study prior to CEA. Finally, a strategy for the appropriate use of CNIE in the management of patients with carotid disease will be suggested. CNIE as used here refers to an integrated package of diagnostic modalities including standard duplex ultrasound, ophthalmic artery velocity measurements, and other tests which will be described. It should be understood that in validated laboratories, the information derived from these studies will be considered as a whole in diagnosing carotid disease.