Completion imaging after carotid endarterectomy in the Vascular Study Group of New England

• Published in: Journal of vascular surgery 2011-08, Vol.54 (2), p.376-385.e3
• Main Authors: Wallaert, Jessica B., MD, Goodney, Philip P., MD, MS, Vignati, John J., MD, Stone, David H., MD, Nolan, Brian W., MD, MS, Bertges, Daniel J., MD, Walsh, Daniel B., MD, Cronenwett, Jack L., MD
• Format: Article
• Language: English
• Subjects: Angiography - utilization; Biological and medical sciences; Carotid Stenosis - diagnostic imaging; Carotid Stenosis - mortality; Carotid Stenosis - surgery; Chi-Square Distribution; Endarterectomy, Carotid - adverse effects; Endarterectomy, Carotid - mortality; Female; Humans; Kaplan-Meier Estimate; Logistic Models; Male; Medical Audit; Medical sciences; Neurology; New England; Odds Ratio; Practice Patterns, Physicians' - statistics & numerical data; Predictive Value of Tests; Proportional Hazards Models; Recurrence; Reoperation; Retrospective Studies; Risk Assessment; Risk Factors; Stroke - diagnostic imaging; Stroke - etiology; Stroke - surgery; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Time Factors; Treatment Outcome; Ultrasonography, Doppler, Duplex - utilization; Vascular diseases and vascular malformations of the nervous system; Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2011.01.032

Objectives 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 (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-expl