Cost-effective evaluation and treatment for carotid disease

J. L. Ballard, M. K. Deiparine, J. J. Bergan, T. J. Bunt, J. D. Killeen and L. L. Smith
Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda University School of Medicine, Calif, USA.

OBJECTIVE: To compare carotid endarterectomy (CEA) based solely on Duplex ultrasonography (DU) with CEA based on DU and arteriography. DESIGN AND SETTING: Retrospective case series analysis in a regional tertiary care center. PATIENTS: Consecutive sample of 194 patients undergoing 218 CEAs from January 1, 1993, through June 30, 1995, with either preoperative DU plus arteriography (165 CEAs) or DU only (53 CEAs). MAIN OUTCOME MEASURES: Concordance of the 2 diagnostic imaging techniques and influence of these on the conduct of surgery, surgical outcome, and resource cost. RESULTS: There was agreement (kappa = 0.85) between DU and arteriography in the detection of a carotid occlusion or a stenosis greater than 45%. Arteriography demonstrated 26 aortic arch branch lesions (15.8%), 22 intracranial abnormalities (13.3%), and 6 type C ulcers (3.6%), in addition to 1 nonoccluded internal carotid artery (ICA) (0.61%) and 1 contralateral severe ICA stenosis (0.61%) inaccurately estimated by Duplex. These findings prompted 3 changes (1.8%) in surgical therapy, including 2 decisions in favor of CEA and 1 subclavian-carotid bypass added to CEA. There was no difference in the stroke and death rate for CEA based solely on DU compared with CEA based on DU and arteriography (P = .43). The mean total hospital cost was $5,534 for DU only CEA vs $7,608 for DU plus arteriogram CEA (mean difference = $2,074, P < .01). CONCLUSIONS: The addition of carotid arteriography to a diagnostic Duplex ultrasound study that already suggested the need for CEA did not change the operative plan in 98% (162/165) of the cases. Carotid endarterectomy based solely on DU is appropriate and cost-effective.