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Ratner M, Rockman C, Chandra P, Cayne N, Jacobowitz G, Lamparello PJ, Maldonado T, Sadek M, Berland T, Garg K. The Effect of Ipsilateral Carotid Revascularization on Contralateral Carotid Duplex Parameters in Patients with Bilateral Carotid Stenosis. Ann Vasc Surg 2024; 99:414-421. [PMID: 37918660 DOI: 10.1016/j.avsg.2023.09.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/30/2023] [Accepted: 09/12/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Duplex-derived velocity measurements are often used to determine the need for carotid revascularization. There is evidence that severe ipsilateral carotid stenosis can cause artificially elevated velocities in the contralateral carotid artery, which may decrease following ipsilateral revascularization. The objective of this study was to determine if contralateral carotid artery duplex velocities decrease following ipsilateral carotid endarterectomy or stenting procedures. METHODS This is a single institutional retrospective study of prospectively collected data on all patients who underwent carotid revascularization from 2013 to 2021. Patients with immediate preoperative and first postoperative Duplex scan within 4 months of carotid revascularization at our vascular laboratory were included for analysis. Patients with contralateral occlusion were excluded. Duplex criteria used to define moderate (50-69%) and severe (>70%) stenosis were systolic velocity ≥125 cm/sec and ≥230 cm/sec, respectively. RESULTS Between 2013 and 2021, 129 patients with bilateral carotid stenosis underwent either carotid endarterectomy (98) or a stenting procedure (31). The majority of patients (90%) underwent intervention for severe stenosis. Preoperatively, the contralateral artery was categorized as severe in 30.4% patients. After ipsilateral carotid revascularization, 86 patients (67.2%) saw a decrease in the contralateral artery peak systolic velocity (PSV), while the remaining remained stable or increased. Fifty-four patients had a change in designated stenosis severity in the contralateral artery. Between the carotid endarterectomy and stenting cohorts, there was no significant difference in the proportion of patients whose contralateral velocity decreased (69.4% vs. 61.3%, P = 0.402). Patients with coronary artery disease and diabetes were significantly less likely to experience a decrease in the contralateral artery PSV after ipsilateral intervention (P = 0.018 and P = 0.033). CONCLUSIONS In patients with bilateral carotid disease, ipsilateral revascularization can change the contralateral artery velocity and perceived disease severity. Most patients were noted to have a decrease in the contralateral artery PSV, although almost one-third either stayed stable or increased. On multivariable analysis, patients with coronary artery disease and diabetes were less likely to see a decrease in the contralateral artery PSV after intervention. Patients who are at risk for artificial elevation of the contralateral artery may warrant a re-evaluation of the contralateral artery after ipsilateral intervention. These patients are potentially better assessed with axial imaging, although further research is needed.
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Affiliation(s)
- Molly Ratner
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, New York
| | - Caron Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, New York
| | - Pratik Chandra
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, New York
| | - Neal Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, New York
| | - Glenn Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, New York
| | - Patrick J Lamparello
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, New York
| | - Thomas Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, New York
| | - Mikel Sadek
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, New York
| | - Todd Berland
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, New York
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Medical Center, New York, New York.
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Kronick MD, Chopra A, Swamy S, Brar V, Jung E, Abraham CZ, Liem TK, Landry GJ, Moneta GL. Peak systolic velocity and color aliasing are important in the development of duplex ultrasound criteria for external carotid artery stenosis. J Vasc Surg 2020; 72:951-957. [PMID: 31964570 DOI: 10.1016/j.jvs.2019.10.099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/25/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The external carotid artery (ECA) serves as a major collateral pathway for ophthalmic and cerebral artery blood supply. It is routinely examined as part of carotid duplex ultrasound, but criteria for determining ECA stenosis are poorly characterized and typically extrapolated from internal carotid artery data. This is despite the fact that the ECA is smaller in diameter, with a higher resistance and lower volume flow pattern. We hypothesized that using the cutoff of a peak systolic velocity (PSV) ≥125 cm/s, extrapolated from internal carotid artery data, will overestimate the prevalence of ≥50% ECA stenosis and aimed to determine a more appropriate criterion. METHODS From December 2016 to July 2017, consecutive carotid duplex ultrasound studies performed in our university hospital Intersocietal Accreditation Commission-accredited vascular laboratory were prospectively identified and categorized with respect to prevalence and distribution of ECA PSVs and color aliasing, an indication of turbulent flow or flow acceleration. Presence of color aliasing was determined by two individual reviewers and agreement assessed by Cohen κ coefficient. ECA stenosis was calculated by the North American Symptomatic Carotid Endarterectomy Trial (NASCET) method in patients with computed tomography angiography (CTA) performed within 3 months of carotid duplex ultrasound without an intervening intervention. Receiver operating characteristic analysis was performed to identify best criteria for determining ≥50% ECA stenosis. RESULTS There were 1324 ECAs from 662 patients analyzed; 174 patients had a total of 252 ECAs with PSV ≥125 cm/s (19% of the total sample). Of those ECAs with PSVs ≥125 cm/s, 30.5% were between 125 and 149 cm/s, 22.2% were between 150 and 174 cm/s, 13.1% were between 175 and 199 cm/s, and 34.1% were ≥200 cm/s. There were 341 ECAs that were analyzed for the presence of color aliasing. In 86 ECAs with PSV ≥200 cm/s, 58.1% had color aliasing, whereas in 255 ECAs with PSV <200 cm/s, only 19.2% had color aliasing (P = .0001). There were 325 CTA studies reviewed and assessed for the presence of a ≥50% ECA stenosis as determined by CTA. Overall, the combination of an ECA PSV ≥200 cm/s with the presence of color aliasing provided the highest combination of sensitivity (90%), specificity (96%), positive predictive value (83%), and negative predictive value (98%) and the greatest area under the curve of 0.971 for determining the presence of a ≥50% ECA stenosis based on CTA. CONCLUSIONS A PSV ≥125 cm/s alone probably overestimates the prevalence of ≥50% ECA stenosis. A PSV ≥200 cm/s combined with color aliasing is highly predictive of >50% ECA stenosis based on correlation with CTA.
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Affiliation(s)
- Matthew D Kronick
- Division of Vascular Surgery, Department of Surgery and Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore.
| | - Atish Chopra
- Division of Vascular Surgery, Department of Surgery and Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Shivam Swamy
- Division of Vascular Surgery, Department of Surgery and Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Varneet Brar
- Division of Vascular Surgery, Department of Surgery and Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Enjae Jung
- Division of Vascular Surgery, Department of Surgery and Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Cherrie Z Abraham
- Division of Vascular Surgery, Department of Surgery and Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Timothy K Liem
- Division of Vascular Surgery, Department of Surgery and Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Gregory J Landry
- Division of Vascular Surgery, Department of Surgery and Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
| | - Gregory L Moneta
- Division of Vascular Surgery, Department of Surgery and Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Ore
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Kolkert JL, van den Dungen JJ, Loonstra J, Tielliu IF, Verhoeven EL, Beck AW, Zeebregts CJ. Overestimation of contralateral internal carotid artery stenosis before ipsilateral surgical endarterectomy. Eur J Radiol 2011; 77:68-72. [DOI: 10.1016/j.ejrad.2009.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2009] [Revised: 05/24/2009] [Accepted: 07/15/2009] [Indexed: 11/27/2022]
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Maldonado TS. What are Current Preprocedure Imaging Requirements for Carotid Artery Stenting and Carotid Endarterectomy: Have Magnetic Resonance Angiography and Computed Tomographic Angiography Made a Difference? Semin Vasc Surg 2007; 20:205-15. [DOI: 10.1053/j.semvascsurg.2007.10.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Heijenbrok-Kal MH, Nederkoorn PJ, Buskens E, van der Graaf Y, Hunink MGM. Diagnostic Performance of Duplex Ultrasound in Patients Suspected of Carotid Artery Disease. Stroke 2005; 36:2105-9. [PMID: 16151031 DOI: 10.1161/01.str.0000181753.40455.07] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE To evaluate duplex ultrasonographic thresholds for the determination of 70% to 99% stenosis of the ipsilateral and contralateral internal carotid artery in patients with symptoms of amaurosis fugax, transient ischemic attack (TIA), or minor stroke based on 2 criteria: maximizing accuracy and optimizing cost-effectiveness and to compare these with current recommendations. METHODS From January 1997 to January 2000, a prospective multicenter study was conducted including 350 consecutive patients with symptoms of amaurosis fugax, TIA, or minor stroke who underwent bilateral duplex ultrasonography and digital subtraction angiography. A linear regression analysis was performed to estimate the degree of angiographic stenosis as a function of the peak systolic velocity (PSV). PSV thresholds were calculated for the ipsilateral and contralateral carotid arteries based on maximizing accuracy and optimizing cost-effectiveness. RESULTS The PSV measurements significantly overestimated the angiographic stenosis in the contralateral artery (9.5%; 95% CI, 6.3% to 12.7%) compared with the ipsilateral carotid artery. The recommended PSV threshold for the diagnosis of 70% to 99% stenosis is 230 cm/s. Maximizing accuracy, the optimal PSV threshold for the ipsilateral artery was 280 cm/s, and for the contralateral artery, 370 cm/s for diagnosing a 70% to 99% stenosis. Optimizing cost-effectiveness, the optimal PSV threshold was 220 cm/s for ipsilateral and 290 cm/s for contralateral carotid arteries. CONCLUSIONS PSV measurements overestimate the degree of angiographic stenosis in the contralateral carotid artery in patients with symptoms of amaurosis fugax, TIA, or minor stroke. Separate PSV thresholds should be used for the ipsilateral and contralateral carotid artery. PSV thresholds that optimize cost-effectiveness differ from the recommended thresholds and from thresholds that maximize accuracy.
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Affiliation(s)
- Majanka H Heijenbrok-Kal
- Department of Epidemiology and Biostatistics, Erasmus MC-University Medical Center Rotterdam, The Netherlands.
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Sachar R, Yadav JS, Roffi M, Cho L, Reginelli JP, Aböu-Chebl A, Bhatt DL, Bajzer CT. Severe bilateral carotid stenosis. J Am Coll Cardiol 2004; 43:1358-62. [PMID: 15093867 DOI: 10.1016/j.jacc.2003.11.049] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2003] [Revised: 11/13/2003] [Accepted: 11/17/2003] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The study examined the effect of carotid stenting (CS) on contralateral carotid Doppler-defined degree of stenosis. BACKGROUND Patients with carotid disease are frequently referred for carotid revascularization (carotid endarterectomy [CEA] or CS) based on the results of carotid duplex studies. Although a drop in flow velocities in the contralateral carotid has been described after CEA, the effect of ipsilateral stenting on contralateral velocities has not been defined. METHODS A total of 104 consecutive patients underwent CS and were divided into two cohorts, those with unilateral stenosis, and those with bilateral stenosis. Doppler-defined pre-procedural peak systolic velocities (PSV) and end-diastolic velocities (EDV) in the contralateral carotid were compared with the post-procedural velocities. Post-procedural angiographic stenoses were compared with post-procedural duplex-defined stenoses. RESULTS Among patients with bilateral stenosis, after ipsilateral stenting there was a drop in the contralateral PSV and EDV of 60.3 cm/s (p = 0.005) and 15.1 cm/s (p = 0.03), respectively. There was no change in the contralateral velocities in patients with unilateral stenosis. Among patients with > or =60% stenosis by duplex in the contralateral carotid, 20% dropped to a lower classification of contralateral stenosis after ipsilateral stenting. Furthermore, 71% of patients with significant contralateral stenosis by duplex pre-stenting did not have significant stenosis by angiography. CONCLUSIONS Patients with bilateral carotid disease may have elevated Doppler flow velocities in the contralateral carotid resulting in an artifactually high grade of stenosis. After ipsilateral carotid revascularization, such patients should have a repeat Doppler of the contralateral carotid to assess the true grade of stenosis.
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Affiliation(s)
- Ravish Sachar
- Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA
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Brown OW, Bendick PJ, Bove PG, Long GW, Cornelius P, Zelenock GB, Shanley CJ. Reliability of extracranial carotid artery duplex ultrasound scanning: value of vascular laboratory accreditation. J Vasc Surg 2004; 39:366-71; discussion 371. [PMID: 14743137 DOI: 10.1016/j.jvs.2003.08.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the reliability of carotid duplex ultrasound scanning performed by nonaccredited vascular laboratories and to assess the clinical effect on patient management. METHODS We retrospectively reviewed concordance of findings of carotid duplex ultrasound scanning between laboratories accredited by the Intersocietal Commission for Accreditation of Vascular Laboratories and nonaccredited laboratories in 174 patients with asymptomatic disease referred to tertiary care community hospitals for surgical evaluation for carotid endarterectomy (CEA) between January 2001 and December 2002, and evaluated changes in clinical management made on the basis of repeat examinations. RESULTS Concordant findings were noted in 171 of 348 arteries (49%), predominantly those with minimal or mild disease (114 arteries; 67%). Discordant findings of no clinical significance were found in 54 arteries (16%). Clinically significant discordant findings were noted in 123 arteries (35%) in 107 patients (61%). In 104 arteries (88 patients) stenosis was overestimated by the nonaccredited laboratory secondary to technical error (19 arteries), use of B-mode imaging data alone (36 arteries), and use of inappropriate velocity criteria (49 arteries). None of these patients underwent CEA. Stenosis was significantly underestimated in 19 arteries (19 patients); all of these patients underwent uncomplicated CEA. CONCLUSIONS Incorrect physician interpretation of data is the most common cause of error in carotid duplex ultrasound scanning performed in nonaccredited vascular laboratories. Results of carotid duplex ultrasound scanning from nonaccredited laboratories should be considered with extreme caution, and do not appear reliable in planning treatment of obstructive disease.
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Affiliation(s)
- O William Brown
- Department of Surgery, William Beaumont Hospital, Royal Oak, MI 48037, USA.
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Leonardo G, Crescenzi B, Cotrufo R, Tecame S, De Santo LS, Della Corte A, Fratta M, Cotrufo M. Improvement in accuracy of diagnosis of carotid artery stenosis with duplex ultrasound scanning with combined use of linear array 7.5 MHz and convex array 3.5 MHz probes: validation versus 489 arteriographic procedures. J Vasc Surg 2003; 37:1240-7. [PMID: 12764271 DOI: 10.1016/s0741-5214(02)75138-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Validity of a method to improve the accuracy of carotid artery duplex scanning was tested in comparison with arteriography. STUDY DESIGN In 489 patients who had not previously undergone arteriography, 978 carotid arteries were examined with duplex ultrasound scanning. In method A, a linear array 7.5 MHz transducer with pulsed-wave 4.7 MHz Doppler scanning was used. For the diagnosis and grading of carotid stenosis, peak systolic and end-diastolic velocity of the Doppler waves were recorded. Method B consisted of complete ultrasound imaging and color-flow mapping with a convex array 3.5 MHz transducer with pulsed-wave 2.8 MHz Doppler scanning in all patients who had previously undergone method A. Further velocity measurements were performed at the sites of stenosis. The results of methods A and B were compared with data from neurologic assessment and arteriographic studies. RESULTS Method B showed significantly higher diagnostic agreement with arteriography than did method A (K 95% confidence interval [CI], 0.87-0.93 vs 0.79-0.85; P <.05), and the number of mistakes in grading stenosis was significantly lower (primarily because of decreased overestimation) in patients with internal carotid kinking (>60 degrees of angulation) (P <.05), distal stenosis (>20 mm from bifurcation) (P <.01), or wide acoustic shadowing (>1 cm) (P <.01) and in those without these conditions (P <.05). Compared with arteriography, diagnostic accuracy with the new method proved higher for carotid stenoses 50% or greater, 60% or greater, 70% or greater, and 80% or greater; no statistically significant difference was found for carotid stenosis 96% or greater or for carotid occlusion. Compared with data from neurologic assessment and arteriography, method B proved more accurate than method A in designating patients for carotid endarterectomy (P =.014). CONCLUSIONS The new method significantly improved diagnostic reliability of duplex ultrasound scanning, especially in carotid arteries with kinking, distal stenosis, or wide acoustic shadowing (32.2% of all arteries studied). In clinical practice, we suggest additional use of a lower frequency transducer in cases in which these three conditions are found or suspected at first scanning.
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Affiliation(s)
- Giuseppe Leonardo
- Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, Monaldi Hospital, Division of Cardiovascular Surgery, Naples, Italy
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Moneta GL, Foley MI, Giswold ME, Musicant SE. Vascular surgery for peripheral arterial disease. CLINICAL CORNERSTONE 2003; 4:41-55. [PMID: 12425183 DOI: 10.1016/s1098-3597(02)90015-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The North American Symptomatic Carotid Endarterectomy Trial (NASCET) confirmed that carotid endarterectomy (CEA) can significantly cut the risk of stroke in patients with moderate and severe blockage. The standard today is that patients who have internal carotid artery stenosis > 70% with associated symptoms and who are appropriate surgical candidates should be offered CEA. Aneurysmal disease, a growing public health concern, poses the threat of death from rupture, and lower extremity arterial occlusive disease poses a significant risk of critical leg ischemia and limb loss. Both conditions involve surgical options. In treating their patients, primary care physicians should become familiar with the benefits and risks of vascular surgery to manage the various aspects of peripheral arterial disease.
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Affiliation(s)
- Gregory L Moneta
- Division of Vascular Surgery, Oregon Health & Science University, Portland, Oregon, USA.
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Affiliation(s)
- J L Cronenwett
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA
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Henderson RD, Steinman DA, Eliasziw M, Barnett HJ. Effect of contralateral carotid artery stenosis on carotid ultrasound velocity measurements. Stroke 2000; 31:2636-40. [PMID: 11062287 DOI: 10.1161/01.str.31.11.2636] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Carotid ultrasonography is being increasingly performed as the sole investigation to assess internal carotid artery (ICA) stenosis. A potential source of error in using ultrasound peak systolic velocity (PSV) measurements is that the redistribution of blood flow due to severe stenosis in a contralateral carotid artery may lead to artificially elevated values. METHODS Ultrasonography was performed before and after carotid endarterectomy in symptomatic patients who participated in the North American Symptomatic Carotid Endarterectomy Trial (NASCET). The mean change in PSV in the unoperated artery was assessed across all degrees of angiographically defined stenosis. A simple theoretical resistance model of the cerebral circulation was also derived. RESULTS Complete bilateral ultrasound examinations were performed within 90 days of the initial scan in 386 patients. In the presence of a contralateral severe (70% to 99%) ICA stenosis, the PSV in the unoperated artery was artificially elevated by a mean of 84 cm/s (P:=0.03; 95% CI, 10 to 159 cm/s). The mean elevation was less pronounced for lesser degrees of stenosis (11 to 21 cm/s). Small elevations (3 to 12 cm/s) were observed when the contralateral artery had <70% stenosis. The patterns of observed results were congruent with those from the theoretical model. CONCLUSIONS The present study showed that a severely stenosed contralateral ICA can artificially elevate ultrasound PSV. Since the effect was greatest when bilaterally severe stenoses were present, caution must be exercised when assessing the degree of ICA stenosis on the basis of ultrasonography PSV measurements alone.
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Affiliation(s)
- R D Henderson
- John P. Robarts Research Institute, University of Western Ontario, London, Canada
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