Invited commentary

Abstract

With 827 consecutive post-carotid endarterectomy completion arteriograms, Dr Wieker and colleagues detected 57 (6.9%) defects requiring immediate surgical revision. One in 14 of their cases required reopening of the artery! Despite their significant incidence of defects requiring immediate revision, the authors' overall results are superb (0.2%, 0.5%, and 0.6% 30-day mortality, stroke, and transient ischemic attack rates, respectively), and immediate revision was not associated with worse outcomes. Should we adopt the authors' recommendation to perform completion arteriography after all carotid endarterectomies? Before adopting routine completion angiography in our practices, we should answer three questions. First, can we standardize criteria for arterial re-exploration? The authors' figures demonstrate egregious findings clearly requiring re-exploration, but what about more subtle findings? Second, are there less invasive, less time-consuming, and equally accurate methods for assessing the adequacy of reconstruction? Continuous-wave Doppler interrogation, duplex ultrasound, prearterial closure angioscopy, and electromagnetic flow measurements have all been reported to be effective in detecting thrombus, flaps, and other defects requiring revision. There are no data consistently demonstrating the superiority of routine completion angiography over these methods. Third, does every patient need the same completion study? Does the “easy” endarterectomy (thin mobile neck, low bifurcation, focal plaque, easily visualized perfect end point) require the same completion study as the difficult endarterectomy? Perhaps we can use one modality, such as continuous-wave Doppler, for the straightforward cases and reserve arteriography or duplex ultrasound for the more difficult cases and for those with less than perfect Doppler findings. Because so many surgeons have reported excellent results (comparable to the authors') without performing routine completion arteriography, I find it hard to accept the authors' recommendation. There are, however, a few essential routines. The first is obsessive attention to detail in the performance of carotid endarterectomy, both in creation of the endarterectomy end point and in optimizing flow across the fresh, thrombogenic endarterectomy surface. This requires excellent exposure with clear visualization of the arterial intima distal to the plaque and occasional use of tacking sutures or plication techniques. In addition, any anatomic feature that results in damped flow or high resistance to flow, such as proximal common carotid lesions or distal internal carotid kinks, must be treated. Similarly, obsessive attention to perioperative and intraoperative medical management (aspirin, statins, appropriate heparin dosing, tight blood pressure control) is a prerequisite for superior outcomes. Finally, as alarmingly demonstrated in this study, even when experienced surgeons employ standardized, state-of-the-art techniques, anatomic outcomes can be poor. For this reason, routine intraoperative completion studies are essential. For the authors, routine completion arteriography has proven safe and effective. However, there are many other options for intraoperative quality control. In the absence of compelling data supporting the superiority of any one technique, each surgeon should continue to use what works best for her or him while carefully monitoring outcomes and exploring every opportunity for improvement. Impact of routine completion angiography on outcome after carotid endarterectomyJournal of Vascular SurgeryVol. 69Issue 3PreviewThe objective of this study was to analyze the impact of completion digital subtraction angiography (cDSA) after carotid endarterectomy (CEA) on technical and early clinical results. Full-Text PDF Open Archive