TY - JOUR
T1 - National variation in preoperative imaging, carotid duplex ultrasound criteria, and threshold for surgery for asymptomatic carotid artery stenosis Presented at the Forty-third Annual Symposium of the Society for Clinical Vascular Surgery, Miami, Fla, March 29-April 2, 2015.
AU - Vascular Quality Initiative
AU - Arous, Edward J.
AU - Simons, Jessica P.
AU - Flahive, Julie M.
AU - Beck, Adam W.
AU - Stone, David H.
AU - Hoel, Andrew W.
AU - Messina, Louis M.
AU - Schanzer, Andres
AU - Hallett, Jeb
AU - Abularrage, Christopher
AU - Clair, Daniel
AU - Shepard, Alex
AU - Schneider, Joseph
AU - Reed, Amy
AU - Wang, Grace
AU - Lemmon, Gary
AU - Dalman, Ronald
AU - Gilbertson, Jeffrey
AU - Weaver, Fred
AU - Davies, Mark
AU - Costanza, Michael
AU - Kappes, Steven
AU - Lipsitz, Evan
AU - Jorgensen, Jens
AU - Upchurch, Gilbert
N1 - Publisher Copyright:
© 2015 Society for Vascular Surgery.
PY - 2015/10/1
Y1 - 2015/10/1
N2 - Objective Carotid endarterectomy (CEA) for asymptomatic carotid artery stenosis is among the most common procedures performed in the United States. However, consensus is lacking regarding optimal preoperative imaging, carotid duplex ultrasound criteria, and ultimately, the threshold for surgery. We sought to characterize national variation in preoperative imaging, carotid duplex ultrasound criteria, and threshold for surgery for asymptomatic CEA. Methods The Society for Vascular Surgery Vascular Quality Initiative (VQI) database was used to identify all CEA procedures performed for asymptomatic carotid artery stenosis between 2003 and 2014. VQI currently captures 100% of CEA procedures performed at >300 centers by >2000 physicians nationwide. Three analyses were performed to quantify the variation in (1) preoperative imaging, (2) carotid duplex ultrasound criteria, and (3) threshold for surgery. Results Of 35,695 CEA procedures in 33,488 patients, the study cohort was limited to 19,610 CEA procedures (55%) performed for asymptomatic disease. The preoperative imaging modality used before CEA varied widely, with 57% of patients receiving a single preoperative imaging study (duplex ultrasound imaging, 46%; computed tomography angiography, 7.5%; magnetic resonance angiography, 2.0%; cerebral angiography, 1.3%) and 43% of patients receiving multiple preoperative imaging studies. Of the 16,452 asymptomatic patients (89%) who underwent preoperative duplex ultrasound imaging, there was significant variability between centers in the degree of stenosis (50%-69%, 70%-79%, 80%-99%) designated for a given peak systolic velocity, end diastolic velocity, and internal carotid artery-to-common carotid artery ratio. Although 68% of CEA procedures in asymptomatic patients were performed for an 80% to 99% stenosis, 26% were performed for a 70% to 79% stenosis, and 4.1% were performed for a 50% to 69% stenosis. At the surgeon level, the range in the percentage of CEA procedures performed for a <80% asymptomatic carotid artery stenosis is from 0% to 100%. Similarly, at the center level, institutions range in the percentage of CEA procedures performed for a <80% asymptomatic carotid artery stenosis from 0% to 100%. Conclusions Despite CEA being an extremely common procedure, there is widespread variation in the three primary determinants - preoperative imaging, carotid duplex ultrasound criteria, and threshold for surgery - of whether CEA is performed for asymptomatic carotid stenosis. Standardizing the approach to care for asymptomatic carotid artery stenosis will mitigate the significant downstream effects of this variation on health care costs.
AB - Objective Carotid endarterectomy (CEA) for asymptomatic carotid artery stenosis is among the most common procedures performed in the United States. However, consensus is lacking regarding optimal preoperative imaging, carotid duplex ultrasound criteria, and ultimately, the threshold for surgery. We sought to characterize national variation in preoperative imaging, carotid duplex ultrasound criteria, and threshold for surgery for asymptomatic CEA. Methods The Society for Vascular Surgery Vascular Quality Initiative (VQI) database was used to identify all CEA procedures performed for asymptomatic carotid artery stenosis between 2003 and 2014. VQI currently captures 100% of CEA procedures performed at >300 centers by >2000 physicians nationwide. Three analyses were performed to quantify the variation in (1) preoperative imaging, (2) carotid duplex ultrasound criteria, and (3) threshold for surgery. Results Of 35,695 CEA procedures in 33,488 patients, the study cohort was limited to 19,610 CEA procedures (55%) performed for asymptomatic disease. The preoperative imaging modality used before CEA varied widely, with 57% of patients receiving a single preoperative imaging study (duplex ultrasound imaging, 46%; computed tomography angiography, 7.5%; magnetic resonance angiography, 2.0%; cerebral angiography, 1.3%) and 43% of patients receiving multiple preoperative imaging studies. Of the 16,452 asymptomatic patients (89%) who underwent preoperative duplex ultrasound imaging, there was significant variability between centers in the degree of stenosis (50%-69%, 70%-79%, 80%-99%) designated for a given peak systolic velocity, end diastolic velocity, and internal carotid artery-to-common carotid artery ratio. Although 68% of CEA procedures in asymptomatic patients were performed for an 80% to 99% stenosis, 26% were performed for a 70% to 79% stenosis, and 4.1% were performed for a 50% to 69% stenosis. At the surgeon level, the range in the percentage of CEA procedures performed for a <80% asymptomatic carotid artery stenosis is from 0% to 100%. Similarly, at the center level, institutions range in the percentage of CEA procedures performed for a <80% asymptomatic carotid artery stenosis from 0% to 100%. Conclusions Despite CEA being an extremely common procedure, there is widespread variation in the three primary determinants - preoperative imaging, carotid duplex ultrasound criteria, and threshold for surgery - of whether CEA is performed for asymptomatic carotid stenosis. Standardizing the approach to care for asymptomatic carotid artery stenosis will mitigate the significant downstream effects of this variation on health care costs.
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U2 - 10.1016/j.jvs.2015.04.438
DO - 10.1016/j.jvs.2015.04.438
M3 - Article
C2 - 26067201
AN - SCOPUS:84942822477
SN - 0741-5214
VL - 62
SP - 937
EP - 944
JO - Journal of vascular surgery
JF - Journal of vascular surgery
IS - 4
ER -