Annals of Vascular Surgery

, Volume 8, Issue 3, pp 296–302 | Cite as

Carotid endarterectomy without arteriography

  • Arun Chervu
  • Wesley S. Moore
General Review


Arteriography has been considered the “gold standard” for evaluation of the cerebrovascular circulation prior to carotid endarterectomy. However, arteriography is associated with a neurologic complication rate of up to 12% in certain high-risk groups. Previous studies have shown that the duplex scanner has greater sensitivity than arteriography when both are correlated to the surgical specimen. From January 1986 to December 1991 a total of 174 carotid endarterectomies were performed in 152 patients, of which 61 % were symptomatic. A total of 110 carotid endarterectomies in 92 patients were performed without the use of arteriography. Of the 64 patients in whom arteriograms were obtained, 33 were made at consultation and the others for various indications. Operative findings confirmed the duplex scan findings in all cases. A total of 91 % of patients had intraoperative completion arteriograms. Of the 55 patients who also had intracranial views taken, two had a 50% siphon stenosis and one patient had a small intracranial aneurysm. None of these findings would have changed our management. The overall neurologic complication rate was one (0.66%) death due to stroke and four (2.6%) patients with transient ischemic attacks. Carotid endarterectomy can be safely performed without preoperative arteriography based on a detailed history and physical examination that includes bilateral upper extremity blood pressures and a duplex scan performed by a validated laboratory.


Great Sensitivity Transient Ischemic Attack Intracranial Aneurysm Carotid Endarterectomy Detailed History 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Laerum F. Cytotoxic effects of angiographic contrast media on human endothelium in culture. Acta Radiol [Diagn] 1987;28:99–105.Google Scholar
  2. 2.
    Laerum F, Dehner LP, Rysavy J, et al. Double-blind evaluation of the effects of various contrast media on extremity veins in the dog. Acta Radiol [Diagn] 1987;28:107–113.Google Scholar
  3. 3.
    Osborne RW, Malone JM, Hunter GC, et al. Endothelial fibrinolytic activity: The key to postangiographic thrombosis? Am Coll Surg Surgical Forum 1981;32:328–330.Google Scholar
  4. 4.
    Rose JS. Contrast media, complications, and preparation of the patient. In Rutherford RB, ed. Vascular Surgery. Philadelphia: WB Saunders, 1984, pp 244–252.Google Scholar
  5. 5.
    Hessel SJ, Adams DF, Abrams HL. Complications of angiography. Radiology 1981;138:273–281.PubMedGoogle Scholar
  6. 6.
    Swartz RD, Rubin JE, Leeming BW, et al. Renal failure following major angiography. Am J Med 1978;65:31–37.PubMedGoogle Scholar
  7. 7.
    Kumar S, Hull JD, Subhash L, et al. Low incidence of renal failure after angiography. Arch Intern Med 1981;141:1268–1270.PubMedGoogle Scholar
  8. 8.
    Martin-Paredero V, Dixon SM, Baker JD, et al. Risk of renal failure after major angiography. Arch Surg 1983;118:1417–1420.PubMedGoogle Scholar
  9. 9.
    Gomes AS, Lois JF, Baker JD, et al. Acute renal dysfunction in high-risk patients after angiography: Comparison of ionic and nonionic contrast media. Radiology 1989;170:65–68.PubMedGoogle Scholar
  10. 10.
    Hankey GJ, Warlow CP, Sellar RJ. Cerebral angiographic risk in mild cerebrovascular disease. Stroke 1990;21:209–222.PubMedGoogle Scholar
  11. 11.
    Earnest F, Forbes G, Sandok BA, et al. Complications of cerebral angiography: Prospective assessment of risk. AJR 1984;142:247–253.PubMedGoogle Scholar
  12. 12.
    Dion JE, Gates PC, Fox AJ, et al. Clinical events following neuroangiography: A prospective study. Stroke 1987;18:997–1004.PubMedGoogle Scholar
  13. 13.
    Theodotou BC, Whaley R, Mahaley MS. Complications following transfemoral cerebral angiography for cerebral ischemia: Report of 159 angiograms and correlation with surgical risk. Surg Neurol 1987;28:90–92.PubMedGoogle Scholar
  14. 14.
    O'Holleran LW, Kennelly MM, McClurken M, et al. Natural history of asymptomatic carotid plaque: Five-year follow-up study. Am J Surg 1987;154:659–662.PubMedGoogle Scholar
  15. 15.
    Sterpetti AV, Schultz RD, Feldhaus RJ, et al. Ultrasonographic features of carotid plaque and the risk of subsequent neurologic deficits. Surgery 1988;104:652–660.PubMedGoogle Scholar
  16. 16.
    Langsfeld M, Gray-Weale AC, Lusby RJ. The role of plaque morphology and diameter reduction in the development of new symptoms in asymptomatic carotid arteries. J Vasc Surg 1989;9:548–557.PubMedGoogle Scholar
  17. 17.
    Bornstein NM, Beloev ZG, Norris JW. The limitations of diagnosis of carotid occlusion by doppler ultrasound. Ann Surg 1988;207:315–317.PubMedGoogle Scholar
  18. 18.
    Akers DL, Markowitz IA, Kerstein MD. The value of aortic arch study in the evaluation of cerebrovascular insufficiency. Am J Surg 1987;154:220–223.PubMedGoogle Scholar
  19. 19.
    Moore WS. Does tandem lesion mean tandem risk in patients with carotid artery disease? J Vasc Surg 1988;7:454–455.PubMedGoogle Scholar
  20. 20.
    Akers DL, Bell WH, Kerstein MD. Does intracranial dye study contribute to evaluation of carotid artery disease? Am J Surg 1988;156:87–90.PubMedGoogle Scholar
  21. 21.
    Roederer GO, Langlois YE, Chan ARW, et al. Is siphon disease important in predicting outcome of carotid endarterectomy? Arch Surg 1983;118:1177–1181.PubMedGoogle Scholar
  22. 22.
    Schuler JJ, Flanigan DP, Lim LT, et al. The effect of carotid siphon stenosis on stroke rate, death, and relief of symptoms following elective carotid endarterectomy. Surgery 1982;92:1058–1067.PubMedGoogle Scholar
  23. 23.
    Bendick PJ, Glover JL, Hankin R, et al. Carotid plaque morphology: Correlation of duplex sonography with histology. Ann Vasc Surg 1988;2:6–13.PubMedGoogle Scholar
  24. 24.
    Ricotta JJ, Schenk EA, Ekholm SE, et al. Angiographic and pathologic correlates in carotid artery disease. Surgery 1986;99:284–292.PubMedGoogle Scholar
  25. 25.
    Estol C, Ciaassen D, Hirsch W, et al. Correlative angiographic and pathologic findings in the diagnosis of ulcerated plaques in the carotid artery. Arch Neurol 1991;48:692–694.PubMedGoogle Scholar
  26. 26.
    O'Donnell TF, Erdoes L, Mackey WC, et al. Correlation of B-mode ultrasound imaging and arteriography with pathologic findings at carotid endarterectomy. Arch Surg 1985;120:443–449.PubMedGoogle Scholar
  27. 27.
    Weintraub MI, Lambert D, Rothman AL. Carotid ultrasonography — the new “gold standard”: Surgical and angiographic correlation. Angiology 1985;36:19–22.PubMedGoogle Scholar
  28. 28.
    Goodson SF, Flanigan DP, Bishara RA, et al. Can carotid duplex scanning supplant arteriography in patients with focal carotid artery symptoms? J Vasc Surg 1987;5:551–557.PubMedGoogle Scholar
  29. 29.
    Von Reutern GM, Ortega-Schrkamp E, Spillner S. Is noninvasive Doppler sonography alone sufficient to indicate carotid surgery? In Meyer JS, Lechner M, Reivrch M, eds. Cerebral Vascular Disease II. International Congress Series. Elsevier:New York, 1979, pp 46–49.Google Scholar
  30. 30.
    Blackshear WM, Connar RG. Carotid endarterectomy without angiography. J Cardiovasc Surg 1982;23:477–482.Google Scholar
  31. 31.
    Sandmann W, Hennerici M, Nullen H, et al. Carotid artery surgery without angiography: Risk or progress. In Greenhalgh RM, Rose FC, eds. Progress in Stroke Research II. London:Pitman, 1983, pp 447–461.Google Scholar
  32. 32.
    Gonzalez LL, Partusch L, Wirth P. Noninvasive carotid artery evaluation following endarterectomy. J Vasc Surg 1984;1:403–408.PubMedGoogle Scholar
  33. 33.
    Ricotta JJ, Holen J, Schenk E, et al. Is routine angiography necessary prior to carotid endarterectomy? J Vasc Surg 1984;1:96–102.PubMedGoogle Scholar
  34. 34.
    Crew JR, Dean M, Johnson JM, et al. Carotid surgery without angiography. Am J Surg 1984;148:217–220.PubMedGoogle Scholar
  35. 35.
    Thomas GI, Jones TW, Stavney LS, et al. Carotid endarterectomy after doppler ultrasonographic examination without angiography. Am J Surg 1986;151:616–619.PubMedGoogle Scholar
  36. 36.
    Walsh J, Markowitz I, Kerstein MD. Carotid endarterectomy for amaurosis fugax without angiography. Am J Surg 1986;152:172–174.PubMedGoogle Scholar
  37. 37.
    Marshall WG, Kouchoukos NT, Murphy SF, et al. Carotid endarterectomy based on duplex scanning without preoperative arteriography. Circulation 1988;78(Suppl I):I-1–I-5.Google Scholar
  38. 38.
    Moore WS, Ziomek S, Quiñones-Baldrich WJ, et al. Can clinical evaluation and noninvasive testing substitute for arteriography in the evaluation of carotid artery disease? Ann Surg 1988;208:91–94.PubMedGoogle Scholar
  39. 39.
    Farmilo RW, Scott DJA, Cole SEA, et al. Role of duplex scanning in the selection of patients for carotid endarterectomy. Br J Surg 1990;77:388–390.PubMedGoogle Scholar
  40. 40.
    Hill JC, Carbonneau K, Baliga PK, et al. Safe extracranial vascular evaluation and surgery without preoperative arteriography. Ann Vasc Surg 1990;4:34–38.PubMedGoogle Scholar
  41. 41.
    Ranaboldo C, Davies J, Chant A. Duplex scanning alone before carotid endarterectomy: A 5-year experience. Eur J Vasc Surg 1991;5:415–419.PubMedGoogle Scholar
  42. 42.
    Wagner WH, Treiman RL, Cossman DV, et al. The diminishing role of diagnostic arteriography in carotid artery disease: Duplex scanning as definitive preoperative study. Ann Vasc Surg 1991;5:105–110.Google Scholar
  43. 43.
    Geuder JW, Lamparello PJ, Riles TS, et al. Is duplex scanning sufficient evaluation before carotid endarterectomy? J Vasc Surg 1989;9:193–201.PubMedGoogle Scholar
  44. 44.
    Kempczinski RF, Thiele BL, Strandness DE, et al. Accreditation of vascular laboratories. J Vasc Surg 1990;12:629–630.PubMedGoogle Scholar
  45. 45.
    Vollman RW, Eldrup-Jorgenson J, Hoffman MA. The role of cranial computed tomography in carotid surgery. Surg Clin North Am 1986;66:255–268.PubMedGoogle Scholar
  46. 46.
    Weisberg L, Nice C, Katz M, eds. Rapid onset of neurological deficit (stroke syndrome): Aneurysmal subarachnoid hemorrhage. In Cerebral computed tomography: A text-atlas. Philadelphia:WB Saunders, 1984, pp 135–147.Google Scholar
  47. 47.
    Sise MJ, Sedwitz MM, Rowley WR, et al. Prospective analysis of carotid endarterectomy and select cerebral infarction in 97 patients. Stroke 1989;20:329–332.PubMedGoogle Scholar

Copyright information

© Annals of Vascular Surgery Inc. 1994

Authors and Affiliations

  • Arun Chervu
    • 1
  • Wesley S. Moore
    • 1
  1. 1.Vascular SurgeryUCLA School of MedicineLos Angeles

Personalised recommendations