Article Outline
Dr Mark R. Jackson (Greenville, SC). Dr AbuRahma and colleagues are to be congratulated on their continuing contributions to the treatment of cerebrovascular disease. The present study represents an analysis of restenosis following 200 carotid endarterectomies performed with patch closure as part of a separate trial comparing two patch materials. The authors conclude that duplex criteria for restenosis are higher than those generally accepted for stenosis in non-operated carotid arteries. After reading the manuscript and hearing the presentation, I have the following three questions.
1.Your data show that the greatest discrepancy between duplex evidence of restenosis and CTA findings is in the 50-70% category. However, it is the group with >70% stenosis that is clinically most significant. If I understand Table 1, the Consensus Criteria correctly identified 21 of 22 arteries with >70% restenosis. My question then, is why do we need revised criteria?
2.If your it is your clinical practice is to obtain CT angiography for suspected restenosis before offering surgery or stenting, wouldn't it be better to stick with the standard or consensus (ie: lower and more sensitive) velocity criteria? This would maximize your sensitivity while the CT angio would maximize specificity.
3.Finally, and I apologize that my final question does not directly apply to your manuscript, but would you please comment on your imaging and treatment algorithm for patients identified with >70% restenosis?
Thank you. I enjoyed your paper.
Dr Ali F. AbuRahma. Thank you, Dr Jackson, for your kind comments. I have the following responses to your questions.
1.I agree with you that if you look into the >70% stenosis group, which is the most clinically significant, one patient was not identified applying the consensus criteria. However if you look into the category of 50<70% stenosis, 38% were thought to have 50-<70% stenosis, when applying both the standard and consensus criteria. But when these patients underwent angiography, only 10% actually had 50-<70% stenosis. I believe this group of patients is also important since, if the patient is symptomatic, many of them will undergo further imaging, specifically angiography, and perhaps re-do surgery or carotid stenting. Therefore, they would be inappropriately treated, when, in fact, they have <50% stenosis and not 50-<70% stenosis. In addition, if these patients were told to have 50-<70% stenosis, they would be very disappointed from the first primary surgery.
2.Questions 2 and 3 response: In our practice, if a patient is found to have ≥70% restenosis, and if they are a candidate for carotid stenting, they will undergo carotid angiography and stenting, if indicated. Therefore, we can rely on appropriate carotid duplex ultrasound in this management without the need for further imaging.
