A comparison of quality control methods applied to carotid endarterectomy

Objectives:

To compare the ability of continuous wave Doppler (CWD), B-mode ultrasound (BMU), angioscopy and transcranial Doppler (TCD) to detect technical error during carotid endarterectomy (CEA).

Design:

A prospective, comparative study in 100 consecutive patients.

Setting:

Leicester Royal Infirmary, Leicester, U.K.

Materials:

Intraoperative TCD monitoring was performed using a SciMed PcDop 842 2 MHz TCD. An Olympus 2.8mm flexible angioscope was used to inspect the arterial lumen prior to restoration of bloodflow. After restoration of flow 10Mhz BMU images and 8Mhz CWD velocity spectra of carotid artery blood flow were obtained.

Chief outcome measures:

The detection of intimal flaps, thrombus, stenoses or other errors of surgical technique likely to result in perioperative morbidity.

Main results:

CWD and BMU images were technically inadequate in 9% and 24% of cases respectively and neither technique altered clinical management. Angioscopy demonstrated significant technical errors in 12 cases (four intimal flaps, thrombus in eight). TCD detected shunt malfunction in 13% of patients, emboli during dissection in 23% and early postoperative carotid artery thrombosis in three patients.

Conclusions:

A combination of TCD monitoring and completion angioscopy provided the maximum yield in terms of diagnosing technical error and establishing the cause of perioperative morbidity.