The influence of routine completion arteriography on outcome following carotid endarterectomy

The necessity for routine completion arteriography (RCA) following carotid endarterectomy (CEA) is controversial, with the reported yield of clinically significant findings varying from 3% to 16%. In order to determine the utility of RCA, we reviewed completion studies in 154 consecutive CEAs, defined the frequency and characteristics of arteriographic defects, and correlated RCA defects with early outcome (internal carotid artery [ICA] occlusion, stroke) and late restenosis. All intraoperative RCAs were reviewed by two blinded observers and categorized into three subsets: Group A (n = 69) normal; Group B (n = 29), abnormal, severe defects; Group C (n = 56), abnormal, mild-moderate defect. RCA detected 32 defects in Group B: 10 internal carotid (ICA), seven endpoint flaps, two kinks, one dissection; 16 external carotid (ECA), 10 severe endpoint defects and six total occlusion; six common carotid (CCA), five irregular proximal shelfs, one web. Thirty of 32 defects were successfully repaired as confirmed by normal repeat RCA studies; one ECA defect was not repaired and the ICA dissection was irreparable. In Group C, 67 mild-moderate defects were identified, but not corrected. These included <30% stenosis in the ICA (12), ECA (18), CCA (24), and vein patch corrugation or irregularity (13). For the entire series the postoperative ICA occlusion rate was 2% (3/154), stroke rate 2.6% (4/154), and a subsequent >50% restenosis rate of 7% (11/154). The yield from routine carotid completion arteriograms was significant, with 19% of studies identifying a severe defect that required repair. Although the difference in stroke rates and restenosis between the different groups did not reach statistical significance, patients with normal intraoperative arteriograms initially or after correction of a significant RCA defect had no early carotid occlusion (p = 0.05, Fisher's exact test) compared to patients with residual RCA defects. All early carotid occlusions occurred in patients with unrepaired defects. We conclude that RCA is an important method of quality control after CEA and exerts a subtle, but real, reduction in postoperative complications.