View source for Duplex Ultrasonography to Evaluate Asymptomatic Patients With Known or Suspected Carotid Stenosis

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{{Carotid artery stenosis}}
{{CMG}}

==Diagnostic Testing Guidelines==
===2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease (DO NOT EDIT)<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 | pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505  }} </ref>===
====Diagnostic Testing in Patients With Symptoms or Signs of Extracranial Carotid Artery Disease (DO NOT EDIT)<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 | pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505  }} </ref>====
{|class="wikitable"
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' The initial evaluation of patients with transient retinal or hemispheric neurological symptoms of possible [[ischemic]] origin should include noninvasive imaging for the detection of ECVD (Extracranial Carotid and [[Vertebral artery disease]]). ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Duplex [[ultrasonography]] is recommended to detect [[carotid stenosis]] in patients who develop focal [[neurological]] symptoms corresponding to the [[internal carotid artery]] territory. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' In patients with acute, focal [[ischemic]] [[neurological]] symptoms corresponding to the territory supplied by the left or right [[internal carotid artery]], [[magnetic resonance angiography]] ([[MRA]]) or [[computed tomography angiography]] ([[CTA]]) is indicated to detect carotid stenosis when definitive [[sonography]] cannot be obtained. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' When extracranial or intracranial [[cerebrovascular disease]] is not severe enough to account for neurological symptoms of suspected ischemic origin, [[echocardiography]] should be performed seeking a source of cardiogenic [[embolism]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''5.''' Correlation of findings obtained by several carotid imaging modalities should be part of a program of quality assurance in each laboratory that performs such diagnostic testing. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}

====Duplex Ultrasonography to Evaluate Asymptomatic Patients With Known or Suspected Carotid Stenosis (DO NOT EDIT)<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 | pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505  }} </ref>====

{|class="wikitable"
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]

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| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In asymptomatic patients with known or suspected [[carotid stenosis]], [[duplex ultrasonography]], performed by a qualified technologist in a certified laboratory, is recommended as the initial test to detect [[hemodynamically]] significant carotid stenosis. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}

{|class="wikitable"
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|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)

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|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Carotid duplex [[ultrasonography]] is not recommended for routine screening of asymptomatic patients who have no clinical manifestations of or risk factors for [[atherosclerosis]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>

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|bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' Carotid [[duplex ultrasonography]] is not recommended for routine evaluation of patients with neurological or [[psychiatric disorders]] unrelated to focal [[cerebral ischemia]], such as [[brain tumor]]s, familial or degenerative cerebral or [[motor neuron disorders]], infectious and inflammatory conditions affecting the brain, psychiatric disorders, or [[epilepsy]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>

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|bgcolor="LightCoral"|<nowiki>"</nowiki>'''3.''' Routine serial imaging of the extracranial [[carotid artery|carotid arteries]] is not recommended for patients who have no risk factors for development of [[atherosclerotic]] carotid disease and no disease evident on initial vascular testing. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
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{|class="wikitable"
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' It is reasonable to perform [[duplex ultrasound|duplex ultrasonography]] to detect hemodynamically significant carotid stenosis in asymptomatic patients with [[carotid bruit]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>

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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' It is reasonable to repeat duplex ultrasonography annually by a qualified technologist in a certified laboratory to assess the progression or regression of disease and response to [[therapeutic]] interventions in patients with [[atherosclerosis]] who have had stenosis greater than 50% detected previously. Once stability has been established over an extended period or the patient’s candidacy for further intervention has changed, longer intervals or termination of surveillance may be appropriate. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
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{|class="wikitable"
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]

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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Duplex ultrasonography]] to detect [[hemodynamically]] significant carotid stenosis may be considered in asymptomatic patients with symptomatic [[PAD]], [[coronary artery disease]] ([[CAD]]), or [[atherosclerotic]] [[aortic aneurysm]], but because such patients already have an indication for medical therapy to prevent ischemic symptoms, it is unclear whether establishing the additional diagnosis of ECVD in those without [[carotid bruit]] would justify actions that affect clinical outcomes. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>

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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Duplex ultrasonography might be considered to detect carotid stenosis in asymptomatic patients without clinical evidence of [[atherosclerosis]] who have 2 or more of the following risk factors: [[hypertension]], [[hyperlipidemia]], tobacco [[smoking]], a family history in a first degree relative of atherosclerosis manifested before age 60 years, or a family history of [[ischemic stroke]]. However, it is unclear whether establishing a diagnosis of ECVD would justify actions that affect clinical outcomes. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
====In revascularization candidates====

{|class="wikitable"
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' When an extracranial source of [[ischemia]] is not identified in patients with transient retinal or hemispheric neurological symptoms of suspected ischemic origin, [[CTA]], [[MRA]], or selective [[cerebral angiography]] can be useful to search for intracranial [[vascular disease]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' When the results of initial noninvasive imaging are inconclusive, additional examination by use of another imaging method is reasonable. In candidates for [[revascularization]], [[MRA]] or [[CTA]] can be useful when results of carotid duplex  [[ultrasonography]] are equivocal or indeterminate. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' When intervention for significant carotid stenosis detected by carotid duplex [[ultrasonography]] is planned, MRA, CTA, or catheter-based [[contrast]] [[angiography]] can be useful to evaluate the severity of stenosis and to identify intrathoracic or intracranial vascular lesions that are not adequately assessed by duplex ultrasonography. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''4.''' When noninvasive imaging is inconclusive or not feasible because of technical limitations  or contraindications in patients with transient retinal or hemispheric neurological symptoms of suspected [[ischemic]] origin, or when noninvasive imaging studies yield discordant results, it is reasonable to perform [[catheter]]-based contrast [[angiography]] to detect and characterize extracranial and/or intracranial [[cerebrovascular disease]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''5.''' [[MRA]] without contrast is reasonable to assess the extent of disease in patients with  symptomatic carotid [[atherosclerosis]] and [[renal insufficiency]] or extensive vascular [[calcification]].  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''6.''' It is reasonable to use [[magnetic resonance imaging]] ([[MRI]]) systems capable of consistently generating high-quality images while avoiding low-field systems that do not yield diagnostically accurate results. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''7.''' [[CTA]] is reasonable for evaluation of patients with clinically suspected significant carotid [[atherosclerosis]] who are not suitable candidates for [[MRA]] because of [[claustrophobia]], implanted [[pacemaker]]s, or other incompatible devices. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> 
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{|class="wikitable"
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Duplex carotid [[ultrasonography]] might be considered for patients with nonspecific neurological symptoms when [[cerebral ischemia]] is a plausible cause. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' When complete carotid arterial occlusion is suggested by duplex ultrasonography, [[MRA]], or [[CTA]] in patients with retinal or hemispheric neurological symptoms of suspected ischemic origin, [[catheter]]-based [[contrast]] [[angiography]] may be considered to determine whether the arterial lumen is sufficiently patent to permit carotid [[revascularization]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[Catheter]]-based [[angiography]] may be reasonable in patients with [[renal dysfunction]] to limit the amount of [[radiographic]] [[contrast]]  material required for definitive imaging for evaluation of a single vascular territory. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}

====Carotid Artery Evaluation and Revascularization Before Cardiac Surgery (DO NOT EDIT)<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 | pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505  }} </ref>====

{|class="wikitable"
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]

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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' Carotid duplex [[ultrasound]] screening is reasonable before elective [[coronary artery bypass graft]] (CABG) surgery in patients older than 65 years of age and in those with [[left main coronary artery]] stenosis, [[PAD]], a history of cigarette smoking, a history of [[stroke]] or [[TIA]], or [[carotid bruit]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>

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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' Carotid [[revascularization]] by CEA or CAS with [[embolic]] protection before or concurrent with myocardial [[revascularization]] surgery is reasonable in patients with greater than 80% carotid stenosis who have experienced ipsilateral retinal or hemispheric [[cerebral]] [[ischemic]] symptoms within 6 months. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
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{|class="wikitable"
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]

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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with asymptomatic carotid stenosis, even if severe, the safety and efficacy of carotid revascularization before or concurrent with myocardial [[revascularization]] are not well established. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki>
|}