Association of Completion Imaging Modalities and Carotid Endarterectomy Outcomes in the Vascular Quality Initiative.

Objective

Completion imaging after carotid endarterectomy (CEA) confirms technical success and identifies defects requiring correction. However, the comparative effectiveness of imaging modalities in detecting clinically significant problems remains unclear. This study evaluated completion imaging patterns, intraoperative re-exploration as a surrogate for detection efficacy, and associated postoperative outcomes.

Methods

CEAs performed between 2012-2024 in the VQI were analyzed. Completion imaging was categorized as none, Doppler, duplex ultrasound, or angiography. Intraoperative re-exploration rates were compared across modalities to assess detection of technical defects requiring revision. Postoperative outcomes were analyzed among patients who required re-exploration. Inverse probability weighted (IPW) logistic regression estimated adjusted odds ratios. Temporal trends were also analyzed.

Results

Among 208,786 CEAs, 24% had no completion imaging, 48% used Doppler, 24% duplex, and 4% angiography. Angiography had the highest intraoperative re-exploration rate (none 0.9%, doppler 0.9%, duplex 2.3%, angiography 3.6%; p<0.001). Among the 2,723 patients who required re-exploration, postoperative stroke occurred in 8.3% with no imaging, 12.5% with doppler, 3.7% with duplex, and 22.5% with angiography (p<0.001). In IPW-adjusted analyses, intraoperative duplex was associated with significant reduction in postoperative stroke compared to: no imaging (aOR 0.43, 95%CI 0.27-0.69), doppler (aOR 0.28, 95%CI 0.19-0.40), and angiography (aOR 0.13, 95%CI 0.09-0.20), all p<0.001. Overall, Angiography had the worst stroke outcomes. Doppler and angiography performed worse than duplex across additional endpoints, including ipsilateral stroke, TIA, any neurological event, return to OR, and 30-day mortality. Despite the stronger safety profile of duplex, it remains underused, as most CEAs performed in the last 15 years have utilized doppler or no imaging.

Conclusions

Re-exploration and stroke outcomes after completion imaging reflect each modality's safety and efficacy in detecting significant technical defects. Duplex ultrasound demonstrated the lowest stroke rates and overall complications compared with angiography, doppler, and no imaging, suggesting its superior efficacy and safety. Doppler showed intermediate performance, while angiography carried the highest risk among patients who required re-exploration. Despite strong evidence favoring duplex, the majority of surgeons performing CEAs still rely on doppler or omit any completion imaging. Greater use of duplex ultrasound and incorporation of intraoperative duplex assessment into vascular training may improve intraoperative assessment, although further prospective evaluation is warranted.