Diagnostic Testing Guidelines Recommendation

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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)

Diagnostic Testing in Patients With Symptoms or Signs of Extracranial Carotid Artery Disease (DO NOT EDIT)

Class I

"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). (Level of Evidence: C)"

"2. Duplex ultrasonography is recommended to detect carotid stenosis in patients who develop focal neurological symptoms corresponding to the internal carotid artery territory. (Level of Evidence: C)"

"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. (Level of Evidence: C)"

"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. (Level of Evidence: C)"

"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. (Level of Evidence: C)"

Duplex Ultrasonography to Evaluate Asymptomatic Patients With Known or Suspected Carotid Stenosis (DO NOT EDIT)

Class I

"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. (Level of Evidence: C) "

Class III (No Benefit)

"1. Carotid duplex ultrasonography is not recommended for routine screening of asymptomatic patients who have no clinical manifestations of or risk factors for atherosclerosis. (Level of Evidence: C) "

"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 tumors, familial or degenerative cerebral or motor neuron disorders, infectious and inflammatory conditions affecting the brain, psychiatric disorders, or epilepsy. (Level of Evidence: C) "

"3. Routine serial imaging of the extracranial 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. (Level of Evidence: C) "

Class IIa

"1. It is reasonable to perform duplex ultrasonography to detect hemodynamically significant carotid stenosis in asymptomatic patients with carotid bruit. (Level of Evidence: C)"

"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. (Level of Evidence: C)"

Class IIb

"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. (Level of Evidence: C)"

"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. (Level of Evidence: C)"

In revascularization candidates

Class IIa

"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. (Level of Evidence: C) "

"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. (Level of Evidence: C) "

"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. (Level of Evidence: C) "

"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. (Level of Evidence: C) "

"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. (Level of Evidence: C) "

"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. (Level of Evidence: C) "

"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 pacemakers, or other incompatible devices. (Level of Evidence: C) "

Class IIb

"1. Duplex carotid ultrasonography might be considered for patients with nonspecific neurological symptoms when cerebral ischemia is a plausible cause. (Level of Evidence: C) "

"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. (Level of Evidence: C) "

"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. (Level of Evidence: C) "

Carotid Artery Evaluation and Revascularization Before Cardiac Surgery (DO NOT EDIT)

Class IIa

"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. (Level of Evidence: C) "

"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. (Level of Evidence: C) "

Class IIb

"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. (Level of Evidence: C) "

References

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