Background
There is a paucity of literature on the natural history of extracranial carotid artery
occlusion (CAO). This study reviews the natural history of this patient cohort.
Methods
This single-institution retrospective analysis studied patients with CAO diagnosed
by duplex ultrasound between 2010 and 2021. Patients were identified by searching
our office-based Intersocietal Accreditation Commission accredited vascular laboratory
database. Imaging and clinical data were obtained via our institutional electronic
medical record. Outcomes of interest included ipsilateral stroke, attributable neurologic
symptoms, and ipsilateral intervention after diagnosis.
Results
The full duplex database consisted of 5,523 patients who underwent carotid artery
duplex examination during the study period. The CAO cohort consisted of 139 patients;
incidence of CAO was 2.5%. Mean age at diagnosis was 69.7 years; 31.4% were female.
Hypertension (72.7%), hyperlipidemia (64.7%), and prior smoking (43.9%) were the most
common comorbid conditions. Of the CAO cohort, 61.3% (n = 85) of patients were asymptomatic at diagnosis; 38.8% (n = 54) were diagnosed after a stroke or transient ischemic attack occurring within
6 months prior to diagnosis, with 21.6% occurring ipsilateral to the CAO and 10.1%
occurring contralateral to the CAO. 7.2% (n = 10) had unclear symptoms or laterality at presentation. Of the CAO cohort, 95 patients
(68.3%) had duplex imaging follow-up (mean 42.7 ± 31.3 months). Of those with follow-up
studies, 7 patients (5.0%) developed subsequent stroke ipsilateral to the CAO with
mean occurrence 27.8 ± 39.0 months postdiagnosis. In addition, 5 patients (3.6%) developed
other related symptoms, including global hypoperfusion (2.4%) and transient ischemic
attack (1.2%). Of those, 95 patients with follow-up duplex ultrasound imaging, 6 (4.3%)
underwent eventual ipsilateral intervention, including carotid endarterectomy (n = 4), transfemoral carotid artery stent (n = 1), and carotid bypass (n = 1), with mean occurrence 17.7 ± 23.7 months postdiagnosis. The aggregate rate of
ipsilateral cerebrovascular accident, attributable neurologic symptoms, or ipsilateral
intervention was 11.5%. Of 95 patients with follow-up duplex ultrasound imaging, 5
underwent subsequent duplex studies demonstrating ipsilateral patency, resulting in
a 5.3% discrepancy rate between sequential duplex studies. All 6 patients undergoing
intervention received periprocedural cross-sectional imaging (magnetic resonance angiography
or computed tomography angiography). In 5 of these 6 patients, cross-sectional demonstrated
severe stenosis rather than CAO, disputing prior duplex ultrasound findings.
Conclusions
In this large, institutional cohort of patients with a CAO diagnosis on duplex ultrasound,
a clinically meaningful subset of patients experienced cerebrovascular accident, related
symptoms, or intervention. We also found a notable rate of temporal duplex discrepancies
among patients with CAO diagnoses and discrepancies between CAO diagnosis per duplex
ultrasound and findings on cross-sectional imaging for those patients who underwent
intervention. These results suggest that use of a single duplex ultrasound as a sole
diagnostic tool in CAO may not be sufficient and that physicians should consider close
duplex ultrasound surveillance of these patients, potentially in conjunction with
additional confirmatory imaging modalities. Further investigation into optimal workup
and surveillance protocols for CAO is needed.
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Article info
Publication history
Published online: December 24, 2022
Accepted:
November 28,
2022
Received:
August 13,
2022
Footnotes
The first two authors (G.S. and K.H.) shared first authorship.
This work was presented at the Society for Vascular Surgery's Vascular Annual Meeting in Boston, MA, June 15–18 2022.
Conflicts of interest: The authors have no relevant financial relationships to disclose.
Funding sources: No external funding sources were used to design or execute this study.
Author contributions: Shared First Authorship: G.S. and K.H. Study Concept and Design: G.S., K.H., and T.M. Data Collection: G.S., K.H., and R.G. Data Analysis: G.S. and K.H. Manuscript Writing: G.S., K.H., C.R., R.G., M.S., G.J., H.C., K.G., and T.M. Critical Review: G.S., K.H., C.R., R.G., M.S., G.J., H.C., K.G., and T.M. Oversight and Responsibility: T.M.
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