Corotid endarterectomy for symptomatic carotid artery disease demonstrated by duplex ultrasound with minimal arteriographic findings.

Ulcerated or irregular heterogeneous carotid plaque as seen by duplex ultrasound can cause hemispheric transient ischemic attacks (TIAs) and/or a cerebrovascular accident, even if only associated with nonsignificant carotid stenosis on arteriography. The purpose of this study was to review our experience in patients who underwent a carotid endarterectomy after medical treatment had failed, based on pathologic findings detected by carotid duplex ultrasound with minimal disease on arteriography. The medical records of 14 patients who underwent carotid endarterectomy for TIA symptoms related to ulcerated or irregular heterogeneous plaques were analyzed. All had had preoperative carotid duplex ultrasound, arteriography, and cardiac and neurologic workups to rule out other causes for their TIAs. Medical treatment had failed in all of them. There were 10 men and four women whose median age was 68 years. Carotid duplex ultrasound showed irregular heterogeneous carotid plaque in all patients associated with 20% to 50% stenosis in 12 and approximately 50% to 60% stenosis in two. All had normal to < 20% stenosis on arteriograms. The duplex ultrasound findings were all confirmed at operation. All had an uneventful postoperative course with relief of symptoms. Carotid duplex ultrasound is superior to carotid arteriography in detecting irregular or ulcerative heterogeneous plaque associated with nonsignificant stenosis. Carotid duplex ultrasound can be used to determine the desirability of carotid endarterectomy after failed medical treatment in patients with classical and persistent TIA symptoms despite normal or minimal disease on arteriograms. A successful endarterectomy appears to predict an asymptomatic postoperative course.