AbuRahma Ali F, Abu-Halimah Shadi, Bensenhaver Jessica, Dean L Scott, Keiffer Tammi, Emmett Mary, Flaherty Sarah
Department of Surgery, Robert C Byrd Health Sciences Center, West Virginia University, Charleston, WV 25304, USA.
J Vasc Surg. 2008 Sep;48(3):589-94. doi: 10.1016/j.jvs.2008.04.004. Epub 2008 Jun 30.
The optimal duplex ultrasound (DUS) velocity criteria to determine in-stent carotid restenosis are controversial. We previously reported the optimal DUS velocities for >or=30% in-stent restenosis. This prospective study will further define the optimal velocities in detecting various severities of in-stent restenosis: >or=30%, >or=50%, and 80% to 99%.
The analysis included 144 patients who underwent carotid artery stenting as a part of clinical trials. All patients had completion arteriograms and underwent postoperative carotid DUS imaging, which was repeated at 1 month and every 6 months thereafter. Patients with peak systolic velocities (PSVs) of the internal carotid artery (ICA) of >or=130 cm/s underwent carotid computed tomography (CT)/angiogram. The PSVs and end-diastolic velocities of the ICA and common carotid artery (CCA) and the PSV of the ICA/CCA ratios were recorded. Receiver operating characteristic curve (ROC) analysis was used to determine the optimal velocity criteria for the diagnosis of >or=30, >or=50, and >or=80% restenosis.
The mean follow-up was 20 months (range, 1-78 months). Available for analysis were 215 pairs of imaging (DUS vs CTA/angiography) studies. The accuracy of CTA vs carotid arteriogram was confirmed in a subset of 22 patients (kappa = 0.81). The ROC analysis demonstrated that an ICA PSV of >or=154 cm/s was optimal for >or=30% stenosis with a sensitivity of 99%, specificity of 89%, positive-predictive value (PPV) of 96%, negative-predictive value (NPV) of 97%, and overall accuracy (OA) of 96%. An ICA EDV of 42 cm/s had sensitivity, specificity, PPV, NPV, and OA in detecting >or=30% stenosis of 86%, 62%, 87%, 60%, and 80%, respectively. An ICA PSV of >or=224 cm/s was optimal for >50% stenosis with a sensitivity of 99%, specificity of 90%, PPV of 99%, NPV of 90%, and OA of 98%. An ICA EDV of 88 cm/s had sensitivity, specificity, PPV, NPV, and OA in detecting >or=50% stenosis of 96%, 100%, 100%, 100%, 53%, and 96%. An ICA/CCA ratio of 3.439 had sensitivity, specificity, PPV, NPV, and OA in detecting >or=50% stenosis of 96%, 100%, 100%, 100%, 58%, and 96%, respectively. An ICA PSV of >or=325 cm/s was optimal for >80% stenosis with a sensitivity of 100%, specificity of 99%, PPV of 100%, NPV of 88%, and OA of 99%. An ICA EDV of 119 cm/sec had sensitivity, specificity, PPV, NPV, and OA in detecting >or=80% stenosis of 99%, 100%, 100%, 100%, 75%, and 99%, respectively. The PSV of the stented artery was a better predictor for in-stent restenosis than the end-diastolic velocity or ICA/CCA ratio.
The optimal DUS velocity criteria for in-stent restenosis of >or=30%, >or=50%, and >or=80% were the PSVs of 154, 224, and 325 cm/s, respectively.
用于确定支架内颈动脉再狭窄的最佳双功超声（DUS）速度标准存在争议。我们之前报道了支架内再狭窄≥30%时的最佳DUS速度。这项前瞻性研究将进一步明确检测不同严重程度支架内再狭窄（≥30%、≥50%以及80%至99%）时的最佳速度。
分析纳入了144例作为临床试验一部分接受颈动脉支架置入术的患者。所有患者均完成了动脉造影，并在术后接受颈动脉DUS成像，术后1个月及之后每6个月重复检查。颈内动脉（ICA）收缩期峰值速度（PSV）≥130 cm/s的患者接受颈动脉计算机断层扫描（CT）/血管造影。记录ICA和颈总动脉（CCA）的PSV、舒张末期速度以及ICA/CCA比值的PSV。采用受试者操作特征曲线（ROC）分析来确定诊断≥30%、≥50%和≥80%再狭窄的最佳速度标准。
平均随访时间为20个月（范围1 - 78个月）。可供分析的有215对成像（DUS与CTA/血管造影）研究。在22例患者的亚组中证实了CTA与颈动脉造影的准确性（kappa = 0.81）。ROC分析表明，ICA PSV≥154 cm/s对≥30%狭窄最为理想，敏感性为99%，特异性为89%，阳性预测值（PPV）为96%，阴性预测值（NPV）为97%，总体准确性（OA）为96%。ICA舒张末期速度（EDV）为42 cm/s时，检测≥30%狭窄的敏感性、特异性、PPV、NPV和OA分别为86%、62%、87%、60%和80%。ICA PSV≥224 cm/s对＞50%狭窄最为理想，敏感性为99%，特异性为90%，PPV为99%，NPV为90%，OA为98%。ICA EDV为88 cm/s时，检测≥50%狭窄的敏感性、特异性、PPV、NPV和OA分别为96%、100%、100%、100%、53%和96%。ICA/CCA比值为3.439时，检测≥50%狭窄的敏感性、特异性、PPV、NPV和OA分别为96%、100%、100%、100%、58%和96%。ICA PSV≥325 cm/s对＞80%狭窄最为理想，敏感性为100%，特异性为99%，PPV为100%，NPV为88%，OA为99%。ICA EDV为119 cm/sec时，检测≥80%狭窄的敏感性、特异性、PPV、NPV和OA分别为99%、100%、100%、100%、75%和99%。与舒张末期速度或ICA/CCA比值相比，支架置入动脉的PSV是支架内再狭窄更好的预测指标。
支架内再狭窄≥30%、≥50%和≥80%时的最佳DUS速度标准分别为PSV 154、224和325 cm/s。
