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Multicenter Study
. 2021 Oct;26(5):515-525.
doi: 10.1177/1358863X211011253. Epub 2021 May 19.

Optimization of duplex velocity criteria for diagnosis of internal carotid artery (ICA) stenosis: A report of the Intersocietal Accreditation Commission (IAC) Vascular Testing Division Carotid Diagnostic Criteria Committee

Heather L Gornik  1 , Tatjana Rundek  2 , Hannah Gardener  2 , James F Benenati  3 , Nirvikar Dahiya  4 , Naomi M Hamburg  5 , Ann Marie Kupinski  6   7 , Steven A Leers  8 , Michael P Lilly  9 , Joann M Lohr  10 , John S Pellerito  11 , Kenneth S Rholl  12 , Melissa A Vickery  13 , Marge S Hutchisson  14 , Laurence Needleman  15
Affiliations
Multicenter Study

Optimization of duplex velocity criteria for diagnosis of internal carotid artery (ICA) stenosis: A report of the Intersocietal Accreditation Commission (IAC) Vascular Testing Division Carotid Diagnostic Criteria Committee

Heather L Gornik et al. Vasc Med. 2021 Oct.

Abstract

Diagnostic criteria to classify severity of internal carotid artery (ICA) stenosis vary across vascular laboratories. Consensus-based criteria, proposed by the Society of Radiologists in Ultrasound in 2003 (SRUCC), have been broadly implemented but have not been adequately validated. We conducted a multicentered, retrospective correlative imaging study of duplex ultrasound versus catheter angiography for evaluation of severity of ICA stenosis. Velocity data were abstracted from bilateral duplex studies performed between 1/1/2009 and 12/31/2015 and studies were interpreted using SRUCC. Percentage ICA stenosis was determined using North American Symptomatic Carotid Endarterectomy Trial (NASCET) methodology. Receiver operating characteristic analysis evaluated the performance of SRUCC parameters compared with angiography. Of 448 ICA sides (from 224 patients), 299 ICA sides (from 167 patients) were included. Agreement between duplex ultrasound and angiography was moderate (κ = 0.42), with overestimation of degree of stenosis for both moderate (50-69%) and severe (⩾ 70%) ICA lesions. The primary SRUCC parameter for ⩾ 50% ICA stenosis of peak-systolic velocity (PSV) of ⩾ 125 cm/sec did not meet prespecified thresholds for adequate sensitivity, specificity, and accuracy (sensitivity 97.8%, specificity 64.2%, accuracy 74.5%). Test performance was improved by raising the PSV threshold to ⩾ 180 cm/sec (sensitivity 93.3%, specificity 81.6%, accuracy 85.2%) or by adding the additional parameter of ICA/common carotid artery (CCA) PSV ratio ⩾ 2.0 (sensitivity 94.3%, specificity 84.3%, accuracy 87.4%). For ⩾ 70% ICA stenosis, analysis was limited by a low number of cases with angiographically severe disease. Interpretation of carotid duplex examinations using SRUCC resulted in significant overestimation of severity of ICA stenosis when compared with angiography; raising the PSV threshold for ⩾ 50% ICA stenosis to ⩾ 180 cm/sec as a single parameter or requiring the ICA/CCA PSV ratio ⩾ 2.0 in addition to PSV of ⩾ 125 cm/sec for laboratories using the SRUCC is recommended to improve the accuracy of carotid duplex examinations.

Keywords: carotid artery disease; carotid duplex ultrasound; diagnostic criteria; vascular imaging/diagnostics.

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Conflict of interest statement

Declaration of conflicting interests: The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: JF Benenati, N Dahiya, HL Gornik, NM Hamburg, AM Kupinski, SA Leers, MP Lilly, JM Lohr, JS Pellerito, KS Rholl, T Rundek, MA Vickery, and L Needleman are current or former members of the Board of Directors of the IAC Vascular Testing Division and served in a voluntary capacity. MP Lilly and MA Vickery have served on the Board of Directors of the IAC. AM Kupinski has served as an application reviewer for IAC Vascular Testing. MS Hutchisson is a paid employee of the IAC. H Gardener is a paid statistical consultant of the IAC. JF Benenati is an employee of Penumbra.

Figures

Figure 1.
Figure 1.
Case study flow diagram. CEA, carotid endarterectomy; IAC, Intersocietal Accreditation Commission; ICA, internal carotid artery.
See this image and copyright information in PMC

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