Accurate, practical and cost-effective assessment of carotid stenosis in the UK

摘要: Objectives: To determine whether less invasive imaging tests [ultrasound (US), magnetic resonance angiography (MRA), computed tomographic angiography (CTA) and contrast-enhanced MRA (CEMRA)], alone or combined, could replace intra-arterial (IAA), what effect this would have on strokes and deaths, endarterectomies performed costs, whether less tests were cost-effective. Data sources: Electronic databases covering the years 1980–2003 inclusive, updated to April 2004. Key journals from 1990 end of 2002. Review methods: The authors constituted a panel of experts in stroke, imaging, vascular surgery, statistics and health economic modelling. The accuracy less invasive carotid imaging was systematically reviewed using Standards for Reporting Diagnostic Accuracy (STARD) methodology, supplemented by individual patient data UK primary research audit studies. A systematic review costs tests, outpatient clinics, endarterectomy and stroke performed, along with microcosting exercise. model process care following a transient ischaemic attack (TIA)/minor stroke was developed, populated stroke epidemiology studies UK, effects medical and surgical interventions, outcomes, quality life and costs. survey prevention clinics provided typical timings. Twenty-two different carotid imaging strategies evaluated short- longterm outcomes, quality-adjusted life-years (QALYs) and net benefit. Results: In 41 included (2404 patients, median age 60–65 years), most available 70–99% stenosis. CEMRA accurate [sensitivity 0.94, 95% confidence interval (CI) 0.88 0.97; specificity 0.93, CI 0.89 0.96], compared with US, CTA, which all similar (e.g. US: sensitivity 0.89, 0.85 0.92; specificity 0.84, 95% 0.77 0.89). Data 50–69% stenoses and on combinations too sparse be reliable. There heterogeneity between for all modalities except CTA. (2416 patients) showed that literature overestimated test routine practice and that, general, perform higher sensitivity and asymptomatic than symptomatic arteries. In cost-effectiveness model, current UK timings, allowed more patients reach endarterectomy very quickly, where those with 50–69% stenosis be offered surgery addition to 70–99%, prevented and produced greatest net benefit. This most strategies US as first repeat test, not those with IAA. However, sensitive accuracy, cost timing of endarterectomy. investigated late after TIA, test is crucial should used before surgery. Conclusions: can used in place IAA if radiologists trained imaging are available. Imaging carefully audited. Stroke clinics reduce waiting times at endarterectomy. presenting important results should be confirmed CEMRA, 50–69% stenosis are likely More are required define invasive tests, improvements made collection methods used how presented. Consideration also given use new technologies randomised trials.