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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.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 IAC 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.The full duplex database consisted of 5523 patients who underwent carotid artery duplex exam 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 (TIA) occurring within six 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, ninety-five patients (68.3%) had duplex imaging follow-up (mean 42.7±31.3 months). Of those with follow up studies, seven patients (5.0%) developed subsequent stroke ipsilateral to the CAO with mean occurrence 27.8 ±39.0 months post-diagnosis. In addition, five patients (3.6%) developed other related symptoms, including global hypoperfusion, (2.4%) and TIA (1.2%). Of those 95 patients with follow up duplex ultrasound imaging, six (4.3%) underwent eventual ipsilateral intervention, including CEA (n=4), TF-CAS (n=1), and carotid bypass (n=1), with mean occurrence 17.7±23.7 months post-diagnosis. The aggregate rate of ipsilateral CVA, 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 (MRA or CTA). In 5 of these 6 patients, cross-sectional demonstrated severe stenosis rather than CAO, disputing prior duplex ultrasound findings.In this large, institutional cohort of patients with a CAO diagnosis on duplex ultrasound, a clinically meaningful subset of patients experienced CVA, 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. |
