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Diagnostic accuracy of DSA in carotid artery stenosis: a comparison between stenosis measured on carotid endarterectomy specimens and DSA in 644 cases

  • Original Article - Vascular Neurosurgery - Ischemia
  • Published:
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Abstract

Background and purpose

DSA (digital subtraction angiography) is the gold standard for measuring carotid artery stenosis (CS). Yet, the correlation between DSA and stenosis is not well documented.

Material and methods

We compared CS as measured by DSA to carotid artery specimens obtained from carotid endarterectomy surgery. Patients were divided into three groups according to NASCET criteria (North American Symptomatic Carotid Endarterectomy Trial): stenosis of 30–49% (mild), stenosis of 50–69% (moderate), and stenosis of 70–99% (severe).

Results

This prospective cohort study involved 644 patients. The mean stenosis in the mild stenosis group (n = 128 patients) was 54% ECST (European Carotid Surgery Trial), 40% NASCET, and 72% ESs (endarterectomy specimens). The mean absolute difference between ECST and NASCET was 14%. The mean stenosis in the moderate stenosis group (n = 347 patients) was 66% ECST, 60% NASCET, and 77% ES. The mean absolute difference between ECST and NASCET was 6%. The mean stenosis in the severe group (n = 169 patients) was 80% ECST, 76% NASCET, and 79% ES. No significant correlation coefficients were found between DSA and ES methods. In the mild group, the CC was 0.16 (ESCT) and 0.13 (NASCET); in the moderate group, the CC was 0.05 (ESCT) and 0.01 (NASCET); and in the severe group, the CC was 0.23 (ESCT) and 0.10 (NASCET). For all groups combined, CC was 0.22 for the ECST and 0.20 for the NASCET method.

Conclusion

The relationship between DSA and ES methods to measure CS is almost random. This lack of a relationship between the DSA and ES techniques questions the validity of current DSA-based guidelines.

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Funding

The study was supported by Grant No. NV19-04–00270.

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Authors and Affiliations

  1. Department of Neurosurgery and Neurooncology, First Faculty of Medicine, Charles University in Prague and Military University Hospital Prague, U Vojenské nemocnice 1200/2, Prague 6, 16000, Czech Republic

    Norbert Svoboda, Ondrej Bradac, David Netuka & Vladimir Benes

  2. Department of Pathology, Third Faculty of Medicine – Charles University, Prague, Czech Republic

    Vaclav Mandys

Authors
  1. Norbert Svoboda
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  2. Ondrej Bradac
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  3. Vaclav Mandys
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  4. David Netuka
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  5. Vladimir Benes
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Corresponding author

Correspondence to Norbert Svoboda.

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Ethics approval

The study complied with the Helsinki Declaration of 1975 (as revised in 2004 and 2008). Ethics approval was obtained from the local institutional review board. All patients provided written informed consent.

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The authors declare no competing interests.

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Comments

This manuscript shows us, eloquently, that endarterectomy specimens in these authors’ series do not correlate well with DSA measurement findings in CEA patients. It is important work from an experienced and outstanding center, and worthy of our consideration.

The clinical relevance is less compelling now, since as the authors state, MRA, CTA or even DUS (the latter admittedly double-corroborated) have for the most part replaced DSA in their practice.

So we are at first dismayed that something we have believed in for so long may not have been as accurate as we had believed. But we must consider this. The major CEA cooperative trials have shown a benefit for surgery in properly selected cases, always measured with the gold standard of DSA. So even if DSA does not correlate well with ES, evaluation by DSA is still a valid method to improve stroke outcomes in patients. In other words, although DSA might not have been what it seemed, it still worked. Patients have been helped and strokes have been prevented by surgery that was planned with DSA data.

Now I might suggest that this outstanding group keep track of their ongoing ES specimens and compare them to MRA, CTA, or even DUS findings. We will look forward to seeing that data also.

Christopher M. Loftus

Philadelphia, PA, USA

This article is part of the Topical Collection on Vascular Neurosurgery—Ischemia

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Svoboda, N., Bradac, O., Mandys, V. et al. Diagnostic accuracy of DSA in carotid artery stenosis: a comparison between stenosis measured on carotid endarterectomy specimens and DSA in 644 cases. Acta Neurochir 164, 3197–3202 (2022). https://doi.org/10.1007/s00701-022-05332-5

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