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Common carotid artery peak-systolic velocity ratio predicts high-grade common carotid stenosis
George T. Pisimisis, MD1, Dimitrios Katsavelis, PhD2, Carlos F. Bechara, MD, MS1, Neal R. Barshes, MD, MPH1, Panagiotis Kougias, MD1.
1Baylor College of Medicine, Houston, TX, USA, 2Creighton University School of Health Professions, Omaha, NE, USA.

OBJECTIVES: Screening for common carotid artery (CCA) stenosis with duplex ultrasound (DUS) velocity criteria alone, can be limited due to within-patient and between-patients hemodynamic variability. This study aims to evaluate inter-CCA velocity ratio criteria to predict high-grade CCA stenosis. METHODS: Retrospective review of consecutive patients who underwent computed tomography angiography (CTA) and DUS peak-systolic velocity (PSV) measurements of bilateral CCA, independently recorded, between 2008-2014. Patients with dampened CCA waveforms on DUS, readily indicating high-grade proximal stenosis, consisted group B. The remainder without dampened waveforms constituted group A. Inter-CCA PSV-ratios were calculated by dividing the higher CCA PSV to the lower one of the other side, so the ratios would always be >1. Ratios were subsequently paired with each respective unilateral CCA diameter stenosis (uDS) and differential bilateral CCA diameter stenosis (dDS). A quadratic regression model was fitted to predict uDS and dDS. Receiver operating characteristic (ROC) curve was used to determine optimal ratios for ≥50% CCA stenosis. The study excluded patients with carotid artery occlusion. RESULTS: From total 174 patients, 167 patients were included in group A and 7 in group B. In group A, 31 patients had ≥50% uDS and seventeen ≥50% dDS. All stenoses ≥50% were identified on the same side with the higher PSV. Inter-CCA PSV-ratio predicted ≥50% uDS (r2=0.57, P<.0001) and dDS (r2=0.75, P<0.0001). In group B, all patients had ≥60% stenosis that involved the vessel origin. An increasing inter-CCA PSV-ratio showed a trend towards contralateral high-grade stenosis (r2=0.54, P=0.06). ROC curves for ≥50% uDS showed optimal threshold CCA ratio ≥1.96 with 93% accuracy, 75% sensitivity and 97% specificity (area under curve= 0.857; 95% CI, 0.755-.958) and for ≥50% dDS ratio ≥2.62 with 97% accuracy, 82% sensitivity and 99% specificity (area under curve= 0.938; 95% CI, 0.828-1).
CONCLUSIONS: Duplex ultrasound based common carotid peak-systolic velocity ratio can accurately predict unilateral and differential high-grade common carotid stenosis. Also, in patients with dampened waveforms it implied contralateral severe proximal stenosis. This parameter should be further validated in prospective studies and is a promising adjunct screening tool to detect high-grade common carotid stenosis.

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