Optimizing care for patients with symptomatic carotid disease

Abstract

The first part of this thesis reviews new developments in medical and invasive treatment options in patients with symptomatic carotid disease. Improvements in medical treatment have led to a decline in annual stroke risk, affecting the indication for carotid endarterectomy (CEA). CEA is further challenged by the introduction of carotid angioplasty and stenting. However, CEA continues being the golden standard. These developments necessitate proper patient selection. A potential further role for duplex ultrasound in improving patient selection was subsequently investigated. Its role seems however to be limited in the event of the presence bilateral significant carotid stenosis, when the degree of stenosis may erroneously be estimated too high. Also, the gray-scale median, a quantification method of plaque echolucency which theoretically might indicate plaques prone for rupture and embolisation, could not be validated as predictor for plaque vulnerability. In order to optimize the care chain and, consequently, patient outcome, the clinical treatment course of these patients was analysed. Its durations showed to be significantly shortened over the past decade, however, improvements can be made in those patients who had been externally referred. In the era of centralization, this issue might be of importance. Health care costs rise uncontrollably while resources are constrained by budget cuts. The last chapter provides an insight into the structure of costs made during admission for CEA and studies the cost-effectiveness of two different intraoperative neuromonitoring modalities in order to seek a possibility to reduce costs and re-allocate resources to those patients who need them most