Colour-coded duplex imaging can safely replace diagnostic arteriography in patients with lower-limb arterial disease

Predictive value of lower extremity color doppler ultrasonography before knee arthroplasty on a postoperative cardiovascular event

BACKGROUND

The study intended to determine the presence of lower limb arterial calcification (LLAC) in lower extremity color Doppler ultrasonography (CDUS) before primary total knee arthroplasty (TKA) and its relation with cardiovascular events (CVE) during knee arthroplasty and the postoperative period, as well as to investigate its effect on surgical risk estimation.

METHODS

We designed this study as a retrospective cohort study. The study comprised 467 patients who met the inclusion criteria and had surgery for a primary gonarthrosis diagnosis between January 2005 and December 2015 were included. In the study group, patients with arterial calcification in the lower extremity CDUS were included; however, those reported not to have it were included in the control group. The research data were obtained from preoperative anesthesia records and patient medical records.

RESULTS

72% of the sample had preoperative cardiovascular comorbidity. There was no difference between the groups in terms of comorbidities, except for congestive heart failure (CHF) and peripheral artery disease (PAD). The groups did not differ in terms of ASA scores, either. Both pre- and post-operative CVEs, i.e., ischemic heart disease, dysrhythmia, and CHF, were statistically high in the study group. In terms of postoperative mortality, there was no statistical difference between the groups.

CONCLUSION

The study demonstrates that the presence of LLAC in CDUS is associated with increased risk of perioperative cardiovascular events (CVEs). Ultrasonographic detection of LLAC may give some idea the surgeon about the requirement for additional preoperative cardiac examinations.

Color-Flow Duplex Hemodynamic Assessment of Runoff in Ischemic Lower Limb Revascularization

The objective of this study was to evaluate the existence of hemodynamic arterial flow correlation between preoperative duplex scanning (DS) and intraoperative direct outflow resistance (IDOR) measurements in ischemic lower limb revascularization.

Sixty-eight ischemic lower limbs were submitted to preoperative DS. Anatomic and hemodynamic arterial characteristics of the outflow system were recorded, and the results were considered in the distal anastomosis placement site decision making. IDOR measurements were obtained at the same arterial segment, and Pearson's correlation coefficient test was performed to study the preoperative DS power in predicting the intraoperative outflow resistance.

DS was technically satisfactory and helped define the distal anastomosis site in 93.2% of the cases (supragenicular popliteal artery, 19 [27.9%]; infragenicular popliteal artery, 10 [14.7%]; crural artery, 31 [57.4%]). A positive correlation could be found between preoperative DS and IDOR (0.450; p < .001). This correlation was particularly powerful in the crural artery (0.715; p < .001) when compared with the popliteal arterial segment (0.237; p = .192).

Preoperative DS may help define the best distal arterial and outflow segment to be revascularized based on anatomic and hemodynamic parameters. There is a positive flow correlation between preoperative DS and IDOR that seems to be stronger in crural revascularization surgery.

Role of contrast-enhanced ultrasound arterial mapping in surgical planning for patients with critical limb ischemia

The goal of the study described here was to evaluate the role of contrast-enhanced ultrasound (CEUS) arterial mapping in surgical planning in cases of critical limb ischemia. From March 2007 to December 2012, 565 consecutive patients with critical limb ischemia of the lower limbs were treated and initially examined with only ultrasound (US) arterial mapping. For 479 of the 565 patients, basic US examination results were deemed sufficient for surgical planning (group A). That is, US examination provided sufficient information to decide a surgical plan to treat those patients. In the remaining 86 patients, basic US examination was insufficient for revascularization planning, and CEUS examination was performed (group B). In 5 cases, CEUS results were also insufficient for surgical planning, as a suitable outflow vessel was not visualized. In these cases, a pre-operative arteriogram was performed. To assess the usefulness of CEUS, we compared results of examinations with and without contrast administration, surgical findings and angiographic findings when available. Data were collected prospectively. Examinations were compared by establishing the degree of agreement between results of paired examinations and degree of agreement between CEUS results and surgical findings. Clinical, hemodynamic (ankle-brachial index) and duplex follow-up was performed at 1 and 3 mo to evaluate cumulative patency of the procedures in each group. Within group B, degree of agreement between basic US and CEUS was 46.5%. CEUS resulted in a change in the surgical plan in 46 of 86 patients. Among all 565 patients, degree of agreement between surgical decision based on basic ultrasound arterial mapping and final decision based on surgical findings was 87.1%, and improved to 95.2% with CEUS (p = 0.00001, κ index = 0.823). Degree of agreement between the ultrasound-based decision and surgical findings was 97.5% in group A (κ index = 0.818) and 94.2% in group B (κ = 0.848). There was no significant difference between groups (p = 0.784). Within group B, of the five arteriograms performed, results of only one matched well the US mapping findings. Vessel patency at 1 and 3 mo did not significantly differ between patients whose surgical planning was based on basic US and patients whose planning was based on CEUS (p = 0.418 and p = 0.489, respectively). US arterial mapping is an excellent tool for surgical planning in critical limb ischemia. CEUS arterial mapping improves the accuracy of ultrasound examination in patients with critical limb ischemia, especially in patients with inconclusive non-enhanced exams.

Estudo comparativo de eco-Doppler com arteriografia na avaliação da doença oclusiva aorto-ilíaca

Contexto: A arteriografia com contraste (AC) tem sido o exame tradicional de avaliação de pacientes com suspeita de doença oclusiva aorto-ilíaca (DOAI). Recentemente, métodos menos invasivos, como a eco-Doppler, têm sido usados com a mesma finalidade. Objetivo: Comparar prospectivamente a eco-Doppler com a AC e eventual manometria arterial direta (MAD) na avaliação pré-operatória de pacientes com suspeita de DOAI. Métodos: Foram submetidos a eco-Doppler e a AC 125 pacientes internados para tratamento de doença arterial oclusiva dos membros inferiores, avaliando comparativamente 552 segmentos da aorta infrarrenal e das artérias ilíacas comum e externa. As lesões encontradas foram classificadas em cinco categorias: 1) normal e estenose leve (0 a 19%); 2) estenose moderada (20 a 49%); 3) estenose significativa (50 a 79%); 4) estenose crítica (80 a 99%); e 5) oclusão total. A MAD foi usada em 19 segmentos de 15 pacientes para classificar lesões limítrofes entre duas categorias. Foram calculados índices de validade (sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e acurácia) para distinguir lesões hemodinamicamente significativas de não-significativas e para distinguir estenoses críticas de oclusões. O padrão-ouro foi AC, complementado pela MAD. Foram também calculados coeficientes de correlação kappa entre arteriografias e eco-Doppler para o conjunto dos segmentos aorto-ilíacos. Resultados: Lesões clinicamente relevantes (estenoses de 50 a 99% e oclusões totais) foram observadas na eco-Doppler em 163 segmentos (29,5%) e na AC em 158 segmentos (28,6%). A eco-Doppler mostrou altos índices de validade para distinguir lesões hemodinamicamente significativas de lesões não-significativas em todos os segmentos (acurácia = 92%; kappa = 0,81) e para diferenciar estenoses críticas de oclusões (acurácia = 86%; kappa = 0,73). Os índices de correlação entre os resultados das eco-Doppler e das AC foram ótimos em todos os segmentos aorto-ilíacos. Conclusão: A eco-Doppler apresenta elevados índices de validade e ótimos coeficientes de correlação com a AC na avaliação de pacientes com suspeita de DOAI.

Analysis of agreement between Duplex ultrasound scanning and arteriography in patients with lower limb artery disease

BACKGROUND

Angiography is the gold standard for therapeutic decision-making in lower limb artery disease. However, both the potentiality and safety of Duplex ultrasound scanning suggest that it may become the main diagnostic tool. The present study aimed to investigate the agreement between Duplex scanning and angiography in the diagnosis of stenosis in lower limb artery disease.

METHODS

Forty-nine patients with lower limb artery disease (24 claudication, 12 critical ischemia, 13 skin lesions) underwent angiography and Duplex scanning. The lower limb arterial axis was divided into 15 segments and graded on the basis of the degree of stenosis (0-49%, 50-69%, 70-99% and occlusion). Agreement between angiography and Duplex scanning was assessed by Cohen's kappa statistics (kappa). The sensitivity and specificity of Duplex scanning in detecting significant stenosis at angiography (>/= 70%) were also calculated.

RESULTS

Good diagnostic agreement (kappa = 0.70; 95% CI 0.588-0.825) was achieved in the whole arterial axis. Agreement was good for the aorto-iliac district (kappa = 0.63) with a sensitivity of 63% and a specificity of 96%, and for the femoro-popliteal district (kappa = 0.70) with a sensitivity of 74% and a specificity of 83%. In infrapopliteal arteries, kappa showed a poor agreement, but Duplex scanning detected 28 patent tibial arteries in limbs that were not opacified on arteriography.

CONCLUSIONS

Duplex scanning shows good agreement with angiography in lower limb artery disease on the whole, but poor agreement in infrapopliteal districts, with a low sensitivity and high specificity in detecting significant stenoses or occlusions.

A modified calculation of ankle-brachial pressure index is far more sensitive in the detection of peripheral arterial disease

BACKGROUND

Ankle-brachial pressure index (ABI) is a simple, inexpensive, and useful tool in the detection of peripheral arterial occlusive disease (PAD). The current guidelines published by the American Heart Association define ABI as the quotient of the higher of the systolic blood pressures (SBPs) of the two ankle arteries of that limb (either the anterior tibial artery or the posterior tibial artery) and the higher of the two brachial SBPs of the upper limbs. We hypothesized that considering the lower of the two ankle arterial SBPs of a side as the numerator and the higher of the brachial SBPs as the denominator would increase its diagnostic yield.

METHODS

The former method of eliciting ABI was termed as high ankle pressure (HAP) and the latter low ankle pressure (LAP). ABI was assessed in 216 subjects and calculated according to the HAP and the LAP method. ABI findings were confirmed by arterial duplex ultrasonography. A significant arterial stenosis was assumed if ABI was <0.9.

RESULTS

LAP had a sensitivity of 0.89 and a specificity of 0.93. The HAP method had a sensitivity of 0.68 and a specificity of 0.99. McNemar's test to compare the results of both methods demonstrated a two-tailed P < .0001, indicating a highly significant difference between both measurement methods.

CONCLUSIONS

LAP is the superior method of calculating ABI to identify PAD. This result is of great interest for epidemiologic studies applying ABI measurements to detect PAD and assessing patients' cardiovascular risk.

Ultrasonic endarterectomy for long superficial femoral artery atherosclerotic occlusive disease

OBJECTIVE

To report the long term results of ultrasonic superficial femoral artery endarterectomy (USFAE).

DESIGN

Retrospective study.

PATIENTS AND METHODS

From January 1998 to June 2004 218 USFAE were performed in 202 selected patients (178 males, 192 procedures) with a median age of 65 years (46-87 years). Indications for operation were disabling intermittent claudication in 137 procedures (68%), rest pain in 24 procedures (12%), and limb salvage in 41 procedures (20%). The new medical technology of ultrasonic endarterectomy is based on the application of the mechanical vibrations in the range of low frequency ultrasound. The ultrasonic device consists of the ultrasonic generator, acoustic unit and the flexible wave concentrators with special working tips in the shape of a ring. Follow up consisted of clinical evaluation, ankle-brachial index measurements and duplex scanning.

RESULTS

The mean follow-up time was 30.1 months. The mean length of the endarterectomised SFAs was 29 cm (range, 15-43 cm). The five year cumulative primary patency rate by means of life table analysis was 45.8 +/- 4.4% (SE). Percutaneous transluminal balloon angioplasty and surgical re-interventions were performed in thirty three and five patients respectively resulting in a primary assisted patency rate of 57.5 +/- 4.1%. The five year secondary patency rate was 65.6 +/- 3.8%. Limb salvage was achieved in 35 of the 41 patients with gangrene.

CONCLUSIONS

The long term results of ultrasonic SFA endarterectomy suggest this is an effective technique.

What's new in vascular ultrasound

Duplex ultrasound has long been the method of choice in the diagnosis and evaluation of deep venous thrombosis and carotid artery stenosis and in monitoring lower extremity bypasses. In recent years, innovative procedures and technology have fostered new applications for duplex ultrasound, such as detection of in-stent stenosis and endoleaks, intraoperative evaluation of in situ vein bypasses and monitoring of endovenous procedures, and treatment of common femoral pseudoaneurysms. The low cost and noninvasiveness of duplex ultrasound make it ideal for such studies,as well as for screening for asymptomatic vascular disease.

Role of Duplex Arteriography as the Sole Preoperative Imaging Modality Prior to Lower Extremity Revascularization Surgery in Diabetic and Renal Patients

The limitations and complications associated with contrast angiography (CA) prior to lower extremity revascularization have led to an increased interest in duplex arteriography (DA) as a potential replacement. We report our experience with DA in patients with diabetes and/or chronic renal insufficiency (CRI) that would particularly benefit from a noninvasive approach to preoperative evaluation of the arterial tree. From January 1998 to November 2000, DA was performed in 145 patients with diabetes mellitus and/or CRI prior to 180 arterial reconstructions. One hundred twenty-one procedures were performed on 91 patients with diabetes alone, 41 on 33 patients with diabetes and CRI, and 18 on 15 patients with CRI alone. Patient ages ranged from 36 to 98 years (mean 72 +/- 12 years). Indications for surgery were severe claudication in 33 (18%), rest pain in 37 (21%), nonhealing ischemic ulcers in 52 (29%), and limb gangrene in 58 (32%). Optimal inflow and outflow anastomotic sites were selected according to a diagram based on DA that included arterial tree imaging from mid-aorta to the pedal vessels. Preoperative contrast arteriography was performed in 16 cases (9%) because of extremely poor runoff based on DA and limited visualization of outflow vessels. The distal anastomosis was to the popliteal artery in 89 cases (49%) and to the tibial and pedal arteries in 91 (51%). Intraoperative findings confirmed the preoperative DA results with the exception of one (0.6%) where the distal anastomosis was placed proximal to a significant stenosis requiring an extension graft. The use of DA presents a safe and reliable option to prebypass CA for many patients with diabetes or CRI. The ease of use and favorable patient outcomes achieved by this imaging modality may rival the use of CA for these patients.

Remote endarterectomy: first choice in surgical treatment of long segmental SFA occlusive disease?

OBJECTIVES

to report the long term results of remote superficial femoral artery endarterectomy (RSFAE) with the MollRing Cutter for the treatment of long segmental SFA occlusive disease.

DESIGN

retrospective open study.

PATIENTS AND METHODS

from March 1994 to August 2000 183 RSFAEs were performed in 164 selected patients (105 males, 120 procedures) with a median age of 63 years (43-84 years). Indications for operation were disabling intermittent claudication in 129 procedures (70%), rest pain in 20 procedures (11%), and limb salvage in 34 procedures (19%). Follow up consisted of clinical evaluation, ankle-brachial index measurements and duplex scanning.

RESULTS

the mean follow-up time was 29.3 months. The mean length of the endarterectomised SFAs was 31 cm (range, 17-45cm). The five year cumulative primary patency rate by means of life table analysis was 37.8+/-6.67% (SE). Percutaneous transluminal balloon angioplasty and surgical re-intervention were performed in twenty-nine and four patients respectively resulting in a primary assisted patency rate of 47.9+/-6.27%. Limb salvage was achieved in 30 of the 34 patients. Females had a statistically significant lower primary patency rate, i.e., 26 vs 45% (p -value=0.01).

CONCLUSIONS

the long term results of remote SFA endarterectomy show that it is a safe, effective and durable, minimally invasive procedure. It also leaves open all other options for conventional bypass procedures. The five-year primary patency rate is at least similar to prosthetic above-knee bypass surgery.

Colour duplex ultrasound-guided sclerotherapy: a new approach to the management of patients with peripheral vascular malformations

INTRODUCTION

Colour duplex ultrasound (CDU)-guided sclerotherapy is a valuable modality for treating peripheral vascular malformations (PVMs).

PATIENTS AND METHODS

Between April 1996 and October 1998, 75 patients (age 5-65 years) with PVMs were subjected to CDU. Sclerotherapy was subsequently performed on 40 patients, without sedation, using 3% sodium tetradecyl sulfate, with mean follow-up of 4 years.

RESULTS

CDU of the 33 high-flow lesions (HFLs) revealed direct arteriovenous (AV) communicating channels with very high forward diastolic flow in seven lesions (arteriovenous fistulas, AVFs), but not in the other 25 lesions (non-AVF). One was a mixed lesion picked up by CDU. Sixteen HFLs were subjected to sclerotherapy; 13 (81.25%) regressed. CDU of the 42 low-flow lesions (LFLs) helped categorize them into Type 1, where no supplying arteries could be seen (12 lesions), and Type 2, where supplying arteries were seen (30 lesions). Type 2 lesions could be further subcategorized based on the spectral trace of their supplying arteries: Type 2a, high-resistance flow (25 lesions); and Type 2b, low-resistance flow with a small forward diastolic flow (5 lesions). Twenty-four LFLs were subjected to sclerotherapy; 20 (83.3%) regressed.

CONCLUSION

CDU findings correlated well with the clinical appearances of PVMs, and helped to further subcategorize these lesions based on flow. Significant differences in the Doppler flowmetry parameters of the supplying arteries seen in the HFLs and LFLs have enabled us to suggest values for differentiating between them. CDU was also found to be valuable in the follow-up of these lesions.

The additional value of angiography after colour-coded duplex on decision making in patients with critical limb ischaemia. A prospective study

OBJECTIVE

to investigate prospectively the additional value of intra arterial digital subtraction arteriography (IADSA) for decision making in patients with critical limb ischemia (CLI). Treatment plans based on colour-duplex imaging (CDI) were compared with treatment plans based on IADSA.

METHODS

ninety-eight consecutive patients with 112 legs with CLI were investigated by CDI and IADSA. Treatment plans based on CDI and IADSA were made separately during a multidisciplinary meeting. Both plans were retrospectively analysed with the outcome of the operation or the endovascular procedure as a reference.

RESULTS

eighty-eight patients with 101 legs could be analysed. In 91 out of the 101 legs (90%) CDI offered the same strategy as the IADSA. In 10 legs IADSA provided additional information. Most of the additional information concerned the crural vessels.

CONCLUSION

the preoperative planning of treatment in patients with chronic critical ischaemia of the lower limbs can be based on CDI alone in most patients. For planning crural revascularisation additional information may be needed. If severe calcification prevents adequate visualisation of the crural vessels or no patent anterior or posterior tibial artery with outflow across the ankle is present, IADSA should be performed.

Lower extremity revascularization without preoperative contrast arteriography: experience with duplex ultrasound arterial mapping in 485 cases

This study reviews our experience with duplex ultrasound arterial mapping (DUAM) for preoperative evaluation in 466 patients (262 men) who underwent 485 lower extremity revascularization procedures from January 1, 1998 to May 30, 2001. Preoperative imaging consisted of DUAM alone in 449 procedures and DUAM and contrast angiography (CA) in 36. An attempt to image from the distal aorta to the pedal arteries was made in all the patients. The selection of optimal inflow and outflow bypasses anastomotic sites was based on a schematic drawing following DUAM examination. Inflow disease was also assessed by intraoperative pressure gradient (IPG) between the distal anastomosis and radial arteries, and completion arteriography of the runoff vessels was obtained, which was correlated with the preoperative findings. Indications for surgery were severe claudication in 91 (19%) limbs, tissue loss in 197 (40%), rest pain in 113 (23%), acute ischemia in 46 (10%), popliteal aneurysm in 18 (4%), superficial femoral artery aneurysm in 1, abdominal aortic aneurysm with claudication in 1, and failing graft in 18 (4%). Age ranged from 30 to 97 years (mean 72 +/- 12 (SD) years) and risk factors such as diabetes, hypertension, use of tobacco, coronary artery disease, and end-stage renal disease were present in 45%, 45%, 44%, 44%, and 13% of the patients, respectively. One hundred twenty-one (25%) limbs had at least 1 previous ipsilateral revascularization. The mean DUAM time was 66 +/- 20 (SD) min (30-150 min). Additional preoperative imaging was deemed necessary in 36 cases due to extensive ulcers, edema, severe arterial wall calcification, and very poor runoff. The distal anastomosis was to the popliteal artery in 173 cases and to the tibial and pedal arteries in 255. Inflow procedures to the femoral arteries, embolectomy, thrombectomy, balloon angioplasty, and patch angioplasty accounted for the remaining 57 cases. Overall, 6-, 12-, and -24- month secondary patency rates were 86%, 80%, and 66%, respectively. This early experience shows that high-quality arterial ultrasonography performed by a highly skilled vascular technologist may represent an alternative to conventional arteriography for patients in need of lower extremity revascularization. Because of limitations inherent to the technique and very poor runoff observed on ultrasonographic examination, additional preoperative imaging procedure's are needed for certain patients.

A comparison of colour duplex ultrasonography, papaverine testing and common femoral Doppler waveform analysis for assessment of the aortoiliac arteries

OBJECTIVE

to study the "accuracy" of aortoiliac colour duplex ultrasonography.

DESIGN

prospective study.

SETTING

vascular laboratory, University Hospital.

METHODS

a total of 25 aortoiliac stenoses were studied in 23 patients. For each iliac segment, colour duplex ultrasound, papaverine testing, hyperaemic common femoral Doppler waveform analysis and hyperaemic testing using a thigh pressure cuff were performed. A velocity ratio of two was used to indicate a significant 50% diameter-reducing stenosis, but the velocity differences across stenoses as well as various characteristics of the hyyperaemic common femoral waveform were also studied. Retrospective receiver-operator characteristics and Kappa values were used for analysis.

RESULTS

the Kappa agreement between ultrasonography and papaverine testing was 0.12 using peak systolic velocity ratios and 0.8 using hyperaemic peak systolic velocity differences. Hyperaemic common femoral pulsatility (PI) and resistance index (RI) both gained a Kappa level of 0.60. The reactive hyperaemia produced by a thigh cuff was more pronounced than that produced by papaverine.

CONCLUSION

although the velocity ratio did not appear to perform well against the papaverine test, its apparent over-sensitivity calls into question the sensitivity of papaverine testing itself. The hyperaemic velocity difference at the stenosis or the hyperaemic PI or RI at common femoral level appear useful, non-invasive indicators of significant aortoiliac arterial disease.

Lower-extremity revascularisation without preoperative contrast arteriography in 185 cases: lessons learned with duplex ultrasound arterial mapping

PURPOSE

we have previously reported our experience with lower-extremity duplex-ultrasound arterial mapping (DUAM) compared to contrast arteriography (CA) to predict lower-extremity bypass sites. The present study evaluates arterial revascularisation procedures for chronic limb ischaemia based on DUAM.

MATERIALS AND METHODS

from January 1998 to July 1999, 195 patients (128 men, 67 women) underwent 211 lower-extremity revascularisation procedures based on DUAM. Indications for surgery were tissue loss, severe claudication, rest pain and popliteal aneurysm in 57%, 25%, 14% and 4% of the limbs, respectively. The mean age was 72+/-12 years and risk factors such as diabetes, hypertension, tobacco use, coronary artery and end-stage renal disease were present in 53%, 58%, 53%, 50% and 12% of the patients, respectively. Previous revascularisation procedures had been performed in 23% of the limbs. Preoperative evaluation consisted of DUAM alone (185) or of a combination of DUAM and CA (29 limbs). CA was deemed necessary due to a combination of technical difficulties that jeopardized adequate sonographic imaging and presence of disadvantaged run-off for medico-legal reasons. DUAM consisted of direct imaging of all major arteries from the distal aorta to the pedal circulation. Optimal inflow and outflow bypass anastomotic sites were selected according to a diagram based on DUAM. Adequacy of the inflow was additionally assessed by common-femoral-artery waveform and confirmed by intraoperative pressure measurements. Post-bypass CA was obtained to verify patency of the run-off.

RESULTS

DUAM procedure time averaged 75+/-26 min. For patients who underwent only DUAM, the distal anastomosis was to the popliteal artery in 91 cases and to tibial or pedal arteries in 58 cases. Distal anastomosis was proximal to a significant lesion in two cases that required jump grafts. Cumulative patency rates at 1 and 3 months for popliteal bypasses were 96% and 90%, and for infrapopliteal bypasses 90% and 83%, respectively. Inflow procedures to the femoral artery, patch and balloon angioplasties accounted for the remaining 40 cases. Four primary amputations were performed after CA confirmed DUAM findings.

CONCLUSIONS

contrary to general belief, these data show that high-quality arterial ultrasonography represents a safe alternative to preoperative CA, even for infrapopliteal bypasses. This non-invasive approach may be especially useful for patients with contrast allergy or impaired renal function.

Use of colour duplex imaging to diagnose and guide angioplasty of lower limb arterial lesions

BACKGROUND

The purpose of this study was to investigate whether colour duplex imaging alone could safely and effectively be used to diagnose lower limb arterial lesions and guide subsequent percutaneous transluminal angioplasty (PTA).

METHODS

Patients with discrete lower limb arterial lesions, preferably stenoses, which could be visualized clearly by colour duplex imaging were selected for duplex-guided PTA. Duplex-guided PTA was performed in an operating theatre using conventional balloon catheters.

RESULTS

Duplex imaging was used to diagnose and guide PTA of 55 arterial lesions in 50 legs of 45 patients. There were 53 stenoses and two occlusions. The median (range) ankle : brachial pressure index was 0. 86 (0.52-1.10) before dilatation and 1.00 (0.83-1.40) immediately after dilatation (P = 0.0001). There were no complications during or after any of the procedures and 46 of the 47 symptomatic legs were markedly improved at a median follow-up of 23 days. Radiographic imaging was not required for any of the procedures.

CONCLUSION

It is possible to diagnose and angioplasty lower limb arterial lesions using colour duplex imaging alone.

Values and limitations of duplex ultrasonography as the sole imaging method of preoperative evaluation for popliteal and infrapopliteal bypasses

The purpose of this study was to evaluate whether duplex ultrasound arterial mapping (DAM) can reliably replace standard arteriography (SA) in the preoperative assessment of candidates for popliteal and infrapopliteal bypasses. This is the report of a two-phase study undertaken at our institution from July 1997 to May 1998. Carefully performed DAM averted the need for preoperative SA (51 of 58 procedures). The results of this study can be used as an impetus to initiate larger, multicenter protocols to further evaluate this newer noninvasive approach for patients presenting with severe lower-limb ischemia.

Vascular surgery without arteriography: use of Duplex ultrasound

Although contrast arteriography has served as the historical 'gold standard' for diagnosis of arterial disease, recent improvements in noninvasive diagnostic methods have made it possible to plan surgical treatment without subjecting patients to this invasive procedure. This approach avoids both the risks and costs associated with arteriography. Duplex scanning has become the standard noninvasive test for extracranial carotid artery disease, and it can also be used to directly evaluate the lower extremity arteries. In addition to the standard duplex criteria for classification of carotid stenosis, new criteria are available that reflect the stenosis thresholds identified in randomized clinical trials. Clinical experience has clearly shown that carotid endarterectomy can be performed safely based on the duplex scan alone in the majority of patients: however, arteriography is still indicated in selected cases. The evaluation of lower extremity arterial disease requires examination of multiple arterial segments, and most vascular surgeons still rely on the anatomic detail provided by arteriography for preoperative planning. Still, it may be possible to avoid formal preoperative arteriography in selected patients by using a combination of lower extremity duplex scanning and intraoperative arteriography. Further developments in noninvasive testing will continue to reduce the need for diagnostic arteriography prior to direct arterial surgery.

Aortoiliac reconstructive surgery based upon the results of duplex scanning

OBJECTIVE

To evaluate whether duplex scanning can replace angiography in patients operated for aortoiliac obstructive disease.

DESIGN

Retrospective.

MATERIALS AND METHODS

Between January 1995 and October 1996, 44 patients underwent vascular surgery of the aortoiliac tract. The study population was divided into two groups; patients operated upon the results of duplex scanning only and patients who also underwent angiography prior to surgery. The additional value of angiography and the differences between both groups concerning unexpected peroperative findings, early postoperative failures and the need for additional radiological or surgical interventions in the first three postoperative months were studied.

RESULTS

Duplex scan group: 22 patients were operated upon the results of duplex scanning only. In two patients surgical strategy had to be changed. Early postoperative graft occlusion occurred in one case. A haemodynamically significant graft stenosis within 3 months of surgery occurred in one patient. Duplex/angiography group: 22 patients underwent both duplex scanning and angiography. Six patients underwent diagnostic angiography after failed duplex scanning. In 10 patients angiography was part of percutaneous transluminal angioplasty prior to surgery. In six patients angiograms were performed after successful duplex scanning. Angiography failed in two patients and added information in four of 16 patients. Unexpected findings at operation occurred in four patients. Graft stenosis within 3 months was detected in three patients.

CONCLUSION

After successful duplex scanning information obtained by angiography has only a limited impact on therapeutic decision-making. In the majority of patients vascular reconstructive surgery of aortoiliac arteries can be planned based on duplex scanning only.

Can cruropedal colour duplex scanning and pulse generated run-off replace angiography in candidates for distal bypass surgery

PURPOSE

To compare the diagnostic accuracy of duplex scanning (DS) and pulse generated run-off (PGR) with ia-DSA for the assessment of cruropedal outflow and explore the reliability of clinical decision making based on a work-up with DS/PGR in candidates for peripheral bypass surgery.

METHODS

Popliteal, crural and pedal arteries were evaluated independently with DS and ia-DSA in 126 limbs of 120 consecutive patients for claudication (16%) or critical ischaemia (84%). Arterial segments were graded with DS and ia-DSA as normal, stenosed, or occluded and compared using weighted kappa (kappa) analysis. PGR was used to select the best crural artery for bypass. Proposed management based on DS/PGR and, if applicable, anastomosis site were compared to definitive treatment based on ia-DSA.

RESULTS

Overall agreement between DS and ia-DSA for popliteal and crural arteries was moderate (kappa 0.51, 95% CI 0.48-0.55) with good agreement within the popliteal (kappa 0.67) and anterior tibial (kappa 0.61) arteries. Agreement was moderate within the pedal arterieds (kappa 0.32, 95% CI 0.24-0.40). In 74/126 (59%) limbs proposed management with DS/PGR was identical to ia-DSA. In 23/29 (79%) femoropopliteal and 15/37 (41%) femorocrural bypasses DS/PGR agreed perfectly with ia-DSA with regard to acceptor artery and anastomosis site.

CONCLUSION

DS can accurately assess the popliteal and anterior tibial arteries. In a substantial number of patients with severe lower limb ischaemia decisions for conservative management, PTA and femoropopliteal bypass can be based on a DS/PGR work-up.

The progression and correction of duplex detected velocity shifts in angiographically normal vein grafts

OBJECTIVES

To review the sensitivity of duplex scanning and angiography at detecting vein graft stenoses in patients on a graft surveillance programme.

DESIGN

Prospective, open, non-randomised study.

PATIENTS AND METHODS

Since February 1993, 143 patients with 148 grafts (70% in situ, 30% reversed) have attended postoperative infrainguinal vein graft surveillance for a minimum of 6 weeks. Fifty-seven graft stenoses in 57 grafts were identified by duplex scanning as a localised high velocity jet. Angiography was performed in all except 12 patients.

RESULTS

Angiography confirmed a duplex abnormality in all but 10 patients. Of these, five patients remain stable and asymptomatic with a persisting duplex abnormality. The remaining five patients, although asymptomatic, exhibited disease progression on duplex and surgical intervention confirmed significant stenoses, which were successfully treated.

CONCLUSION

The results suggest that duplex scanning is a reliable imaging modality for detecting vein graft stenoses. Selection for surgical correction can be made, in some circumstances on the basis of clinical and ultrasound criteria alone.

Diabetes: the use of color Doppler sonography for the assessment of vascular complications

The use of color Doppler sonography (CDS) in the assessment of diabetic vascular complications is not yet well established. Among the complications of the disease, retinopathy, nephropathy and peripheral arteriopathy are classically due to a vascular attack, either a micro or a macroangiopathy. The results of CDS in the assessment of retinopathy and nephropathy are correlated with the degree of the disease and the biological findings, but the diagnostic and prognostic benefit of these results remains unclear compared to the conventional tests. Doppler sonography is more helpful in peripheral arteriopathy assessment; it may take the place of arteriography in the most clinical situations. The technique is particularly useful in case of proximal atheromatous-like arteriopathy. When the arteriopathy is distal, mediacalcinosis, specific to diabetes, may interfere with the functional test like the ankle/arm pressure index measurement.

Colour flow duplex imaging of occlusive arterial disease of the lower limb

BACKGROUND

The development of duplex ultrasonography and colour flow imaging has greatly extended the scope of non-invasive assessment of lower limb arterial disease. This review questions whether recent advances might allow colour duplex imaging to displace arteriography as the primary imaging modality for native vessel occlusive disease.

METHODS

A literature review was carried out based predominantly on a Medline database search of English language publications from 1985 to 1996.

RESULTS

Increasing evidence indicates that colour duplex ultrasonography can accurately image the lower limb native arterial tree, and that colour duplex imaging can replace diagnostic arteriography in a large proportion of patients.

CONCLUSION

Arteriography should no longer be considered the gold standard of imaging of peripheral arterial occlusive disease. Future studies should concentrate on the efficacy of colour duplex sonography in guiding clinical decision making.

Peripheral arterial disease. 2: Anatomical investigations

The second article in a two-part Update on the diagnosis of arterial disease.