Duplex ultrasound versus CT angiography for the treatment planning of lower-limb arterial disease

2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia).

METHODS

A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate.

STRUCTURE

Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.

Application opportunity of Doppler ultrasound combined with CT angiography in diabetic lower extremity arterial disease and the analysis of the risk factors

Objective

This study examined the potential of combining Doppler ultrasound (DUS) and CT angiography (CTA) for early detection and intervention of lower extremity arterial disease (LEAD) in diabetes.Concurrently, risk factors influencing LEAD progression were analyzed.

Methods

106 Type-2 diabetes patients with LEAD, having undergone DUS and CTA, were divided into four stages according to Fontaine stage. Results of DUS and CTA were compared across stages and potential risk factors were analyzed.

Results

Positive detection rates of LEAD differed between DUS and CTA for Fontaine stages I and II (P < 0.05), with no significant difference for stages III and IV (P > 0.05). CTA identified subgroups with mild to moderate stenosis and severe stenosis or occlusion, with positive rates on DUS of 17.95% and 89.9% respectively. Hypertension was found as an independent risk factor affecting LEAD progression.

Conclusion

CTA should be performed early for LEAD in diabetes patients at Fontaine stages I and II, regardless of DUS results. For diabetes patients with LEAD, stringent blood pressure control is crucial to delay disease progression.

Peripheral Interventional Strategy Assessment (PISA) for Diabetic Foot Ulcer Revascularization: Preliminary Outcomes of a Multidisciplinary Pilot Study

BACKGROUND

Digital subtraction angiography (DSA) still represents the gold standard for anatomical arterial mapping and revascularization decision-making in patients with chronic limb-threatening ischemia (CLTI), although DUS (Doppler Ultrasound) remains a primary non-invasive examination tool. The Global Vascular Guidelines established the importance of preoperative arterial mapping to guarantee an adequate in-line flow to the foot. The aim of this study was to evaluate the accuracy of DUS in guiding therapeutic vascular treatments on the basis of Global Vascular Guidelines without the need of a second-level examination.

METHODS

Between January 2022 and June 2022, all consecutive patients with CLTI to be revascularized underwent clinical examination and DUS without further diagnostic examinations. Primary outcomes assessed were technical success, and 30-day mortality. Secondary outcomes were 1-year amputation free survival, and time between evaluation and revascularization.

RESULTS

Sixty-eight patients with a mean age of 73.6 ± 8.5 years underwent lower limb revascularization. Technical success was 100%, and the 30-day mortality rate was 2.9%. Mean time between evaluation and revascularization was 29 ± 17 days. One-year amputation free survival was 97.1%.

CONCLUSIONS

DUS without further diagnostic examinations can accurately assess the status of the vascular tree and foot runoff, providing enough information about target vessels to guide revascularization strategies.

Chronic Limb-Threatening Ischemia and the Need for Revascularization

BACKGROUND

Patients presenting with critical limb-threatening ischemia (CLTI) have been increasing in number over the years. They represent a high-risk population, especially in terms of major amputation and mortality. Despite multiple guidelines concerning their management, it continues to be challenging. Decision-making between surgical and endovascular procedures should be well established, but there is still a lack of consensus concerning the best treatment strategy. The aim of this manuscript is to offer an overview of the contemporary management of CLTI patients, with a focus on the concept that evidence-based revascularization (EBR) could help surgeons to provide more appropriate treatment, avoiding improper procedures, as well as too-high-risk ones.

METHODS

We performed a search on MEDLINE, Embase, and Scopus from 1 January 1995 to 31 December 2022 and reviewed Global and ESVS Guidelines. A total of 150 articles were screened, but only those of high quality were considered and included in a narrative synthesis.

RESULTS

Global Vascular Guidelines have improved and standardized the way to classify and manage CLTI patients with evidence-based revascularization (EBR). Nevertheless, considering that not all patients are suitable for revascularization, a key strategy could be to stratify unfit patients by considering both clinical and non-clinical risk factors, in accordance with the concept of individual residual risk for every patient. The recent BEST-CLI trial established the superiority of autologous vein bypass graft over endovascular therapy for the revascularization of CLTI patients. However, no-option CLTI patients still represent a critical issue.

CONCLUSIONS

The surgeon's experience and skillfulness are the cornerstones of treatment and of a multidisciplinary approach. The recent BEST-CLI trial established that open surgical peripheral vascular surgery could guarantee better outcomes than the less invasive endovascular approach.

Evaluation of Short-Term Insulin Pump for Treatment of Patients with Type 2 Diabetes Mellitus Complicated with Lower Extremity Arterial Disease in Endocrinology by Ultrasonography

This research aimed to explore the curative effect of short-term insulin pump in the treatment of type 2 diabetes mellitus (T2DM) patients with lower extremity arterial disease (LEAD) based on ultrasonography. 422 patients (220 males and 202 females) with T2DM in the hospital were selected, and they were randomly divided into control group (n = 211, oral hypoglycemic drugs or diet control, appropriate exercise to lower blood glucose) and experimental group (n = 211, insulin pump was used to reduce blood glucose). After 2 weeks, the therapeutic effect was evaluated by ultrasonography. The results showed that after two weeks of treatment, the difference in lumen intima between the two groups was statistically significant (P < 0.05). The intima-media thickness (IMT) values of the experimental group were 0.83 ± 0.03 mm, 0.62 ± 0.03 mm, and 0.41 ± 0.04 mm, respectively, which were significantly different from those of the control group (1.62 ± 0.54 mm, 1.23 ± 0.14 mm, and 0.78 ± 0.11 mm) (P < 0.05). There was obvious difference in low-density lipoprotein cholesterol (LDL-C) level between the experimental group (2.22 ± 0.46 mmol/L) and the control group (3.21 ± 0.62 mmol/L) (P < 0.05). The LEAD score of the experimental group was 5.51 ± 1.11, which was significantly different from that of the control group (7.08 ± 2.73) (P < 0.05). There was clear difference in LEAD score between the two groups under different course of disease (CD) (P < 0.05). Studies indicated that short-term application of insulin pump therapy could effectively improve the pathological changes of lower limbs in patients with T2DM, which had clinical application value.

[The proximally pedicled anterolateral thigh flap for reconstruction of complex soft tissue wounds of the hip and caudal trunk region]

INTRODUCTION

Groin and lower trunk defects are common problems, especially for elderly patients. While groin defects are often due to prior vascular interventions, trochanteric defects are mainly caused by pressure sores. Plastic reconstructive methods are manifold; however, the pedicled anterolateral thigh (ALT) flap is supposed to be reliable with sustainable results.

OBJECTIVE

We present our experiences using the pedicled ALT flap for soft tissue reconstruction in patients with large wounds of the medial and lateral proximal thigh.

MATERIALS AND METHODS

A total of 16 patients with groin and lower trunk defects due to prior vascular surgery or pressure sores received locoregional soft tissue reconstruction using a proximal pedicled ALT flap. Patient characteristics, defect size, surgery time, clinical outcome and complication rate were assessed.

RESULTS

With the exception of two cases, sufficient soft tissue reconstruction was achieved. In all, 81,3% of patients were categorized as ASA (American Society of Anesthesiologists) 3. The average duration of surgery was 149 min. Length of stay was 18,3 days. A total of 31% needed revision surgery due to limited wound healing problems. Two patients died. All patients showed healed wound conditions when they were discharged.

CONCLUSION

The proximal pedicled ALT-flap is a reliable method for soft tissue reconstruction in groin and lower trunk defects. This reconstructive procedure enables reliable wound closure, especially in elderly patients with substantially reduced general health condition.

Duplex Ultrasound as a reliable alternative to CT angiography for treatment planning of Peripheral Artery Disease

BACKGROUND

The aim of this work is to compare the diagnostic accuracy of Duplex ultrasound (DUS) and CT angiography (CTA) in the study of arterial vessels, in patients with chronic peripheral arterial disease (PAD) of the lower limbs to undergo endovascular revascularization with the use of intraprocedural digital angiography (DSA).

METHODS

94 patients with obstructive pathology of the arterial axes of the lower limbs were enrolled in the study. In all patients, endovascular revascularization treatment was considered the most suitable therapeutic choice. For this reason, ultrasound and CTA was performed preoperatively in all and based on the data obtained it was decided to classify the arterial tree into five segments: iliac, common femoral, superficial femoral, popliteal and infra-geniculate. According to the degree of stenosis or occlusion, the arteries were scored in no stenotic, stenotic and occluded. The comparison of the data provided by the DUS and the CTA was carried out with reference to the parameters obtained by the DSA.

RESULTS

The results of our experience have shown that in the iliac arterial district DUS proved to be less accurate than CT angiography when compared to DSA (Cohen's Kappa agreement of 0.91 and 1.0, respectively). Good diagnostic concordance were found in the femoro-popliteal district (Cohen's Kappa agreement 33 between 0.96 and 0.93). On the contrary, when the data of the infra-geniculate area were compared, CT angiography showed a net deficiency compared to DSA and DUS (Cohen's k: 0.75).

CONCLUSIONS

Due to its accuracy, high-quality DUS performed by well-trained operators may therefore represent a good alternative to CTA in patients undergoing endovascular revascularization, in order to reduce the use of contrast-enhanced radiological imaging especially when a condition of intolerance to the contrast medium and/or renal insufficiency coexists.