A Prospective Feasibility Study of Duplex Ultrasound Arterial Mapping, Digital-Subtraction Angiography, and Magnetic Resonance Angiography in Management of Critical Lower Limb Ischemia by Endovascular Revascularization

Comparison between vascular Doppler ultrasound and contrast exams in chronic peripheral arterial disease

Background

Vascular Doppler ultrasound (DUS) has evolved over recent years because of improvements in the technology involved in the acquisition and processing of sound and image data. The method is an excellent option for use in diagnosis of peripheral arterial disease considering its availability, low cost, and absence of harmful effects. The breakdown of logistics supply chains caused by the COVID-19 pandemic caused worldwide shortages of iodinated contrast, highlighting the need to validate alternative diagnostic methods.

Objective

To use DUS for decision-making when choosing between by-pass and endovascular surgery for femoropopliteal arterial disease and compare the results to those of iodinated contrast exams.

Methods

We compared DUS with examinations using contrast for identification of stenoses/occlusions and indication of surgical treatment (by-pass vs. endovascular). In the first phase of the study the results were merely compared, DUS vs. angiotomography. Then, in the second phase, the vascular ultrasound results were used for screening between by-pass and endovascular treatment, comparing DUS with angiotomography in cases scheduled for by-pass and with arteriography in endovascular patients.

Results

In phase 1, the sensitivity of DUS compared to CT angiography was 100% for the SFA territory. When considering solely the choice of bypass vs. endovascular treatment, the results showed 100% agreement for phase 1 and 94% for phase 2.

Conclusion

Notwithstanding the sample size, the study fulfilled its objective of demonstrating the reliability of DUS for indicating the treatment choice between by-pass and endovascular surgery.

Superficial Femoral Artery in-Stent Restenosis Treated with Paclitaxel-Coated Balloon Angioplasty - Results of Three-Year Follow-Up

BACKGROUND

In-stent restenosis remains a common and important complication after endovascular treatment of superficial femoral artery peripheral artery disease. It occurs in 14 to 35% of cases in 1 year and there is still no efficient treatment for this condition. Paclitaxel-coated balloons have shown promising results.

OBJECTIVE

Investigate the 3 year results of superficial femoral artery in-stent restenosis treated with paclitaxel-coated balloon angioplasty, using the Lutonix™ 035 device.

METHODS

We conducted a retrospective observational study with patients with symptomatic (Rutherford 2 to 5) superficial femoral artery in-stent restenosis, that were treated with paclitaxel-coated balloon angioplasty using the Lutonix™ 035 device, in a single center from January 2016 to December 2020. Duplex scan was used to follow the patients. Primary patency was obtained through Kaplan-Meier analysis. Mortality, and amputation rates were also evaluated.

RESULTS

105 patients were included. Two patients had technical failure and required an additional stent, and were thus excluded. 103 patients were analyzed. Primary patency was 91.26, 80.47, and 67.71%, respectively, in the first, second, and third year after the procedure. There were no deaths 30 days after the procedure. There were no major amputations during the 3 year follow-up.

CONCLUSION

Paclitaxel-coated balloon angioplasty with the Lutonix™ 035 device was a safe and effective treatment to superficial femoral artery in-stent restenoses. The results were maintained along the 3 year follow-up.

Doppler Ultrasound as a Unique Diagnosis Test in Peripheral Arterial Disease

BACKGROUND

The aim of this study was to analyze duplex ultrasound (DUS) and intraoperative angiography concordance for diagnosis of lower limb peripheral artery disease and its value for surgical planning.

MATERIALS AND METHODS

This was a prospective, observational study, including patients who underwent revascularization of the lower limbs during 2018, diagnosed by DUS only or combined with preoperative computed tomography (CT) angiography. The concordance between preoperative DUS or CT angiography and the intraoperative angiography was studied using the Cohen kappa coefficient (k). The degree of agreement between the DUS-based surgical plan and the final surgical technique was also evaluated.

RESULTS

Fifty-one patients were included, with mean age of 71.8 ± 11.96 years (46-94); 23 had chronic kidney disease (45%). In 17 patients (34%), preoperative CT angiography was also performed. DUS showed a sensitivity of 100% (95% confidence interval (CI) [83.3-100%]), 80% (95% CI [50.21-100%,]), and 100% (95% CI [96.43-100%]) at the iliac, femoral, and popliteal sector, respectively, and a specificity of 93.55% (95% CI [83.29-100%]), 95.45% (95% CI [84.48-100%]), and 90.48% (95% CI [75.54-100%]) at the iliac, femoral, and popliteal sector, respectively. The positive predictive value for DUS was 60% (95% CI [7.06-100%]), 88.9% (95% CI [62.8-100%]), and 87.5% (95% CI [68.17-100%]) for the iliac, femoral, and popliteal sectors, respectively, whereas the negative predictive value was 100% (95% CI [98.28-100%]), 91.3% (95% CI [77.61-100%]), and 100% (95% CI, [97.37-100%]). The concordance between DUS and intraoperative angiography showed a k index of 0.587 (P = 0.000) in the iliac sector, 0.799 in the femoral sector (P = 0.000), and 0.699 in the popliteal sector (P = 0.000). The concordance between CT angiography/intraoperative angiography had a k index of 0.71 in the iliac sector (P = 0.0093), 0.566 in the femoral sector (P = 0.006), and 0.5 in the popliteal sector (P = 0.028). DUS-based surgical plan was accurate in 86% of cases (n = 44).

CONCLUSIONS

Our experience suggests that DUS arterial mapping of the femoral and popliteal areas is better than CT angiography and can be considered as a unique preoperative imaging test during the surgical planning in patients undergoing a lower limb revascularization procedure.

Carotid intima-media thickness and plaques in internal carotid artery as surrogate markers of lower limb arterial lesions in Chinese patients with diabetic foot

Peripheral arterial disease (PAD) can impair healing of diabetic foot (DF) in patients with diabetes mellitus. To determine whether carotid intima-media thickness (CIMT) can predict lower limb arterial lesions in patients with DF, this cross-sectional study enrolled patients with DF at West China Hospital (China) between January 2012 and December 2015. Ultrasonography was used to measure CIMT, assess the internal carotid arteries (ICA) for plaques, and evaluate lower limb segmental arteries for stenosis. The optimal CIMT cutoff for detecting lower limb PAD was determined by receiver operating characteristic (ROC) curve analysis. Factors associated with PAD were identified by logistic regression analyses. A total of 167 patients (mean age: 69.7±10.3 years; 102 men) were included. Patients with PAD were older and had higher levels of total cholesterol and low-density lipoprotein than patients without PAD (P<0.05). The area under the ROC curve was 0.747 (P<0.001). At the optimal CIMT cutoff of 0.71 mm, the sensitivity, specificity, positive predictive value, and negative predictive value were 79.65, 61.11, 81.08, and 58.93%, respectively. Compared with those without PAD, more patients with PAD had CIMT ≥0.71 mm (79.65 vs 38.89%; P<0.001) and ICA plaques (66.37vs 11.11%; P<0.001). Multivariate logistic regression revealed that age (odds ratio [OR]: 1.118; 95% confidence interval [95%CI]: 1.056–1.183; P<0.001), ICA plaques (OR: 13.452; 95%CI: 4.450–40.662; P<0.001), and CIMT ≥0.71 mm (OR: 2.802; 95%CI: 1.092–7.188; P=0.032) were associated with PAD.CIMT may be a surrogate marker of PAD in patients with DF.

Arterial Duplex Ultrasound is the Most Cost-Effective, Noninvasive Diagnostic Imaging Modality before Treatment of Lower-Extremity Arterial Occlusive Disease

Introduction

Multiple noninvasive imaging modalities (duplex ultrasound, magnetic resonance angiography, and computed tomographic angiography) are now available for diagnostic evaluation of lower-extremity arterial occlusive disease (LEOD). This study was performed to determine the effectiveness of duplex ultrasound as the primary diagnostic imaging test before endovascular treatment and to estimate the potential cost-savings compared with the use of other technologies.

Methods

The diagnostic evaluations of all patients treated for LEOD by a single vascular specialist between July 2004 and February 2008 were reviewed. The medical records were reviewed for the initial noninvasive diagnostic imaging study, type of intervention, and patency of revascularization. Medicare reimbursement rates (2007) for each imaging modality were used to compare costs of diagnostic testing.

Results

A total of 128 endovascular interventions were performed in 89 patients. Arterial duplex imaging was the primary and only diagnostic study performed prior to endovascular treatment in 108 (84%) of procedures. If preintervention magnetic resonance angiography or computed tomographic angiography had been used in these patients instead of duplex, the costs for diagnostic imaging alone would have increased by $96,064 and $44,762, respectively.

Conclusion

Arterial duplex ultrasound can be effectively used as the preferred modality for noninvasive imaging of LEOD, resulting in substantial cost savings.

Systematic reviews and meta-analyses for more profitable strategies in peripheral artery disease

In the peripheral arteries, a thrombus superimposed on atherosclerosis contributes to the progression of peripheral artery disease (PAD), producing intermittent claudication (IC), ischemic necrosis, and, potentially, loss of the limb. PAD with IC is often undiagnosed and, in turn, undertreated. The low percentage of diagnosis (∼30%) in this setting of PAD is of particular concern because of the potential worsening of PAD (amputation) and the high risk of adverse vascular outcomes (vascular death, coronary artery disease, stroke). A Medline literature search of the highest-quality systematic reviews and meta-analyses of randomized controlled trials documents that, due to risk of bias, imprecision, and indirectness, the overall quality of the evidence concerning diagnostic tools and antithrombotic interventions in PAD is generally low. Areas of research emerge from the information collected. Appropriate treatments for PAD patients will only derive from ad-hoc studies. Innovative imaging techniques are needed to identify PAD subjects at the highest vascular risk. Whether IC unresponsive to physical exercise and smoking cessation identifies those with a heritable predisposition to more severe vascular events deserves to be addressed. Devising ways to improve prevention of vascular events in patients with PAD implies a co-ordinated approach in vascular medicine.

Meta-analysis of contemporary short- and long-term mortality rates in patients diagnosed with critical leg ischaemia

BACKGROUND

Critical leg ischaemia (CLI) has been associated with high mortality rates. There is a lack of contemporary data on both short- and long-term mortality rates in patients diagnosed with CLI.

METHODS

This was a systematic literature search for studies prospectively reporting mortality in patients diagnosed with CLI. Meta-analysis and meta-regression models were developed to determine overall mortality rates and specific patient-related factors that were associated with death.

RESULTS

A total of 50 studies were included in the analysis The estimated probability of all-cause mortality in patients with CLI was 3·7 per cent at 30 days, 17·5 per cent at 1 year, 35·1 per cent at 3 years and 46·2 per cent at 5 years. Men had a statistically significant survival benefit at 30 days and 3 years. The presence of ischaemic heart disease, tissue loss and older age resulted in a higher probability of death at 3 years.

CONCLUSION

Early mortality rates in patients diagnosed with CLI have improved slightly compared with previous historical data, but long-term mortality rates are still high.

Cool excimer laser-assisted angioplasty (CELA) and tibial balloon angioplasty (TBA) in management of infragenicular arterial occlusion in critical lower limb ischemia (CLI)

We aim to compare cool excimer laser-assisted angioplasty (CELA) versus tibial balloon angioplasty (TBA) in patients with critical limb ischemia (CLI) with tibial artery occlusive disease. The primary end point is sustained clinical improvement (SCI) and amputation-free survival (AFS). The secondary end points are binary restenosis, target extremity revascularization (TER), and cost-effectiveness. From June 2005 to October 2010, 1506 patients were referred with peripheral vascular disease and 572 with CLI. A total of 80 patients underwent 89 endovascular revascularizations (EVRs) for tibial occlusions, 47 using TBA and 42 using CELA. All patients were Rutherford category 4 to 6. Three-year SCI was enhanced with CELA (81%) compared to TBA (63.8%; P = .013). Three-year AFS significantly improved with CELA (95.2%) versus TBA (89.4%; P = .0165). Three-year freedom from TER was significantly improved with CELA (92.9%) versus 78.7% TBA (P = .026). Three-year freedom from MACE was comparable in both the groups (P = .455). Patients with CELA had significantly improved quality time without symptoms of disease or toxicity of treatment (Q-TWiST) at 3 years (10.5 months; P = .048) with incremental cost of €2073.19 per quality-adjusted life year gained. Tibial EVR provides exceptional outcome in CLI. The CELA has superior SCI, AFS, and freedom from TER, with improved Q-TWiST and cost-effectiveness.

Ten-year technical and clinical outcomes in TransAtlantic Inter-Society Consensus II infrainguinal C/D lesions using duplex ultrasound arterial mapping as the sole imaging modality for critical lower limb ischemia

OBJECTIVE

The aim of this study was to evaluate duplex ultrasound arterial mapping (DUAM) as the sole imaging modality when planning for bypass surgery (BS) and endovascular revascularization (EvR) in patients with critical limb ischemia for TransAtlantic Inter-Society Consensus (TASC) II C/D infrainguinal lesions.

METHODS

This was a retrospective review evaluating the accuracy of DUAM as the sole imaging tool in determining patient suitability for BS vs EvR. Primary outcomes were the sensitivity and specificity of DUAM compared with intraoperative digital subtraction angiography. Secondary outcomes were procedural, hemodynamic, and clinical outcomes, amputation-free survival, and freedom from major adverse clinical events.

RESULTS

From 2002 to 2012, a total of 4783 patients with peripheral arterial disease were referred, of whom 622 critical limb ischemia patients underwent revascularization for TASC C and D lesions (EvR: n = 423; BS: n = 199). Seventy-four percent of EvR and 82% of BS were performed for TASC D (P = .218). The DUAM showed sensitivity of 97% and specificity of 98% in identifying lesions requiring intervention. Of the 520 procedures performed with DUAM alone, there was no difference regarding the number of procedures performed for occlusive or de novo lesions (EvR: 65% and 71%; BS: 87% and 78%; P = .056). Immediate clinical improvement to the Rutherford category ≤3 was 96% for EvR and 97% for BS (P = .78). Hemodynamic success was 79% for EvR and 77% for BS (P = .72). Six-year freedom from binary restenosis was 71.6% for EvR and 67.4% for BS (P = .724). Six-year freedom from target lesion revascularization was 81.1% for EvR and 70.3% for BS (P = .3571). Six-year sustained clinical improvement was 79.5% for EvR and 66.7% for BS (P = .294). Six-year amputation-free survival was 77.2% for EvR and 74.6% for BS (P = .837). There was a significant difference in risk of major adverse clinical events between EvR and BS (51% vs 70%; P = .034). Only 16.4% of patients required magnetic resonance angiography, which tended to overestimate lesions with 84% agreement with intraoperative findings. Six-year binary restenosis was 71% for DUAM procedures compared with 55% for magnetic resonance angiography procedures (P = .001), which was solely based on the prospective modality.

CONCLUSIONS

The DUAM epitomizes a minimally invasive, economically proficient modality for road mapping procedural outcome in BS and EvR. It allows for high patient turnover with procedural and clinical success without compromising hemodynamic outcome. The DUAM is superior to other available modalities as the sole preoperative imaging tool in a successful limb salvage program.

Critical and acute limb ischemia: an overview

Some patients with peripheral arterial disease may present with critical limb ischemia, a condition associated with high rates of morbidity and mortality. Early diagnosis and effective medical therapy and revascularization are indicated to avoid amputation and reduce mortality. Ideally, a multidisciplinary approach with collaboration between endovascular interventionist, vascular surgeons, podiatrist, infectious disease, and wound care specialist is recommended for these patients.

Chapter II: Diagnostic methods

Non-invasive vascular studies can provide crucial information on the presence, location, and severity of critical limb ischaemia (CLI), as well as the initial assessment or treatment planning. Ankle-brachial index with Doppler ultrasound, despite limitations in diabetic and end-stage renal failure patients, is the first-line evaluation of CLI. In this group of patients, toe-brachial index measurement may better establish the diagnosis. Other non-invasive measurements, such as segmental limb pressure, continuous-wave Doppler analysis and pulse volume recording, are of limited accuracy. Transcutaneous oxygen pressure (TcPO(2)) measurement may be of value when rest pain and ulcerations of the foot are present. Duplex ultrasound is the most important non-invasive tool in CLI patients combining haemodynamic evaluation with imaging modality. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are the next imaging studies in the algorithm for CLI. Both CTA and MRA have been proven effective in aiding the decision-making of clinicians and accurate planning of intervention. The data acquired with CTA and MRA can be manipulated in a multiplanar and 3D fashion and can offer exquisite detail. CTA results are generally equivalent to MRA, and both compare favourably with contrast angiography. The individual use of different imaging modalities depends on local availability, experience, and costs. Contrast angiography represents the gold standard, provides detailed information about arterial anatomy, and is recommended when revascularisation is needed.

Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) in acute lower limb ischaemia

For various reasons some patients are unable to undergo intra-arterial thrombolysis for acute limb ischaemia. This interventional case series study prospectively evaluated the effect of thrombolytic treatment with 100 mg recombinant tissue plasminogen activator (rt-PA), administered intravenously, in patients with acute thrombosis of the lower limb arteries and onset of symptoms within 12 h prior to treatment. During a 3-year period (2007-2009), 18 of 86 patients satisfied the inclusion criteria and were included in the study (age range 65-80 years; 11 women). Complete and partial thrombolysis was observed in eight (44.4%) and six (33.3%) patients, respectively. All patients experienced clinical improvement. There were no amputations during the 36-month follow-up period and no haemorrhagic complications in the first 30 days post-treatment. Five patients died (27.8%) during follow-up from unrelated causes. This small study demonstrated that thrombolytic treatment with intravenous rt-PA in selected patients with acute limb ischaemia is feasible.

Duplex ultrasound scanning of peripheral arterial disease of the lower limb

OBJECTIVES

To assess the reliability and applicability of duplex ultrasound scanning (DUS) of lower limb arteries, compared with digital subtraction angiography (DSA), in patients with peripheral arterial disease (PAD).

DESIGN

A prospective, blinded, comparative study.

MATERIALS AND METHODS

A total of 169 patients were examined by DUS and DSA. Intermittent claudication (IC) was present in 42 (25%) patients and critical limb ischaemia (CLI) in 127 (75%) patients. To allow segment-to-segment comparison, the arterial tree was divided into 15 segments. In total, 2535 segments were examined using kappa (κ) statistics to test the agreement.

RESULTS

The agreement between DUS and DSA was very good (κ>0.8) or good (0.8 ≥ κ>0.6) in most segments, but moderate (0.6 ≥ κ>0.4) in the tibio-peroneal trunk and the peroneal artery. Agreement between the two techniques was significantly better in the supragenicular (κ=0.75 (95% confidence interval (CI): 0.70-0.80)) than in the infragenicular segments (κ=0.63 (0.59-0.67)) (p<0.001). Similarly, the technical success rate was significantly higher in the supragenicular segments (DUS: 100%; DSA: 99%) than in the infragenicular segments (both 93%) (p<0.001). DUS was the best technique for imaging of the distal crural arteries (92% vs. 97%; p<0.001) and DSA was the best technique for imaging of the proximal crural arteries (95% vs. 91%; p<0.01). Neither the agreement nor the technical success rate was influenced by the severity of PAD, that is, IC versus CLI.

CONCLUSION

The agreement between DUS and DSA was generally good, irrespective of the severity of ischaemia. DUS performed better in the supragenicular arteries than in the infragenicular arteries. However, DUS compared favourably with DSA in both tibial vessels, particularly in the distal part, which makes DUS a useful non-invasive alternative to DSA.

Análise espectral segmentar no seguimento de pacientes revascularizados

CONTEXTO: Pacientes tratados por revascularização arterial (enxertos e angioplastias) nos membros inferiores acometidos por doença arterial oclusiva periférica foram seguidos por até 2 anos pós-tratamento usando ultrassom vascular (análise espectral segmentar, AES). OBJETIVO: Demonstrar que a AES pode ser utilizada no seguimento dos pacientes tratados por doença arterial oclusiva periférica. MÉTODOS: As medidas de AES realizadas foram: velocidade sistólica de pico, índice de pulsatilidade e forma da onda de velocidade de fluxo. Essas foram comparadas em cada paciente no pré e pós-tratamento (com intervalos de 3 meses) para diagnóstico de perviedade. RESULTADOS: Medidas realizadas no pós-operatório nas artérias imediatamente distais aos segmentos tratados mostraram aumento consistente de velocidade sistólica de pico e índice de pulsatilidade com mudanças na forma da onda de velocidade de fluxo de unifásica para bi ou trifásica. A velocidade sistólica de pico e o índice de pulsatilidade aumentaram respectivamente em 92,26 e 98,2% (tratamentos no segmento aorto-ilíaco), em 112,83 e 62,39% (tratamentos no segmento fêmoro-poplíteo) e em 149,08 e 28,8% (tratamentos no segmento poplíteo-tibial). Tais mudanças nos padrões de velocidade de fluxo ocorreram em todos os pacientes e permaneceram quase inalteradas enquanto os tratamentos estivessem pérvios. Quando ocorria falência nos tratamentos (oclusões ou estenoses hemodinamicamente significantes), os parâmetros caíam a níveis similares aos de antes do tratamento. Se a falência do tratamento era corrigida por nova revascularização (enxerto ou angioplastia), os parâmetros de AES voltavam a se comportar como após o tratamento inicial. CONCLUSÃO: A AES pode ser usada no seguimento dos pacientes com revascularização dos membros devido a doença arterial oclusiva periférica, demonstrando tanto a perviedade quanto a falência do tratamento.

Value of MDCT angiography in developing treatment strategies for critical limb ischemia

OBJECTIVE

The purpose of this study was to assess the value of MDCT angiography in the development of strategies for the treatment of patients with critical limb ischemia.

MATERIALS AND METHODS

During a 12-month period, 150 patients were referred to our department for CT angiography of the peripheral arteries. All patients (n = 28) with clinical stage IV peripheral arterial occlusive disease were included in this retrospective study. The treatment reports, discharge summaries, and follow-up examinations were reviewed to ascertain the number of patients correctly treated on the basis of the CT angiographic findings.

RESULTS

After CT angiography, endovascular treatment was indicated for eight patients, surgical revascularization for four patients, and a combined endovascular and surgical approach for two patients. That the correct treatment decision had been made in all 14 cases was confirmed on the basis of successful endovascular or surgical revascularization. In eight patients, medical treatment was indicated, and one patient underwent amputation at the level of the thigh. Five patients were referred for complementary digital subtraction angiography, but no additional findings were made. During follow-up, three of the original 28 patients were in grave general condition and died within 7 weeks after CT angiography. Thirteen patients needed no additional treatment during the follow-up period through January 2008. After a median treatment-free interval of 381 days, 12 patients underwent additional revascularization because of clinical progression of disease.

CONCLUSION

MDCT angiographic findings lead to accurate recommendations for the management of critical limb ischemia. Thus CT angiography seems to be an important technique for the management of stage IV peripheral arterial occlusive disease in patients without absolute contraindications to CT angiography.

Accuracy and Cost Comparison of Ultrasound Versus Alternative Imaging Modalities, Including CT, MR, PET, and Angiography

Ultrasound (US) has become widely used in clinical medicine for the diagnosis of a variety of disease processes. The unique ability of US to provide accurate information through an efficacious, painless, portable, and nonionizing method has expanded its role and application in diverse medical settings. Given the current economic environment and the related interest in creating the greatest value for health care expenditures, US has been evaluated to compare its clinical accuracy/efficacy and cost-effectiveness versus other imaging modalities. The following literature review reports the results of research studies aimed at comparing the accuracy/efficacy and cost of US versus alternative imaging modalities, including magnetic resonance imaging, computed tomography, contrast angiography, and single-photon emission computed tomography.