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

Routinely ultrasound surveillance improves outcome after endovascular treatment of peripheral arterial disease: propensity-matched comparisons of clinical outcomes after ultrasound or clinical-hemodynamic based surveillance programs

BACKGROUND

Endovascular treatment (EVT) has replaced open repair as the first option in intermittent claudication (IC) and chronic limb-threatening ischemia (CLTI) in several centers. However, evidence of the most optimal post-procedural surveillance strategy is sparse. This study aimed to compare two routine surveillance programs after EVT of IC/CLTI: clinical and hemodynamic assessment (CHA) vs. duplex ultrasound (DUS) and clinical/hemodynamic assessment in combination.

METHODS

Between February 2012 and December 2015, all patients with EVT of IC/CLTI were allocated to either CHA or DUS-based routine surveillance programs. The allocation-ratio was 1:2 (CHA:DUS), and propensity score matching (PSM) was used to control baseline differences between the groups. Follow-up visits in the CHA group consisted of clinical assessment and ABI at 3, 6, 12 and 24 months. Follow-up visits in DUS group consisted of clinical assessment, ABI, and target vessel DUS at 1, 3, 6, 12, 18 and 24 months.

RESULTS

In total, 340 legs in 305 patients suffering from IC/CLTI were included; 111 (33%) in the CHA-group and 229 (67%) in the DUS group. The two groups were identical except for a significantly lower incidence of diabetes mellitus in the CHA group than the DUS group, 55% vs. 72%, respectively (P=006). Based on PSM, the CHA-group vs. the DUS-group was burdened of an increased risk of amputation (12.5% vs. 8.27%, HR=0.41 [95% CI: 0.17-0.96]), and a higher mortality (21.2% vs. 12.8%, HR=0.37 [95% CI: 0.19-0.72]). The reported differences in reintervention rate (7.5% vs. 12.8%, HR=1.12 [95% CI: 0.44-2.84]) were insignificant. The mean follow-up was 317 days (SD=0.214) in the CHA group and 611 days (SD=0.298) in the DUS group.

CONCLUSIONS

Our results suggest that DUS-based routine surveillance after EVT of IC/CLTI is superior to CHA-based routine surveillance in improved amputation rate and mortality.

Comparison Between Below Knee Contrast Enhanced Tomographic 3D Ultrasound and CT, MR or Catheter Angiography for Peripheral Artery Imaging

OBJECTIVE

Clear imaging of below knee and foot arteries is essential to plan distal reconstructions. Contrast enhanced tomographic 3D ultrasound (CEtUS) is novel and entirely safe with no exposure to ionising radiation or nephrotoxic contrast. In the present study, inter- and intra-observer agreement of CEtUS was calculated, and compared with below knee angiography.

METHODS

In the same week as computed tomography, magnetic resonance or catheter angiography, CEtUS was performed using intravenous 1.2 mL bolus injections of Sonovue with a maximum of 5 mL administered per patient. CEtUS was reported by a vascular scientist blinded to the angiograms reported by a consultant radiologist. Images were compared using a modified Society of Vascular Surgery (SVS) runoff score.

RESULTS

Of the 181 patients recruited with peripheral arterial disease, 20 were excluded from analysis as they withdrew consent, could not be cannulated, or their images were non-diagnostic. In the remaining 161 patients, there were 175 comparative patient images split into two groups: 81 had calf imaging and 94 had pedal imaging representing 405 and 198 imaged arteries, respectively. Weighted quadratic kappa/ICC values for intra- and inter-observer agreement were excellent (κ/ICC = 0.83 to 0.95) and had narrow confidence intervals in both groups. When comparing angiography and CEtUS, weighted quadratic κ/ICC agreement was moderate with acceptable confidence intervals in both groups (Calf κ/ICC = 0.54; Pedal κ/ICC = 0.53). Agreement decreased from popliteal to pedal vessels as diameter decreased. Agreement between CEtUS and digital subtraction angiography was best, and computed tomography angiography the weakest.

CONCLUSION

CEtUS is a novel imaging modality with strong observer agreement that achieves clear peripheral and foot images without ionising radiation exposure or nephrotoxic X-ray contrast media. CEtUS enhances visualisation of runoff vessels, which may play a role in planning of limb salvage or targeted assessment.

Ultrasound in the Modern Management of the Diabetic Foot Syndrome: A Multipurpose Versatile Toolkit

Ultrasound (US) is a noninvasive and versatile technology that in recent years found acceptance in almost all the medical specialties, with diagnostic and interventional applications. In the diabetic foot syndrome (DFS), US found specific indications mainly in the screening, quantification, and follow-up of the vascular component of the pathology, but also in the study of the deformities and structural modifications induced by neuropathy and in the diagnosis and surgical management of infections, especially those that induce anatomical changes, like abscesses and fasciitis. This review will summarize all these application of US, giving special attention to the vascular aspects, and on the predominant role that US gained in recent times to guide the indication to revascularization, on the new standardized approach to the study of the arterial tree of the limb and the foot, the so-called duplex ultrasound arterial mapping, which significantly increased the utilization of US to plan the revascularizations in this complex pathology. Outside the vascular fields, the diagnosis of neuropathy and infection and the intraoperative use of US in the surgical management of abscesses and fasciitis will be discussed, leaving the last part to the new and interesting applications of US in the management of DFU, a field that is still in evolution, offering new possibilities to the health care professionals involved in the management of these chronic wounds. The variety of applications both in diagnostic and operative fields makes US a rather versatile technology-a toolkit-that should have a special place among those at reach of the specialists of DFS care.