Aorto-iliac reconstruction without arteriography

Duplex selection facilitates single point-of-service endovascular and surgical management of aortoiliac occlusive disease

We attempted to optimize management of aortoiliac occlusive disease by using duplex imaging to aid in selection of favorable lesions for percutaneous transluminal angioplasty (PTA)/stenting, by avoiding nontherapeutic arteriography, and by providing single point-of-service care in which endovascular and open surgical reconstruction were combined. One-hundred consecutive patients with symptomatic (91 claudication, 9 limb threat) inflow occlusive disease based on clinical examination and physiologic testing underwent physician-directed duplex scanning of the infrarenal aorta through the femoral bifurcation. Iliac lesions suited to endovascular intervention were defined as focal (length <5 CM), high-grade stenoses with a peak velocity >300 cm/sec and velocity ratio >2 by duplex and were differentiated from unfavorable (diffuse/long iliac stenosis, occlusions, aneurysms, femoral occlusive disease) inflow lesions. Patients with favorable iliac lesions according to duplex were considered candidates for PTA/stenting in an endo-capable operating room, without prior diagnostic angiography. On the basis of duplex imaging, 38 patients possessed endovascularly favorable iliac lesions, 58 patients had unfavorable aortoiliofemoral disease, and 4 obese patients had inadequate studies. Duplex interpretation correctly classified disease distribution/severity in 92% of 50 patients who subsequently underwent intraoperative or diagnostic arteriography. Thirty-one of the 45 (69%) total interventions performed in this patient group were based on duplex findings alone. Of 29 patients with favorable lesions by duplex scanning who had intervention, 25 (86%) received iliac PTA/stenting, while 4 patients required inflow surgical reconstruction for nonfocal iliac disease demonstrated on operative arteriography. Duplex imaging correctly identified the need for concomitant outflow reconstruction/bypass in 11 of the 25 (44%) patients treated by iliac PTA/stenting. Primary and assisted patency rates of iliac PTA/stenting were 83% and 100% at 24 months by life-table analysis. Duplex imaging in patients with symptomatic aortoiliac occlusive disease can provide sufficient information to permit endovascular and surgical intervention without formal diagnostic arteriography in most patients.

Selection of patients with infrainguinal arterial occlusive disease for percutaneous transluminal angioplasty with duplex scanning

AIM

To evaluate the role of duplex scanning in the selection of patients with infrainguinal arterial occlusive disease for percutaneous transluminal angioplasty (PTA).

MATERIAL AND METHODS

From January 1995 through May 2000, 702 patients (952 limbs), with chronic lower extremity ischemia due to infrainguinal atherosclerotic disease diagnosed by duplex scanning, were retrospectively studied. Diagnostic angiography (130 limbs) or infrainguinal PTA (108 limbs) was performed in 238 limbs. Two investigators retrospectively analyzed the duplex examinations and angiographies in a blinded manner and used similar criteria for the interpretation of lesions suitable or not suitable for PTA.

RESULTS

The superficial femoral, popliteal and crural artery lesions were correctly selected for PTA in 85%, 66% and 32%, respectively. The accuracy, sensitivity, specificity, negative predictive value and positive predictive value of duplex scanning to appropriately categorize femoropopliteal lesions as suitable or unsuitable for PTA were 89%, 83%, 92%, 94% and 78%, respectively. The accuracy of duplex scanning for predicting the performance of infrainguinal PTA was 83%.

CONCLUSION

Duplex scanning has an important impact on the selection of treatment modalities in limbs with infrainguinal arterial occlusive disease. Femoropopliteal lesions can be reliably selected to PTA according to duplex scan findings.

Surgical reconstruction without preoperative angiography in patients with aortoiliac occlusive disease

The objective of this study was to evaluate the feasibility of performing surgical reconstructions in patients with aortoiliac occlusive disease with findings obtained solely from duplex scanning. Between January 1995 through December 1999, among 112 patients who underwent surgical intervention due to aortoiliac occlusive disease, 44 were operated on with findings obtained solely from preoperative duplex scanning. Deviations from preoperatively planned surgical interventions according to duplex scan findings and the outcome were analyzed. Our results showed that surgical reconstructions for treatment of aortoiliac occlusive disease can be safely performed by using duplex scanning as the sole preoperative diagnostic modality in patients with conclusive duplex scan findings.

Duplex scanning as the sole preoperative imaging method for infrainguinal arterial surgery

OBJECTIVE

to evaluate preoperative duplex as the sole investigation prior to lower limb reconstruction. Design retrospective analysis.

MATERIALS AND METHODS

between January 1995 and December 1999, 157 of 329 surgical interventions for chronic infrainguinal arterial or aneurysmal disease were performed without preoperative angiography.

RESULTS

in patients undergoing femoral artery endarterectomy, the extent of the stenosis and the status of the distal deep femoral artery were correctly diagnosed with duplex scanning in all but one patient. Duplex scan findings in patients undergoing infrainguinal bypass procedures were in agreement with the findings obtained from on-table angiography in regard to the selection of optimal outflow anastomotic sites in 123 (98%). Duplex scanning correctly evaluated the status of runoff in 113 (90%). There were no significant differences in 30-day occlusion rate and patency at 12 months between reconstructions performed with and without preoperative angiography.

CONCLUSION

in patients with conclusive duplex scan findings there is no need to perform angiography prior to lower limb reconstruction.

Current trends in peripheral vascular surgery. When is surgical intervention the best option?

Surgery continues to play an important role in the management of peripheral vascular disease. Revascularization procedures provide excellent outcomes for many patients at risk for loss of a limb or seriously impaired quality of life. Although endovascular techniques are now being used for managing many vascular problems, the traditional surgical approaches still offer well-documented benefits.

Review of the assessment of single level and multilevel arterial occlusive disease in lower limbs by duplex ultrasound

The purpose of this article is to review the performance of duplex ultrasound scanning in assessing lower limb arterial disease with emphasis on patients with multisegmental occlusive lesions. Several studies have reported that duplex scanning can be as accurate as angiography to localize arterial stenoses. In spite of these promising results, there still remain some difficulties and controversies. Among them, it has been reported that multisegmental disease may affect the accuracy of duplex scanning. Indeed, some studies have indicated a lower sensitivity for detecting significant stenoses distal to severe or total occlusions. It also was demonstrated that second-order stenoses were detected with lower sensitivity compared to first-order stenoses. The main reason proposed to explain this lower sensitivity is that the highly reduced flow distal to occluded or highly stenotic segments increases the difficulty of detecting significant Doppler velocity changes in the distal or secondary stenoses. The intrinsic limitations of the peak systolic velocity ratio used as a classification criterion are presented. Finally, new and promising developments in power Doppler imaging and ultrasound contrast agents are discussed, because they may allow expansion of the capabilities of current ultrasound scanning systems and provide more accurate diagnosis of patients with multiple disease.

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.

Lower extremity vascular reconstruction and endovascular surgery without preoperative angiography

BACKGROUND

Recent studies have shown the feasibility of performing lower extremity revascularization based on noninvasive vascular studies alone.

METHODS

We undertook a prospective study of patients with lower extremity ischemia who underwent revascularization without preoperative angiography. Preoperative evaluation was done with noninvasive studies including segmental pressures, ankle arm index, duplex scan, and selective use of magnetic resonance angiography. Intraoperative angiography and intra-arterial pressure measurements were used prior to revascularization. Standard patency analysis and follow-up examination were performed.

RESULTS

In all, 47 patients underwent 65 procedures (27 iliac, 38 infrainguinal) over a 3-year period. Intraoperative angiography and operative findings correlated with the noninvasive studies. There was one immediate failure, and life table analysis demonstrated primary patency rates of 92% for iliac reconstruction (29 months) and 82% for infrainguinal reconstruction (40 months).

CONCLUSION

Preoperative evaluation for lower extremity revascularization utilizing only noninvasive vascular testing gives satisfactory results and is a safe and potentially durable alternative to routine preoperative angiography in most cases.