Ultrasound imaging of infrainguinal arterial disease has a high interobserver agreement

Diagnosis and Risk Assessment of Lower Extremity Peripheral Arterial Disease

Managing patients with peripheral arterial disease (PAD) requires an accurate assessment of the severity of the condition and the risk factors likely to predict disease progression. The spectrum of patient presentation ranges from asymptomatic to critical limb ischemia. Because about half of patients with PAD have coronary or cerebrovascular disease, the examination of presenting patients should be directed toward the entire cardiovascular system. The main diagnostic goal is to establish whether the symptoms are predominantly caused by PAD and to what degree the presenting problem is compounded by other comorbidities, such as diabetic neuropathy, arthritis, or venous disorders. The diagnostic process includes history taking, physical examination, noninvasive diagnostic testing, differential diagnosis, laboratory studies, and the use of the various imaging modalities, which in general are reserved for those PAD cases in which the clinician has already decided to intervene.

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.

Bare metal stent versus paclitaxel eluting stent for intermediate length femoropopliteal arterial lesions (BATTLE trial): study protocol for a randomized controlled trial

BACKGROUND

Currently, endovascular treatment is indicated to treat femoropopliteal lesions ≤15 cm. However, the Achilles' heel of femoropopliteal endovascular repair remains restenosis. Paclitaxel eluting stents have shown promising results to prevent restenosis in femoropopliteal lesions compared to percutaneous transluminal angioplasty. A recently released prospective registry using a newer generation of self-expandable nitinol stents (Misago®; Terumo Corp., Tokyo, Japan) supports primary bare metal stenting as a first-line treatment for femoropopliteal lesions. To date, no studies have been designed to compare bare metal stents to paclitaxel eluting stents for the treatment of femoropoliteal lesions. The BATTLE trial was designed to compare paclitaxel eluting stents (Zilver® PTX®) and a last generation bare self-expandable nitinol stents (Misago® RX, Terumo Corp., Tokyo, Japan) in the treatment of intermediate length femoropopliteal lesions (≤14 cm).

METHODS/DESIGN

A prospective, randomized (1:1), controlled, multicentric and international study has been designed. One hundred and eighty-six patients fulfilling the inclusion criteria will be randomized to one of the two assessments of endovascular repair to treat de novo femoropopliteal lesions ≤14 cm in symptomatic patients (Rutherford 2 to 5): bare stent group and paclitaxel eluting stent group. The primary endpoint is freedom from in-stent restenosis at 1 year defined by a peak systolic velocity index >2.4 (restenosis of >50%) at the target lesion and assessed by duplex scan. Our main objective is to demonstrate the clinical superiority of primary stenting using Zilver® PTX® stent system versus bare metal self-expandable stenting in the treatment of femoropopliteal lesions in patients with symptomatic peripheral arterial disease.

DISCUSSION

This is the first randomized and controlled study to compare the efficacy of bare metal stents and paclitaxel eluting stents for the treatment of femoropopliteal lesions. It may clarify the indication of stent choice for femoropopliteal lesions of intermediate length.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT02004951. 3 December 2013.

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.

Medical and endovascular management of critical limb ischemia

Critical limb ischemia (CLI) is the term used to designate the condition in which peripheral artery disease has resulted in resting leg or foot pain or in a breakdown of the skin of the leg or foot, causing ulcers or tissue loss. If not revascularized, CLI patients are at risk for limb loss and for potentially fatal complications from the progression of gangrene and the development of sepsis. The management of CLI requires a multidisciplinary team of experts in different areas of vascular disease, from atherosclerotic risk factor management to imaging, from intervention to wound care and physical therapy. In the past decade, the most significant change in the treatment of CLI has been the increasing tendency to shift from bypass surgery to less invasive endovascular procedures as first-choice revascularization techniques, with bypass surgery then reserved as backup if appropriate. The goals of intervention for CLI include the restoration of pulsatile, inline flow to the foot to assist wound healing, the relief of rest pain, the avoidance of major amputation, preservation of mobility, and improvement of patient function and quality of life. The evaluating physician should be fully aware of all revascularization options in order to select the most appropriate intervention or combination of interventions, while taking into consideration the goals of therapy, risk-benefit ratios, patient comorbidities, and life expectancy. We discuss the incidence, risk factors, and prognosis of CLI and the clinical presentation, diagnosis, available imaging modalities, and medical management (including pain and ulcer care, pharmaceutical options, and molecular therapies targeting angiogenesis). The endovascular approaches that we review include percutaneous transluminal angioplasty (with or without adjunctive stenting); subintimal angioplasty; primary femoropopliteal and infrapopliteal deployment of bare nitinol, covered, drug-eluting, or bioabsorbable stents; cryoplasty; excimer laser-assisted angioplasty; excisional atherectomy; and cutting balloon angioplasty.

Whole-body MR angiography with body coil acquisition at 3 T in patients with peripheral arterial disease using the contrast agent gadofosveset trisodium

RATIONALE AND OBJECTIVES

Whole-body magnetic resonance angiography (WB-MRA) at 3 T with body coil acquisition has not previously been investigated. In this study, WB-MRA was performed in this manner using the blood pool contrast agent gadofosveset trisodium.

MATERIALS AND METHODS

Eleven consecutive patients (five men, six women) with symptomatic peripheral arterial disease (two with critical limb ischemia, nine with claudication) were examined. Conventional digital subtraction angiography (DSA) of the aorta and the inflow and runoff arteries was used as the reference method. WB-MRA was performed using four slightly overlapping stations covering the arteries from the neck to the ankles. The arterial system was divided into 42 segments that were analyzed for the presence of significant arterial disease (> or =50% luminal narrowing or occlusion) by two blinded observers.

RESULTS

Sensitivities for detecting a significant arterial lesion with WB-MRA using gadofosveset as the contrast agent were 0.66 (95% confidence interval [CI], 0.49-0.79) and 0.68 (95% CI, 0.52-0.81) for the two observers. Specificities were 0.82 (95% CI, 0.74-0.88) and 0.93 (95% CI, 0.87-0.96), respectively. Intermodality agreement between WB-MRA and DSA was moderate to good, with overall kappa values of 0.44 (95% CI, 0.29-0.59) and 0.63 (95% CI, 0.5-0.77) for the two observers. Interobserver agreement for WB-MRA was good, at kappa = 0.60 (95% CI, 0.50-0.71).

CONCLUSION

WB-MRA at 3 T with body coil acquisition in patients with peripheral arterial disease showed good reproducibility but only moderate to good agreement with DSA. Further assessment of the method's clinical application is warranted.

Emerging Evidence for Neuroischemic Diabetic Foot Ulcers: Model of Care and How to Adapt Practice

Although neuropathic ulceration remains the commonest type of foot ulcers among patients with diabetes, recent data suggest that ischemic (and therefore, neuroischemic) ulcers are on the rise. The high prevalence and incidence of diabetes and its attendant foot complications, coupled with the current trend where increasingly diabetes care is being provided by general practitioners (primary care physicians) would mean that primary care practices are expected to see greater numbers of diabetic foot ulcer patients. Unfortunately, these settings are frequently ill-equipped to appropriately manage diabetic foot ulcers either due to lack of adequately trained personnel and access to multidisciplinary foot care teams. Whereas neuropathic foot ulceration may appear to be less challenging, neuroischemic or ischemic ulcers portend a higher risk of adverse outcomes, including non-healing, infection, amputation, and death. The last 2 decades have witnessed a paradigm shift from neuropathy as the main etiological factor in diabetic foot disease to an ever-increasing preponderance of ischemic and/or neuroischemic ulceration. Available literature does not always consider the limited access primary care practices have to specialized multidisciplinary foot care teams. Additionally, in the case of neuroischemic and/or ischemic ulcers, existing guidelines on their diagnosis and management are varied and unclear. This review aimed at providing a simple understanding to the complex evidence base for diagnosing and treating neuroischemic and/or ischemic ulcers in a primary care setting. It emphasizes the need for urgent vascular review in all patients with ischemic/ neuroischemic ulcers and advocates effective participation of vascular specialists in diabetic foot clinics and combined ward rounds.

Whole-body magnetic resonance angiography at 3 tesla using a hybrid protocol in patients with peripheral arterial disease

The purpose of this study was to determine the diagnostic performance of 3T whole-body magnetic resonance angiography (WB-MRA) using a hybrid protocol in comparison with a standard protocol in patients with peripheral arterial disease (PAD). In 26 consecutive patients with PAD two different protocols were used for WB-MRA: a standard sequential protocol (n = 13) and a hybrid protocol (n = 13). WB-MRA was performed using a gradient echo sequence, body coil for signal reception, and gadoterate meglumine as contrast agent (0.3 mmol/kg body weight). Two blinded observers evaluated all WB-MRA examinations with regard to presence of stenoses, as well as diagnostic quality and degree of venous contamination in each of the four stations used in WB-MRA. Digital subtraction angiography served as the method of reference. Sensitivity for detecting significant arterial disease (luminal narrowing > or = 50%) using standard-protocol WB-MRA for the two observers was 0.63 (95%CI: 0.51-0.73) and 0.66 (0.58-0.78). Specificities were 0.94 (0.91-0.97) and 0.96 (0.92-0.98), respectively. In the hybrid protocol WB-MRA sensitivities were 0.75 (0.64-0.84) and 0.70 (0.58-0.8), respectively. Specificities were 0.93 (0.88-0.96) and 0.95 (0.91-0.97). Interobserver agreement was good using both the standard and the hybrid protocol, with kappa = 0.62 (0.44-0.67) and kappa = 0.70 (0.59-0.79), respectively. WB-MRA quality scores were significantly higher in the lower leg using the hybrid protocol compared to standard protocol (p = 0.003 and p = 0.03, observers 1 and 2). Distal venous contamination scores were significantly lower with the hybrid protocol (p = 0.02 and p = 0.01, observers 1 and 2). In conclusion, hybrid-protocol WB-MRA shows a better diagnostic performance than standard protocol WB-MRA at 3 T in patients with PAD.

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

Duplex ultrasound arterial mapping (DUAM) allows precise evaluation of peripheral vascular disease (PVD). However, magnetic resonance angiography (MRA) and digital-subtraction angiography (DSA) are the diagnostic tools used most frequently prior to intervention. Our aim was to compare clinical pragmatism, hemodynamic outcomes, and cost-effectiveness when using DUAM alone compared to DSA or MRA as preoperative assessment tools for endovascular revascularization (EvR) in critical lower limb ischemia (CLI). From 2002 through 2005, 465 patients were referred with PVD. Of these, 199 had CLI and 137 required EvR. Preoperative diagnostic evaluation included DUAM (n = 41), DSA (n = 50), or MRA (n = 46). EvR was aortoiliac in 27% of cases and infrainguinal in 73%. Patients were assessed at day 1, 6 weeks, 3 months, and 6 months. Composite end points were relief of rest pain, ulcer/gangrene healing, and increase in perfusion pressure, as measured by ankle-brachial index (ABI) and digital pressures. Patency by DUAM, limb salvage, morbidity, mortality, length of stay, and cost-effectiveness were compared between groups using nonparametric t-test, analysis of variance, and Kaplan-Meier analysis. The three groups were comparable in terms of age, sex, comorbidity, and Society for Vascular Surgery/International Society of Cardiovascular Surgery clinical classification. Six-month mean improvement in ABI in the DUAM group was comparable to that in the DSA group (P = 0.25) and significantly better than that in the MRA group (P < 0.05). Six-month patency rates for the DUAM group were comparable to those in the DSA group (P = 0.68, relative risk [RR] = 0.74, 95% confidence interval [CI] 0.18-2.99) and superior to that in the MRA group (P = 0.022, RR = 0.255, 95% CI 0.09-0.71). Length of hospital stay was lower in the DUAM group compared with the DSA group (P < 0.0001) and the MRA group (P = 0.0003). The cost of DUAM is lower than that of both DSA and MRA. DUAM accurately identified the total number of target lesions for revascularization; however, MRA overestimated it. Our results indicate that DUAM is outstanding when compared with other available modalities as a preoperative imaging tool in a successful EvR program. DUAM is a minimally invasive preoperative evaluation for EvR and offers precise consecutive data with patency and limb salvage rates comparable to EvR based on DSA and superior to MRA. We believe that our feasibility study has established DUAM as an economically proficient primary modality for investigating patients with CLI that significantly shortens length of hospital stay.

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.

[Ultrasound in vascular surgery]

Diagnosing vascular diseases by ultrasound is of major interest to vascular surgeons and now regarded as the primary noninvasive technique. This paper presents developments in four different fields: stenoses of the carotid arteries, peripheral artery occlusive diseases (PAOD) including surveillance programs, diseases of the veins, and abdominal aortic aneurysm. Calculating the extent of a carotid artery stenosis is now accurate, but plaque imaging remains complex. Examination by ultrasound should precede any invasive techniques in PAOD. Duplex surveillance on a routine basis is no longer recommended after infrainguinal bypass. In future vascular diseases will be diagnosed primarily by ultrasound. Diagnosis of abdominal aneurysm is now absolutely reliable, whereas planning and follow-up of endoluminal techniques are quite restricted.

Diagnosis and risk assessment of lower extremity peripheral arterial disease

Managing patients with peripheral arterial disease (PAD) requires an accurate assessment of the severity of the condition and the risk factors likely to predict disease progression. The spectrum of patient presentation ranges from asymptomatic to critical limb ischemia. Because about half of patients with PAD have coronary or cerebrovascular disease, the examination of presenting patients should be directed toward the entire cardiovascular system. The main diagnostic goal is to establish whether the symptoms are predominantly caused by PAD and to what degree the presenting problem is compounded by other comorbidities, such as diabetic neuropathy, arthritis, or venous disorders. The diagnostic process includes history taking, physical examination, noninvasive diagnostic testing, differential diagnosis, laboratory studies, and the use of the various imaging modalities, which in general are reserved for those PAD cases in which the clinician has already decided to intervene.

Les explorations non invasives de l’AOMI

FOR THE DIAGNOSIS OF AN ARTERIOPATHY: The approach is basically clinical, and vascular explorations are represented by the measurement of ankle blood pressure and calculation of the pressure index, a simple test that should systematically complete the examination. THE SEARCH FOR LOCAL LESIONS OF POTENTIALLY POOR PROGNOSIS: These are principally aneurysm and stenosis of the derivation routes that should be searched for using a Doppler in order to localise them and, completed by measurement of ankle blood pressure, specify the upstream impact and the ultrasound-Doppler analysis of certain selected areas. BEFORE REVASCULARISATION: The arteriography, examination of reference until recently, has certain limits that explain its more restricted use and the widened use of ultrasound-Doppler explorations, combined with magnetic resonance imaging and scanning.

Quand, comment et pourquoi réaliser une imagerie des artères des membres inférieurs ?

Noninvasive screening of lower limb arterial disease has long been performed using color Doppler ultrasonography, whereas surgical or endovascular treatment planning relied on conventional angiography. With continued improvements of noninvasive imaging modalities, it is now possible to image the entire lower limb vasculature without arterial catheterization. Multidetector row helical CT angiography has the advantage of visualizing the arterial lumen and arterial wall calcifications, and nephrotoxicity is reduced by decreasing amounts of contrast medium. Three-dimensional MR angiography is a safe procedure, with high contrast sensitivity, and has recently benefited from step table technology that allows a single injection of contrast medium. The literature shows that both helical CT and MR angiography have high levels of accuracy, but outcome studies of their respective role in the setting of acute and chronic lower limb ischemia are lacking. These noninvasive techniques should play a major role in two main situations: first, in critical ischemia where therapeutic planning should ideally be achieved non invasively; second, in the follow-up of treated patients presenting with recurrent ischemia.

Ultrasound contrast-agent improves imaging of lower limb occlusive disease

OBJECTIVES

to evaluate if ultrasound contrast-agent infusion could improve duplex-ultrasound imaging of peripheral arterial disease (PAD) and increase the agreement with digital subtraction arteriography (DSA).

DESIGN

prospective and consecutive study.

MATERIAL

of 60 consecutive PAD patients, 15 were found to have an inconclusive duplex-ultrasound scan of the trifurcation and were included in the study. All 15 patients (53% male) were scheduled for DSA, all being candidates for vascular surgery due to claudication (n = 3, 20%), rest pain (n = 5, 33%) and tissue loss (n = 7, 47%).

METHODS

on the day before DSA, a duplex-ultrasound scan of the trifurcation was performed. If the duplex-ultrasound scan was found inconclusive, it was repeated during continuous ultrasound contrast-agent infusion. DSA was performed unaware of the duplex-ultrasound results and served as the gold standard.

RESULTS

after contrast-agent administration, the number of inconclusively diagnosed segments was significantly reduced by 26 (70%), from 37 to 11(p < 0.001). In 19 segments (73%) contrast-agent infusion changed the diagnosis in accordance with the DSA (p < 0.05). Values of sensitivity and positive predictive value were improved from 0.20 (0.04-0.62) to 0.47 (0.26-0.69) and 0.50 (0.10-0.91) to 0.80 (0.49-0.93), respectively. Specificity and negative predictive value were unchanged. Agreement between duplex-ultrasound and DSA were improved from poor (kappa = 0.18 (95% CI: 0-0.82)) to moderate (kappa = 0.45 (0.17-0.74)) (p = 0.44).

CONCLUSION

ultrasound contrast-agents improve the diagnostic ability of duplex-ultrasound when scanning difficult arterial segments in patients suffering from PAD.