Duplex scan surveillance of infra-inguinal bypass grafts

The Role of Pre and Postprocedural Color Duplex Ultrasound for the Treatment of Lower Limb Ischemia by Subintimal Angioplasty

Introduction

Subintimal angioplasty (SIA) is the endovascular recanalization of vessels in the subintimal plane and most often is used to treat long-segment occlusions involving the femoropopliteal segment. This study demonstrates the value of pre- and postprocedural color duplex ultrasound (CDU) imaging.

Methods

Forty-three subintimal angioplasty procedures were performed to treat lower-extremity arterial occlusions. CDU was used as the definitive imaging modality in all cases. There were 26 women and 17 men, with a mean age of 76 years. Sixteen patients had anklebrachial index < 0.45. Most patients had significant medical comorbidities, placing them at high risk for arterial bypass procedures.

Results

In all patients, the extent of the occlusion was accurately diagnosed with CDU before intervention. SIA was technically successful in 42 of 43 patients (98%). The postprocedure CDU follow-up (1–2 months) demonstrated 10 patients had reoccluded (24%). Our primary patency rate was 42% at 30 months.

Conclusion

SIA can be an effective method of treatment in aged, high-risk patients with lower-extremity ischemia and threatened limb loss. CDU accurately locates the site of and measures the length of arterial occlusions in such patients, allowing the interventionalist to plan the site of arterial puncture and to prognosticate the likely success. CDU obviates the need for diagnostic angiography and remains the modality of choice for surveillance after SIA intervention.

VA Vascular Injury Study (VAVIS): VA-DoD extremity injury outcomes collaboration

BACKGROUND

Limb injuries comprise 50-60% of U.S. Service member's casualties of wars in Afghanistan and Iraq. Combat-related vascular injuries are present in 12% of this cohort, a rate 5 times higher than in prior wars. Improvements in medical and surgical trauma care, including initial in-theatre limb salvage approaches (IILS) have resulted in improved survival and fewer amputations, however, the long-term outcomes such as morbidity, functional decline, and risk for late amputation of salvaged limbs using current process of care have not been studied. The long-term care of these injured warfighters poses a significant challenge to the Department of Defense (DoD) and Department of Veterans Affairs (VA).

METHODS/DESIGN

The VA Vascular Injury Study (VAVIS): VA-DoD Extremity Injury Outcomes Collaborative, funded by the VA, Health Services Research and Development Service, is a longitudinal cohort study of Veterans with vascular extremity injuries. Enrollment will begin April, 2015 and continue for 3 years. Individuals with a validated extremity vascular injury in the Department of Defense Trauma Registry will be contacted and will complete a set of validated demographic, social, behavioral, and functional status measures during interview and online/ mailed survey. Primary outcome measures will: 1) Compare injury, demographic and geospatial characteristics of patients with IILS and identify late vascular surgery related limb complications and health care utilization in Veterans receiving VA vs. non-VA care, 2) Characterize the preventive services received by individuals with vascular repair and related outcomes, and 3) Describe patient-reported functional outcomes in Veterans with traumatic vascular limb injuries.

DISCUSSION

This study will provide key information about the current process of care for Active Duty Service members and Veterans with polytrauma/vascular injuries at risk for persistent morbidity and late amputation. The results of this study will be the first step for clinicians in VA and military settings to generate evidence-based treatment and care approaches to these injuries. It will identify areas where rehabilitation medicine and vascular specialty care or telehealth options are needed to allow for better planning, resource utilization, and improved DoD-to-VA care transitions.