Underutilisation of duplex scanning for the assessment of lower extremity arterial disease.
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Angiography↗
Biomedical subjects
D A Legemate
Publications and source records attributed to D A Legemate.
The value of non-invasive techniques for the assessment of critical limb ischaemia.
OBJECTIVE: The European Consensus Document (ECD) defines critical ischaemia (CI) according to clinical (Fontaine) and blood pressure parameters. However, clinical symptoms may be non-specific and CI may exist without severely reduced blood pressures. This study prospectively investigated the additive value of transcutaneous oxygen tension (pO2) and toe blood pressure measurements to assess the presence of CI. METHODS: Forty-nine patients with 65 legs clinically classified as Fontaine stages III (n = 23) and IV (n = 26) were studied. Ankle and toe systolic blood pressure and pO2 were measured to assess the presence of CI (cut-off values were 50, 30 and 30 mmHg, respectively). The surgeon was blinded for the toe pressure and pO2 results. The treatment received within 1 month after presentation was recorded as being either conservative or invasive (vascular surgery or PTA). RESULTS: An ankle pressure of < or = 50 mmHg classified only 17% of the legs as having CI. By adding toe pressure and pO2, significantly more legs (63%; p < 0.0001) were classified as CI, of which 68% received invasive therapy. Forty-nine percent of the legs with an ankle pressure > 50 mmHg were treated invasively, whereas only 32% of the legs classified as not having CI by means of toe pressure and pO2 underwent invasive therapy. If the need for invasive treatment is used as the "gold standard" for the presence of CI, 54% of the legs would accurately be classified on the basis of the ankle blood pressure. The combination of toe pressure and pO2 would have yielded 71% and the ECD criteria 72% and accurately classified legs. The odds ratio for invasive therapy given a pO2 or toe pressure above the cut-off value was 14. CONCLUSION: Ankle blood pressure measurements have limited diagnostic value. Adding toe and/or oxygen pressures enhances the detection of CI requiring invasive therapy.
Aged↗
Hyperaemic colour duplex scanning for the detection of aortoiliac stenoses. A comparative study with intra-arterial pressure measurement.
OBJECTIVES: Intra-arterial pressure measurement is considered the "gold standard" for the haemodynamic evaluation of aortoiliac lesions. When compared to pressure measurement duplex scanning fails to detect some of the haemodynamically significant lesions. To improve the assessment of the haemodynamic significance of these lesions by duplex scanning, the flow-related duplex parameters delta PSV and EDV at rest and after exercise were compared with intra-arterial pressure gradients before and during increased blood flow. PATIENTS AND METHODS: Forty-five aortoiliac segments with an isolated stenosis were studied prospectively. Doppler samples were taken at the site of the stenosis both at rest and after exercise on a bicycle ergometer, followed by intraarterial pressure measurement at rest and during pharmacologically induced increased blood flow. RESULTS: At rest a delta PSV (delta PSVr) of 1.6 m/s showed a sensitivity and specificity of 85% and 88%, respectively. After exercise a delta PSV (delta PSVe) of 1.6 m/s showed a sensitivity of 100% at the cost of only a slight reduction in specificity when compared to delta PSVr. The end diastolic velocity at rest (EDVr) had only limited clinical value. The EDV after exercise (EDVe) provided important information if the velocity was 0.5 m/s or lower or if the velocity was 1.6 m/s or greater. CONCLUSION: The delta PSV and the EDV after exercise can be of value in the assessment of the haemodynamic significance of aortoiliac stenoses.
Aorta, Abdominal↗
Retrograde aortic and selective organ perfusion during thoracoabdominal aortic aneurysm repair.
OBJECTIVES: To evaluate the possible prevention of renal and intestinal ischaemia during surgery of thoracoabdominal aortic aneurysms (TAAA) by use of retrograde and selective organ perfusion. DESIGN: Prospective study. MATERIALS: Thirty-three consecutive patients underwent TAAA repair, six of whom had a previous type B dissection: 14 patients (35%) had type I TAAA, 12 patients type II (32%), three patients type III (15%) and four patients type IV (18%). Mean age was 61 years (range 22-84 years). METHODS: In patients with type I TAAA, retrograde aortic perfusion was performed by means of a left atrium femoral artery bypass or partial cardiopulmonary bypass. In type II, III and IV the same procedure was performed; however, following cross-clamping and opening of the abdominal aorta, the coeliac trunc, superior mesenteric and both renal arteries were selectively perfused with four Pruitt-catheters (9 Fr.), connected as an octopus to the extracorporal circulation. RESULTS: All patients survived the surgical procedure. The minimal volume flow through each octopus catheter was 60 ml/min. Urine output was uninterrupted in all patients, irrespective of the aortic cross-clamp time. Only one patient (3%), who already had renal insufficiency, developed renal failure. Total in-hospital mortality was 15%, paraplegia occurred in 12%. CONCLUSION: Retrograde aortic and selective organ perfusion is a safe technique and can prevent ischaemic renal and intestinal damage during cross-clamping of the aorta in thoracoabdominal aneurysm surgery.
Adult↗
Diabetes mellitus is not a contra-indication for peripheral vascular intervention in patients with leg ischemia.
BACKGROUND: The effect of diabetes mellitus on the patency of peripheral vascular interventions was investigated in patients with arterial insufficiency of the leg in a retrospective follow-up study performed between 1993 and 1995. METHODS: In 65 patients without and 36 with diabetes 124 vascular reconstructions were performed because of rest pain and/or ulceration. RESULTS: In diabetic patients ulcers were found more frequently and more distal bypasses were performed. No significant differences were observed between diabetics and non-diabetics as to bypass patency, number of re-interventions and amputations. Smoking and age were significant factors influencing bypass patency. CONCLUSION: Diabetes mellitus in patients with critical leg ischaemia appears to be no reason to refrain from vascular surgery.
Aged↗
Colour duplex scanning and pulse-generated run-off for assessment of popliteal and cruropedal arteries before peripheral bypass surgery.
BACKGROUND: This prospective pilot study compared the diagnostic accuracy of duplex scanning and pulse-generated run-off (PGR) with intra-arterial digital subtraction angiography (IADSA) for assessment of popliteal, crural and pedal arteries, and explored the reliability of investigation with the combination of duplex scanning and PGR in patients who needed femorodistal reconstruction. METHODS: In 23 limbs, 345 arterial segments were graded independently with duplex scanning and IADSA as normal, stenosed or occluded and compared using weighted kappa analysis. PGR was rated as good, poor or no run-off and compared with pedal arch patency on IADSA. Based on information derived from duplex scanning and PGR a vascular surgeon proposed treatment and the distal anastomosis site for bypass, which was compared with definitive treatment as determined by IADSA. RESULTS: Overall agreement between duplex scanning and IADSA for popliteal and crural arteries was moderate (kappa 0.47, 95 per cent confidence interval (c.i.) 0.39-0.55) with best agreement within the popliteal and proximal tibial arteries. Agreement within pedal arteries was fair (kappa 0.35, 95 per cent c.i. 0.17-0.53). PGR detected good run-off in five of 21 pedal arteries shown to be occluded on IADSA. In 16 of 23 patients treatment based on duplex scanning and PGR was identical to that based on IADSA. Eight of eleven femoropopliteal bypasses were predicted accurately. CONCLUSION: Operative strategy could have been based on investigation by duplex scanning and PGR in a substantial number of patients scheduled for femoropopliteal bypass surgery. Agreement between duplex scanning and IADSA within very distal arterial segments was fair.
Adult↗
Diagnosis of arterial disease of the lower extremities with duplex ultrasonography.
The development of duplex scanning carries the prospect of an entire non-invasive work-up of patients with peripheral arterial occlusive disease. To obtain the best available estimates of its diagnostic accuracy, a meta-analysis of 71 studies evaluating duplex scanning was performed. Independent methodological judgement left 16 studies for data extraction. Pooled estimates (95 per cent confidence interval of sensitivity and specificity for detection of a stenosis greater than or equal to 50 per cent or occlusion in the aortoiliac tract were 86 (80-91) per cent and 97 (95-99) per cent respectively. The results for the femoropopliteal tract compared well with this, with a sensitivity of 80 (74-85) per cent and a specificity of 96 (94-98) per cent. The accuracy of detection of a stenosis greater than or equal to 50 per cent or an occlusion in the infragenicular arteries was lower with a sensitivity and specificity of 83 (59-96) per cent and 84 (69-93) per cent respectively. Duplex scanning is an accurate tool for assessment of atherosclerotic lesions in the aortoiliac and femoropopliteal tract and can replace routine preinterventional angiography in a substantial number of patients.
Aorta↗
[Duplex ultrasonography study in the diagnosis of cerebral, abdominal and peripheral artery stenoses].
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Aortic Diseases↗
Impact of ultrasonographic duplex scanning on therapeutic decision making in lower-limb arterial disease.
Ultrasonographic duplex scanning has become a valuable diagnostic technique in detecting and grading stenoses and occlusions of the aortoiliac and femoropopliteal arteries. However, the question remains as to whether a treatment strategy can be designed without diagnostic angiography. This prospective study evaluated the impact of duplex scanning on therapeutic decision making. Patients with intermittent claudication, rest pain or ischaemic ulceration of the lower limb who were eligible for invasive treatment were studied. If treatment was considered necessary, a duplex scan was performed instead of diagnostic angiography. The surgeon made a therapeutic decision based on clinical assessment and information obtained from the duplex scan. If it was felt that duplex scanning gave insufficient information, diagnostic angiography was then performed. A group of 112 consecutive patients were studied prospectively; 12 were excluded for logistical reasons. The 100 remaining patients (intermittent claudication in 69, rest pain in 16, ischaemic ulceration in 15) were evaluated. Based on non-invasive tests 22 patients were treated conservatively, 36 were scheduled for percutaneous transluminal angioplasty (PTA) and 32 were scheduled for surgery. Angiography was requested to determine the definitive treatment policy in 28 patients: four of the 22 were scheduled for conservative treatment and 24 of the 32 were scheduled for surgery. All PTAs were performed without prior diagnostic angiography. Angiography was considered necessary in a further ten patients to formulate a therapeutic strategy. In 62 patients the treatment strategy could be determined without diagnostic angiography. Twenty-three of the 39 angiograms performed did not give additional information on treatment strategy. Integrated use of duplex scanning for the investigation of patients with arterial occlusive disease of the lower limb can reduce the need for diagnostic angiography.
Aged↗
Value of Duplex scanning in the selection of patients for percutaneous transluminal angioplasty.
Duplex scanning is becoming increasingly important in the diagnosis and follow-up of arterial lesions, though most surgeons and radiologists currently still prefer diagnostic angiography prior to percutaneous transluminal angioplasty (PTA). We performed PTA based on Duplex scanning alone in 31 selected patients during the last 6 months of 1991. Seventeen patients were treated for lower extremity ischemia and 14 for (a)-symptomatic stenosis in a peripheral bypass. Results of Duplex scanning were compared to the finding of PTA to assess the value of Duplex scanning done prior to PTA. Duplex scanning showed 51 lesions eligible for PTA, in 48 of 51 lesions (94%) the location as found with Duplex scanning was in agreement with the findings of the angiogram during PTA. Of a total of 31 patients scheduled for PTA, Duplex scanning predicted the indication for PTA adequately in 26 patients (84%). No complications were seen. Duplex scanning proved to be a valuable tool in the detection of lesions suitable for PTA. Furthermore, puncture site and route can be determined by means of Duplex scanning.
Aged↗
Long-term results of semiclosed endarterectomy of the superficial femoral artery and the outcome of failed reconstructions.
PURPOSE: The optimal method of treatment of superficial femoral artery occlusive disease has yet to be established. Therapeutic options include percutaneous transluminal angioplasty for short lesions and reversed or in situ autologous saphenous vein bypass for long lesions. Currently, staged revascularization with polytetrafluoroethylene as an initial conduit and autologous vein for secondary procedures is suggested. An alternative to these procedures is endarterectomy of the occluded superficial femoral artery, followed by a femoropopliteal bypass in cases of endarterectomy failure. Our results with this procedure are reviewed in this article. METHODS: From 1980 until 1990, 259 endarterectomies of the superficial femoral artery were attempted, 231 of which were successfully performed in 197 patients (145 men and 52 women), with an average age of 64 years (range 40 to 82 years). The indication for successfully performed endarterectomy was claudication in 186 patients (80%), rest pain in 21 (9%), and gangrene in 24 (11%). The postoperative mortality rate was 0.8% with a complication rate of 10%. RESULTS: Eighty-two failures occurred during follow-up, of which 33 were treated with peripheral bypass. Five additional bypasses were performed because of occlusions distal from the endarterectomized segment. The 5-year primary overall patency rate of successfully performed endarterectomy was 71% (SE 3.6). The 5-year overall secondary bypass patency rate was 61% (SE 11.3). The combined endarterectomy and bypass patency rate (tertiary patency) was 79% (SE 3.3) after 5 years and 45% (SE 7.6) after 10 years. The overall amputation rate was 5.6% and the amputation rate was 1.6% in patients treated for claudication. CONCLUSIONS: The combination of endarterectomy and peripheral bypass provides a valuable alternative to the current treatment of superficial femoral artery occlusive disease.
Arterial Occlusive Diseases↗
How can the assessment of the hemodynamic significance of aortoiliac arterial stenosis by duplex scanning be improved? A comparative study with intraarterial pressure measurement.
PURPOSE: The current diagnostic criteria used to assess the severity of stenoses in the aortoiliac arteries by duplex scanning are mainly based on information related to changes in cross-sectional area and are flow independent. Consequently, duplex scanning fails to detect approximately one quarter of hemodynamically significant aortoiliac lesions compared with intraarterial pressure measurements. The aim of this study is to improve the assessment of the hemodynamic significance of aortoiliac lesions by duplex scanning. METHODS: A prospective study in 60 patients was performed in which duplex scanning at rest was compared with intraarterial pressure measurements before and after the administration of papaverine. A simplified Bernoulli equation was used to calculate pressure gradients across stenoses (delta PBern). Two flow-related parameters, the increase in peak systolic velocity (delta PSV) across the stenosis and the end-diastolic velocity at the site of the stenosis, were also measured and compared with intraarterial pressure measurements. RESULTS: delta PBern and delta PSV showed a sensitivity and specificity of 81% and 88%, respectively, for the detection of hemodynamically significant lesions at rest. However, delta PBern could often not give an accurate calculation of the pressure gradient. Receiver operator characteristic analysis showed that a cut-off level for delta PSV in the range of 1.4 to 1.5 m/s was best able to detect significant lesions at rest. The end-diastolic velocity parameter had a limited diagnostic value. CONCLUSION: Although useful in clinical decision making, delta PBern often could not give an accurate calculation of the pressure gradient. delta PSV is a simple and practical spectral analysis parameter to differentiate between significant and insignificant stenoses. This parameter also has the potential to detect hemodynamically less critical lesions if duplex scanning is performed under conditions of increased flow. Further evaluation is needed.
Aorta, Abdominal↗
Endarterectomy of the superficial femoral artery: a procedure worth reconsidering.
The preferred management of superficial femoral artery occlusive disease remains unresolved. The oldest technique for restoring vascular continuity, endarterectomy, has been largely replaced by bypass operations and percutaneous transluminal angioplasty. We have continued to perform semi-closed endarterectomy in selected cases and review here a series of 231 consecutive cases in 197 patients treated during the last 10 years. The indication for the endarterectomy was disabling claudication in 186 operations (80%), rest pain in 21 (9%) and gangrene in 24 (11%). The superficial femoral artery abnormality consisted of 1-10 cm occlusion in 52 cases (23%), > 10 cm occlusion in 96 (41%), single stenosis in 21 (9%), multiple stenoses in 28 (12%) and it was unknown in 34 cases (15%). Postoperative mortality was 0.8% with a complication rate of 10%. Five year cumulative primary patency was 71% overall, 75% in patients with disabling claudication, 61% in those with rest pain and 46% in those with gangrene. Eight year patency was 55% (S.E. 5.4%). No difference in 5-year cumulative patency was seen between treatment for stenosis or occlusion (74 and 70%, respectively). The results of earlier studies and the current study raise the question of whether endarterectomy should be the first treatment of choice in obstructive lesions of the superficial femoral artery. The results of endarterectomy are better than can be achieved with angioplasty and compare well with the results of femoropopliteal bypass. Endarterectomy has specific advantages above femoro-popliteal bypass: the autologous saphenous vein is spared for future use and in case of failure of the endarterectomy, femoro-popliteal bypass remains possible.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Acute complicated pancreatitis: redefining the role of interventional radiology.
Computed tomographic (CT) scans in 30 patients who had undergone percutaneous drainage for acute complicated pancreatitis were retrospectively studied to determine the role of percutaneous drainage. Fifty-nine collections were percutaneously drained in these 30 patients. Eighty-one catheters were placed in the 59 collections (average, 1.4 catheters per patient). Patients required an average of three catheter manipulations, seven abdominal CT scans, 5 weeks of catheter drainage, a mean hospital stay of 82 days (range, 42-122 days), and a mean intensive care unit stay of 31 days (range, 1-62 days). Percutaneous intervention was successful in 14 patients, partially successful in four, and unsuccessful in eight. A temporizing effect was seen in four patients. Percutaneous intervention was successful in one of 10 central (pancreas and lesser sac areas) collections and 28 of 49 peripheral collections. Surgical debridement was necessary in 16 patients because of failed or incomplete percutaneous drainage. Complications occurred in five patients, and the mortality rate was 33%. Drainage of central areas should initially be performed by a surgeon, while peripheral collections should be drained percutaneously as they develop.
Acute Disease↗
Value of duplex scanning compared with angiography and pressure measurement in the assessment of aortoiliac arterial lesions.
To detect haemodynamically significant lesions in the aortoiliac arteries, invasive tests such as angiography and intra-arterial pressure measurement (IAPM) are considered valuable diagnostic tools. The value of duplex scanning as a direct non-invasive examination technique was prospectively compared with intra-arterial digital subtraction angiography (IADSA) and IAPM at rest, and after the administration of papaverine in 60 patients. Excellent agreement, as assessed by the kappa statistic, was shown between duplex scanning and IADSA (kappa = 0.81). A fair agreement was shown between duplex scanning and IAPM (kappa = 0.63), and between IADSA and IAPM (kappa = 0.63). Duplex scanning and IADSA both missed some less haemodynamically critical lesions if IAPM was considered the 'gold standard'. It is concluded that duplex scanning detects haemodynamically significant lesions as effectively as angiography and so may be considered a new and valuable diagnostic tool. IAPM remains necessary to detect some lesions of borderline haemodynamic significance. However, with future developments, duplex scanning has the potential to replace the need even for IAPM.
Angiography, Digital Subtraction↗
Spectral analysis criteria in duplex scanning of aortoiliac and femoropopliteal arterial disease.
To validate the use of duplex scanning in the detection of lesions in the aortoiliac and femoropopliteal arteries, duplex scanning was prospectively compared to intra-arterial digital subtraction angiography in 61 patients with peripheral atherosclerotic disease. Based on a peak systolic velocity ratio greater than or equal to 2.5 or the absence of a Doppler signal, the overall sensitivity and specificity to detect lesions of greater than or equal to 50% diameter reduction was 84% and 96%, although some segments in the femoropopliteal arteries showed a sensitivity of only 60%-70%. Occlusions were detected with an overall sensitivity of 92% and specificity of 99%. The existence of a bi/triphasic Doppler signal, a window in the systolic spectral waveform and an end diastolic velocity greater than or equal to 60 cm/s has additional value in further grading of stenoses. This study shows that duplex scanning is highly comparable to angiography in the detection greater than or equal to 50% diameter reducing lesions in the aortoiliac arteries. Further evaluation is needed for the femoropopliteal arteries.
Angiography, Digital Subtraction↗
Duplex scanning in the diagnosis of acute deep vein thrombosis of the lower extremity.
In a prospective study the value of duplex scanning in the diagnosis of acute femoro-popliteal thrombosis was compared to conventional contrast venography (CV) as a gold standard. A total of 126 legs in 117 patients suspected of having deep vein thrombosis (DVT) or pulmonary embolism (PE) were examined with both methods. CV and duplex scanning were diagnostic in 98.5 and 97%, respectively. Femoro-popliteal thrombosis was present in 64 legs (prevalence 54%). The sensitivity and specificity of duplex scanning were 90.6% and 94.6%, respectively. A marked improvement in sensitivity from 83.3 to 97% and overall accuracy from 88.7 to 96% was noticed between the first and second half of the study period. Of the individual duplex criteria in the diagnosis of DVT, abnormal vessel wall compressibility was the most accurate. The Doppler measurements however allow evaluation of venous areas difficult to assess with B-mode and add discrimination between partial or total vein occlusion. Duplex scanning is more accurate compared to CV in grading the anatomical extent of thrombosis. Agreement between venography and duplex scanning was found in 75% of the vein segments, in about 20% CV suggested more thrombus formation compared to duplex scanning. Thrombus in the deep femoral vein was documented by duplex scanning in 24 patients including two cases of isolated deep femoral vein thrombosis. Venography failed to visualise the deep femoral vein with sufficient diagnostic accuracy in 88% of the patients vs. 8.5% with duplex scanning. Duplex scanning is an accurate non-invasive test in the diagnosis of acute femoro-popliteal thrombosis and superior to CV in the detection of non-occlusive and deep femoral vein thrombosis.
Acute Disease↗
Duplex scanning in cerebral, abdominal and peripheral arterial disease.
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Aorta, Abdominal↗