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Identifying peripheral arterial disease in the elderly patients using machine-learning algorithms. Aging Clin Exp Res 2022; 34:679-685. [PMID: 34570316 DOI: 10.1007/s40520-021-01985-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/12/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Peripheral artery disease (PAD) is a common syndrome in elderly people. Recently, artificial intelligence (AI) algorithms, in particular machine-learning algorithms, have been increasingly used in disease diagnosis. AIM In this study, we designed an effective diagnostic model of PAD in the elderly patients using artificial intelligence. METHODS The study was performed with 539 participants, all over 80 years in age, who underwent the measurements of Doppler ultrasonography and ankle-brachial pressure index (ABI). Blood samples were collected. ABI and two machine-learning algorithms (MLAs)-logistic regression and a random forest (RF) model-were established to diagnose PAD. The sensitivity and specificity of the models were analyzed. An additional RF model was designed based on the most significant features of the original RF model and a prospective study was conducted to demonstrate its external validity. RESULTS Thirteen of the 28 features introduced to the MLAs differed significantly between PAD and non-PAD participants. The respective sensitivities and specificities of logistic regression, RF, and ABI were as follows: logistic regression (81.5%, 83.8%), RF (89.3%, 91.6%) and ABI (85.1%, 84.5%). In the prospective study, the newly designed RF model based on the most significant seven features exhibited an acceptable performance rate for the diagnosis of PAD with 100.0% sensitivity and 90.3% specificity. CONCLUSIONS An RF model was a more effective method than the logistic regression and ABI for the diagnosis of PAD in an elderly cohort.
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH, Aboyans V, Aksoy M, Alexandrescu VA, Armstrong D, Azuma N, Belch J, Bergoeing M, Bjorck M, Chakfé N, Cheng S, Dawson J, Debus ES, Dueck A, Duval S, Eckstein HH, Ferraresi R, Gambhir R, Gargiulo M, Geraghty P, Goode S, Gray B, Guo W, Gupta PC, Hinchliffe R, Jetty P, Komori K, Lavery L, Liang W, Lookstein R, Menard M, Misra S, Miyata T, Moneta G, Munoa Prado JA, Munoz A, Paolini JE, Patel M, Pomposelli F, Powell R, Robless P, Rogers L, Schanzer A, Schneider P, Taylor S, De Ceniga MV, Veller M, Vermassen F, Wang J, Wang S. Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia. Eur J Vasc Endovasc Surg 2019; 58:S1-S109.e33. [PMID: 31182334 PMCID: PMC8369495 DOI: 10.1016/j.ejvs.2019.05.006] [Citation(s) in RCA: 678] [Impact Index Per Article: 135.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
GUIDELINE SUMMARY Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, CA, USA.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, IL, USA
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, and University of Berne, Berne, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia, Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, TX, USA
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN, USA
| | - Victor Aboyans
- Department of Cardiology, Dupuytren, University Hospital, France
| | - Murat Aksoy
- Department of Vascular Surgery American, Hospital, Turkey
| | | | | | | | - Jill Belch
- Ninewells Hospital University of Dundee, UK
| | - Michel Bergoeing
- Escuela de Medicina Pontificia Universidad, Catolica de Chile, Chile
| | - Martin Bjorck
- Department of Surgical Sciences, Vascular Surgery, Uppsala University, Sweden
| | | | | | - Joseph Dawson
- Royal Adelaide Hospital & University of Adelaide, Australia
| | - Eike S Debus
- University Heart Center Hamburg, University Hospital Hamburg-Eppendorf, Germany
| | - Andrew Dueck
- Schulich Heart Centre, Sunnybrook Health, Sciences Centre, University of Toronto, Canada
| | - Susan Duval
- Cardiovascular Division, University of, Minnesota Medical School, USA
| | | | - Roberto Ferraresi
- Interventional Cardiovascular Unit, Cardiology Department, Istituto Clinico, Città Studi, Milan, Italy
| | | | - Mauro Gargiulo
- Diagnostica e Sperimentale, University of Bologna, Italy
| | | | | | | | - Wei Guo
- 301 General Hospital of PLA, Beijing, China
| | | | | | - Prasad Jetty
- Division of Vascular and Endovascular Surgery, The Ottawa Hospital and the University of Ottawa, Ottawa, Canada
| | | | | | - Wei Liang
- Renji Hospital, School of Medicine, Shanghai Jiaotong University, China
| | - Robert Lookstein
- Division of Vascular and Interventional Radiology, Icahn School of Medicine at Mount Sinai
| | | | | | | | | | | | | | - Juan E Paolini
- Sanatorio Dr Julio Mendez, University of Buenos Aires, Argentina
| | - Manesh Patel
- Division of Cardiology, Duke University Health System, USA
| | | | | | | | - Lee Rogers
- Amputation Prevention Centers of America, USA
| | | | - Peter Schneider
- Kaiser Foundation Hospital Honolulu and Hawaii Permanente Medical Group, USA
| | - Spence Taylor
- Greenville Health Center/USC School of Medicine Greenville, USA
| | | | - Martin Veller
- University of the Witwatersrand, Johannesburg, South Africa
| | | | - Jinsong Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shenming Wang
- The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, Mills JL, Ricco JB, Suresh KR, Murad MH. Global vascular guidelines on the management of chronic limb-threatening ischemia. J Vasc Surg 2019; 69:3S-125S.e40. [PMID: 31159978 PMCID: PMC8365864 DOI: 10.1016/j.jvs.2019.02.016] [Citation(s) in RCA: 654] [Impact Index Per Article: 130.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.
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Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, Calif.
| | - Andrew W Bradbury
- Department of Vascular Surgery, University of Birmingham, Birmingham, United Kingdom
| | - Philippe Kolh
- Department of Biomedical and Preclinical Sciences, University Hospital of Liège, Wallonia, Belgium
| | - John V White
- Department of Surgery, Advocate Lutheran General Hospital, Niles, Ill
| | - Florian Dick
- Department of Vascular Surgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Robert Fitridge
- Department of Vascular and Endovascular Surgery, The University of Adelaide Medical School, Adelaide, South Australia
| | - Joseph L Mills
- Division of Vascular Surgery and Endovascular Therapy, Baylor College of Medicine, Houston, Tex
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University Hospitalof Poitiers, Poitiers, France
| | | | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, Minn
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Gryseleyn R, Schlund M, Pigache P, Wojcik T, Raoul G, Ferri J. Influence of preoperative imaging on fibula free flap harvesting. JOURNAL OF STOMATOLOGY, ORAL AND MAXILLOFACIAL SURGERY 2017; 118:265-270. [PMID: 28529045 DOI: 10.1016/j.jormas.2017.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/22/2017] [Accepted: 05/12/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The fibula free flap (FFF) is the gold standard for the reconstruction of large maxillofacial defects. Magnetic resonance angiography (MRA) seems to supersede digital subtraction angiography (DSA) as the reference in preoperative evaluation, being non-invasive and having equivalent diagnostic results. The aim of this study was to assess the impact of preoperative MRA versus DSA on the viability of FFF and its success rate. MATERIAL AND METHODS A total of 216 patients, who underwent mandibular or maxillary FFF reconstruction from January 1995 to January 2011, were retrospectively included in the study. Of them, 101 patients underwent preoperative DSA and 115 underwent MRA. Recorded criteria were as follows: age, sex, tobacco consumption, defect etiology, preoperative vascular assessment, donor-site choice and flap failure. The DSA group was compared to the MRA group. RESULTS The harvested side was switched in 15.7% of cases with preoperative MRA versus 4% with DSA. Our success rate was higher (96.1%) with MRA than with DSA (88.1%) (P<0.05). More atherosclerotic patients (P=0.004) were diagnosed through MRA. MRA and DSA showed similar results in anatomical variation detection. CONCLUSION MRA is less invasive and more effective in atherosclerosis detection than DSA. Therefore, donor-site switching was more frequent in the MRA group, which led to a better success rate. MRA should replace DSA as the reference in preoperative assessment.
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Affiliation(s)
- R Gryseleyn
- Service de stomatologie et chirurgie maxillo-faciale, université Lille 2, hôpital Roger-Salengro, CHU Lille, 59000 Lille, France
| | - M Schlund
- Service de stomatologie et chirurgie maxillo-faciale, université Lille 2, hôpital Roger-Salengro, CHU Lille, 59000 Lille, France.
| | - P Pigache
- Service de stomatologie et chirurgie maxillo-faciale, université Lille 2, hôpital Roger-Salengro, CHU Lille, 59000 Lille, France
| | - T Wojcik
- Département de cancérologie cervico-faciale, centre Oscar-Lambret, université Lille 2, 59000 Lille, France
| | - G Raoul
- Service de stomatologie et chirurgie maxillo-faciale, université Lille 2, hôpital Roger-Salengro, CHU Lille, 59000 Lille, France; Inserm U 1008, controlled drug delivery systems and biomaterials, 59000 Lille, France
| | - J Ferri
- Service de stomatologie et chirurgie maxillo-faciale, université Lille 2, hôpital Roger-Salengro, CHU Lille, 59000 Lille, France; Inserm U 1008, controlled drug delivery systems and biomaterials, 59000 Lille, France
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Hingorani A, Ascher E, Marks N, Mutyala M, Shiferson A, Flyer M, Jacob T. Comparison of Computed Tomography Angiography to Contrast Arteriography for Patients Undergoing Evaluation for Lower Extremity Revascularization. Vasc Endovascular Surg 2016; 41:115-9. [PMID: 17463200 DOI: 10.1177/1538574406297265] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In an effort to explore alternatives to contrast arteriography, we compared computed tomography angiography to contrast arteriography for defining anatomic features of patients undergoing lower extremity revascularization. From November 2003 to March 2004, 36 inpatients with chronic lower extremity ischemia underwent contrast arteriography and computed tomography angiography before undergoing lower extremity revascularization procedures. A Siemens 16 slice multiplanar computed tomography device with bolus tracking was used for these exams. The reports of these tests and images were compared prospectively, and the differences in the aorto-iliac segment, femoral-popliteal, and infrapopliteal segments were noted. The vessels were classified as mild disease (<50%), moderate disease (50%-70%), severe (71%-99%), and occluded. The studies and treatment plans based on these data were compared. The mean age was 76 ± 12 years (SD). Indications for the procedures included gangrene (45%), ischemic ulcer (32%), rest pain (19%), and severe claudication (3%); 69% were diabetics. Accuracy of computed tomography angiography in the aorto-iliac, femoral-popliteal, and infrapopliteal segments was 100%, 81%, and 59%, respectively. Thirteen of 18 (72%) of these disagreements resulted in a different procedure than that suggested by computed tomography angiography. A review of the data obtained in this series indicated that computed tomography angiography appears to be unable to obtain adequate information in this highly selected population at our institution.
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Affiliation(s)
- Anil Hingorani
- Division of Vascular Surgery, Department of Surgery, Mainmonides Medcine Center, Brooklyn, New York 11219, USA
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6
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Estudio de concordancia diagnóstica entre la angiorresonancia magnética y la arteriografía en la isquemia crítica de miembros inferiores. ANGIOLOGIA 2015. [DOI: 10.1016/j.angio.2014.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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7
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The Use of Duplex Ultrasound Arterial Mapping (DUAM) and Preoperative Diagnostics in Patients with Atherosclerotic Ischaemia of Lower Extremities. POLISH JOURNAL OF SURGERY 2012; 84:276-84. [DOI: 10.2478/v10035-012-0047-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Bonel HM, Saar B, Hoppe H, Keo HH, Husmann M, Nikolaou K, Ludwig K, Szucs-Farkas Z, Srivastav S, Kickuth R. MR Angiography of Infrapopliteal Arteries in Patients with Peripheral Arterial Occlusive Disease by Using Gadofosveset at 3.0 T: Diagnostic Accuracy Compared with Selective DSA. Radiology 2009; 253:879-90. [DOI: 10.1148/radiol.2533081627] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Ascher E, Hingorani AP, Marks N, Puggioni A, Shiferson A, Tran V, Jacob T. Predictive factors of femoropopliteal patency after suboptimal duplex-guided balloon angioplasty and stenting: is recoil a bad sign? Vascular 2009; 16:263-8. [PMID: 19238867 DOI: 10.2310/6670.2008.00091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Currently, the value of stenting during femoropopliteal balloon angioplasty (FPBA) remains unclear. Herein we evaluate the patency rates of successful duplex-guided balloon angioplasty (DAGBA) alone versus suboptimal DAGBA followed by stenting and the prestenting dissection versus recoil as potential indicators of stent success or failure. Over a period of 27 months, we performed 291 duplex-guided FPBAs (194 stenoses; 97 occlusions) on 244 limbs in 220 patients. Disabling claudication was the indication in 67%. Critical limb ischemia was the indication in the remaining 33%. Self-expanding nitinol stents were used when plaque dissection and/ or recoil caused diameter reduction > or = 40%. Serial follow-up duplex scans were obtained. Severe restenosis (> 70%) was measured by B-mode imaging and a peak systolic velocity ratio > 3. Follow-up ranged from 1 to 41 months (mean 10 +/- 8.3 months). The overall mean interval for restenosis and occlusion was 6.5 +/- 4.2 months and 5.6 +/- 6.1 months, respectively. Stents did affect overall patency results compared with not using stents. Reasons for stenting were plaque recoil, dissection, or both in 98 (53%), 44 (24%), and 42 (23%) cases, respectively. Six-month patency was 59%, 94%, and 69%, respectively. The difference between plaque recoil and dissection was significant (p<.04). The use of stents during FPBA may be associated with balloon angioplasty site failure in the femoropopliteal segment. To our knowledge, this is the first report ever to document plaque recoil as a predictor of balloon angioplasty site failure notwithstanding stent placement.
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Affiliation(s)
- Enrico Ascher
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY 11219, USA.
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10
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Diehm N, Pattynama P, Jaff M, Cremonesi A, Becker G, Hopkins L, Mahler F, Talen A, Cardella J, Ramee S, van Sambeek M, Vermassen F, Biamino G. Clinical Endpoints in Peripheral Endovascular Revascularization Trials: a Case for Standardized Definitions. Eur J Vasc Endovasc Surg 2008; 36:409-19. [DOI: 10.1016/j.ejvs.2008.06.020] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2008] [Accepted: 06/14/2008] [Indexed: 11/25/2022]
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Hingorani AP, Ascher E, Marks N, Puggioni A, Shiferson A, Tran V, Jacob T. Limitations of and Lessons Learned from Clinical Experience of 1,020 Duplex Arteriography. Vascular 2008; 16:147-53. [DOI: 10.2310/6670.2008.00014] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective: Due to the inherent risks, deficiencies and cost associated with contrast arteriography (CA), our group has been utitilizing duplex arteriography (DA) for evaluating the arteries of the lower extremity for patients undergoing lower extremity revascularization. In an effort to further explore the strengths and weaknesses of DA, we reviewed our evolving experience with DA from January 1, 1998, to January 1, 2005. Patients and Methods: The arterial segments starting from mid-abdominal aorta to the pedal arteries were studied in cross-sectional and longitudinal planes using a variety of scanheads of 7–4, 10–5, 12–5, 5–2 and 3–2 MHz extended operative frequency range to obtain high-quality B-mode, color and power Doppler images as well as velocity spectra. In 906 patients, 1,020 duplex arteriograms were obtained. The ages ranged from 30–98 years old with a mean of 73±11 (SD) years. Fifty percent of the patients were diabetics. Indications for the examination included: tissue loss (409), rest pain (221), claudication (310), acute ischemia (74), popliteal aneurysm (45), SFA aneurysm (2), abdominal aortic aneurysms (AAA) (10) and failing bypass (55). Prior procedures had been performed in 262. DA was performed by six technologists (4 of whom are MDs). In all, 207 DA were performed intraoperatively and the remainder, preoperatively. Results: The resultant procedures based upon DA included: bypass to the popliteal artery (262) and bypass to an infrapopliteal artery (325), endovascular procedures (363), thrombectomy (11), embolectomy (9), inflow bypass procedures to the femoral arteries (46), débridment (4), amputation (8) and no intervention (75). The areas not visualized well included: iliac (73), femoral (26), popliteal (17), and infrapopliteal (221). Additional imaging after DA was deemed necessary in 102 cases to obtain enough information to plan lower extremity revascularization. Factors associated with increased need to obtain CA included: DM ( p<.001), infrapopliteal calcification ( p<.001), older age ( p = .01) and limb threatening ischemia ( p<.001). Factors not associated with the need to obtain CA included: which technologist performed the exam, whether the technologist has a medical degree and whether the patient underwent prior revascularization. Conclusions: In 90% of patients reviewed, DA is able to obtain the needed information to plan lower extremity revascularization. Severe tibial vessel calcification is the most common cause of an incomplete DA exam and determines when alternative imaging modalities need to be obtained.
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Affiliation(s)
- Anil P. Hingorani
- *Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Enrico Ascher
- *Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Natalie Marks
- *Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | | | | | - Victor Tran
- *Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
| | - Theresa Jacob
- *Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY
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Gargiulo M, Maioli F, Ceccacci T, Morselli-Labate AM, Faggioli G, Freyrie A, Giovanetti F, Testi G, Muccini N, Stella A. What's Next After Optimal Infrapopliteal Angioplasty? Clinical and Ultrasonographic Results of a Prospective Single-Center Study. J Endovasc Ther 2008; 15:363-9. [DOI: 10.1583/08-2423.1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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13
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Lowery AJ, Hynes N, Manning BJ, Mahendran M, Tawfik S, Sultan S. 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. Ann Vasc Surg 2007; 21:443-51. [PMID: 17628263 DOI: 10.1016/j.avsg.2006.08.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Revised: 07/24/2006] [Accepted: 08/10/2006] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- A J Lowery
- Western Vascular Institute, University College Hospital, Galway, Ireland
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Diehm N, Kickuth R, Baumgartner I, Srivastav SK, Gretener S, Husmann MJ, Jaccard Y, Do DD, Triller J, Bonel HM. Magnetic Resonance Angiography in Infrapopliteal Arterial Disease. Invest Radiol 2007; 42:467-76. [PMID: 17507820 DOI: 10.1097/01.rli.0000262581.52315.ef] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE To prospectively determine the accuracy of 1.5 Tesla (T) and 3 T magnetic resonance angiography (MRA) versus digital subtraction angiography (DSA) in the depiction of infrageniculate arteries in patients with symptomatic peripheral arterial disease. PATIENTS AND METHODS A prospective 1.5 T, 3 T MRA, and DSA comparison was used to evaluate 360 vessel segments in 10 patients (15 limbs) with chronic symptomatic peripheral arterial disease. Selective DSA was performed within 30 days before both MRAs. The accuracy of 1.5 T and 3 T MRA was compared with DSA as the standard of reference by consensus agreement of 2 experienced readers. Signal-to-noise ratios (SNR) and signal-difference-to-noise ratios (SDNRs) were quantified. RESULTS No significant difference in overall image quality, sufficiency for diagnosis, depiction of arterial anatomy, motion artifacts, and venous overlap was found comparing 1.5 T with 3 T MRA (P > 0.05 by Wilcoxon signed rank and as by Cohen k test). Overall sensitivity of 1.5 and 3 T MRA for detection of significant arterial stenosis was 79% and 82%, and specificity was 87% and 87% for both modalities, respectively. Interobserver agreement was excellent k > 0.8, P < 0.05) for 1.5 T as well as for 3 T MRA. SNR and SDNR were significantly increased using the 3 T system (average increase: 36.5%, P < 0.032 by t test, and 38.5%, P < 0.037 respectively). CONCLUSIONS Despite marked improvement of SDNR, 3 T MRA does not yet provide a significantly higher accuracy in diagnostic imaging of atherosclerotic lesions below the knee joint as compared with 1.5 T MRA.
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Affiliation(s)
- Nicolas Diehm
- Division of Angiology, Swiss Cardiovascular Center, Inselspital, University of Bern, Bern, Switzerland
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Hingorani A, Ascher E, Marks N. Preprocedural imaging: new options to reduce need for contrast angiography. Semin Vasc Surg 2007; 20:15-28. [PMID: 17386360 DOI: 10.1053/j.semvascsurg.2007.02.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In vascular surgery, the gold standard for evaluation of the lower-extremity arterial tree has long been contrast arteriography (CA). Associated risks of CA are well-documented and include severe allergic reactions, arterial injury and/or hemorrhage, and contrast-induced nephropathy. Increasingly, less-invasive techniques, with fewer inherent risks for complication, are being explored as diagnostic alternatives. Magnetic resonance angiography, computed tomography angiography, and duplex arteriography, each offer distinct advantages, though are not without limitation. This review explores the indications, advantages, and disadvantages of these newer technologies and provides a comparison to CA as a means for defining the anatomic features of patients undergoing lower-extremity revascularization. This data suggests that noninvasive imaging technologies may, in the future, play an increasingly important role in the surgical evaluation of the patient with lower-extremity ischemia.
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Affiliation(s)
- Anil Hingorani
- Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY 11219, USA.
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Sensibilidad, especificidad y fiabilidad de la ecografía Doppler arterial en el diagnóstico de la isquemia crítica de los miembros inferiores con relación a la arteriografía. ANGIOLOGIA 2007. [DOI: 10.1016/s0003-3170(07)75035-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Ascher E, Marks NA, Hingorani AP, Schutzer RW, Mutyala M. Duplex-guided endovascular treatment for occlusive and stenotic lesions of the femoral-popliteal arterial segment: A comparative study in the first 253 cases. J Vasc Surg 2006; 44:1230-7; discussion 1237-8. [PMID: 17055689 DOI: 10.1016/j.jvs.2006.08.025] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2006] [Accepted: 08/10/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The standard technique of balloon angioplasty with or without subintimal dissection of infrainguinal arteries requires contrast arteriography and fluoroscopy. We attempted to perform this procedure with duplex guidance to avoid the use of nephrotoxic contrast material and eliminate or minimize radiation exposure. METHODS From September 2003 to June 2005, 196 patients (57% male) with a mean age of 73 +/- 10 years (range, 42-97 years) had a total of 253 attempted balloon angioplasties of the superficial femoral and/or popliteal artery under duplex guidance in 218 limbs. Critical ischemia was the indication in 38% of cases, and disabling claudication was the indication in 62%. Hypertension, diabetes, chronic renal insufficiency, smoking, and coronary artery disease were present in 78%, 51%, 41%, 39%, and 37% of patients, respectively. The TransAtlantic Inter-Society Consensus (TASC) classification was used for morphologic description of femoral-popliteal lesions. The common femoral artery was cannulated under direct duplex visualization. Still under duplex guidance, a guidewire was directed into the proximal superficial femoral artery, across the diseased segment(s), and parked at the tibioperoneal trunk. The diseased segment(s) were then balloon-dilated. Balloon diameter and length were chosen according to arterial measurements obtained by duplex scan. Hemodynamically significant defects causing diameter reductions greater than 30% and peak systolic velocity ratios greater than 2 were stented with a variety of self-expandable stents under duplex guidance. Completion duplex examinations and ankle-brachial indices were obtained routinely before hospital discharge. RESULTS There were 11 (4%) TASC class A lesions, 31 (12%) TASC class B lesions, 177 (70%) TASC class C lesions, and 34 (14%) TASC class D lesions in this series. The overall technical success was 93% (236/253 cases). Eight of the 17 failed subintimal dissections belonged to TASC class C and the remaining 9 to TASC class D. End-stage renal disease was the only significant predictor of subintimal dissection failure in patients with femoral-popliteal occlusions (5/17 cases; P < .04). Intraluminal stents were placed in 153 (65%) of 236 successful cases. Overall pre-procedure and post-procedure ankle-brachial indices changed from a mean of 0.69 +/- 0.16 (range, 0.2-1.1) to 0.95 +/- 0.14 (range, 0.55-1.3), respectively (P < .0001). The mean duration of follow-up was 10 +/- 7 months (range, 1-29 months). The overall 30-day survival rate was 100%. Overall limb salvage rates were 94% and 90% at 6 and 12 months, respectively. Six-month patency rates for TASC class A, B, C, and D lesions were 89%, 73%, 72%, and 63%, respectively. Twelve-month patency rates for TASC class A, B, C, and D lesions were 89%, 58%, 51%, and 45%, respectively. CONCLUSIONS Duplex-guided balloon angioplasty and stent placement seems to be a safe and effective technique for the treatment of infrainguinal arterial occlusive disease. Technical advantages include direct visualization of the puncture site, accurate selection of the proper size balloon and stent, and confirmation of the adequacy of the technique by hemodynamic and imaging parameters. Additional benefits are avoidance of radiation exposure and contrast material.
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Gjønnaess E, Morken B, Sandbaek G, Stranden E, Slagsvold CE, Jørgensen JJ, Nylaende M, Abdelnoor M, Dullerud R. Gadolinium-enhanced Magnetic Resonance Angiography, Colour Duplex and Digital Subtraction Angiography of the Lower Limb Arteries from the Aorta to the Tibio-peroneal Trunk in Patients with Intermittent Claudication. Eur J Vasc Endovasc Surg 2006; 31:53-8. [PMID: 16269254 DOI: 10.1016/j.ejvs.2005.09.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2005] [Accepted: 09/12/2005] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To evaluate the sensitivity, specificity, positive and negative predictive value of contrast-enhanced (gadolinium) magnetic resonance imaging (CE-MRA) and colour duplex ultrasound (CDU) of lower limb arteries. DESIGN Prospective, single centre study. MATERIAL AND METHODS A consecutive series of 58 patients with intermittent claudication (IC) were examined with CE-MRA and CDU from the infrarenal aorta to the tibio-peroneal trunk with digital subtraction angiography (DSA) as reference. The arterial tree was divided into 15 segments, pooled into three regions; suprainguinal, thigh and knee. Sensitivity, specificity, positive and negative predictive values for significant obstructions were calculated. Cohen Kappa statistics was used to establish agreement between the three methods. RESULTS The sensitivity (specificity in parentheses) for significant obstructions in the suprainguinal region were 96% (94%) for CE-MRA and 91% (96%) for CDU, in the thigh region 92% (95%) for CE-MRA and 76% (99%) for CDU, and in the knee region 93% (96%) for CE-MRA and 33% (98%) for CDU. CDU failed to visualize 10% of suprainguinal, 2% of thigh and 13% of knee-region arterial segments. CONCLUSIONS Both CE-MRA and CDU are good alternatives to DSA in the suprainguinal- and thigh-region. In the knee region only CE-MRA can be relied upon as an alternative to DSA. Imaging by CDU is not suited to situations were evaluation of runoff vessels is important.
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Affiliation(s)
- E Gjønnaess
- Department of Radiology, Aker University Hospital, Oslo, Norway.
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