Calf vessel preservation in peripheral vascular disease--angiography versus pulse generated run-off

Can cruropedal colour duplex scanning and pulse generated run-off replace angiography in candidates for distal bypass surgery

PURPOSE

To compare the diagnostic accuracy of duplex scanning (DS) and pulse generated run-off (PGR) with ia-DSA for the assessment of cruropedal outflow and explore the reliability of clinical decision making based on a work-up with DS/PGR in candidates for peripheral bypass surgery.

METHODS

Popliteal, crural and pedal arteries were evaluated independently with DS and ia-DSA in 126 limbs of 120 consecutive patients for claudication (16%) or critical ischaemia (84%). Arterial segments were graded with DS and ia-DSA as normal, stenosed, or occluded and compared using weighted kappa (kappa) analysis. PGR was used to select the best crural artery for bypass. Proposed management based on DS/PGR and, if applicable, anastomosis site were compared to definitive treatment based on ia-DSA.

RESULTS

Overall agreement between DS and ia-DSA for popliteal and crural arteries was moderate (kappa 0.51, 95% CI 0.48-0.55) with good agreement within the popliteal (kappa 0.67) and anterior tibial (kappa 0.61) arteries. Agreement was moderate within the pedal arterieds (kappa 0.32, 95% CI 0.24-0.40). In 74/126 (59%) limbs proposed management with DS/PGR was identical to ia-DSA. In 23/29 (79%) femoropopliteal and 15/37 (41%) femorocrural bypasses DS/PGR agreed perfectly with ia-DSA with regard to acceptor artery and anastomosis site.

CONCLUSION

DS can accurately assess the popliteal and anterior tibial arteries. In a substantial number of patients with severe lower limb ischaemia decisions for conservative management, PTA and femoropopliteal bypass can be based on a DS/PGR work-up.

Have the results of infrainguinal bypass improved with the widespread utilisation of postoperative surveillance?

OBJECTIVES

The objectives of this study were to assess the impact of Duplex surveillance on the results of infrainguinal vein grafts. A review has been performed comparing the outcome of vein grafts undergoing Duplex surveillance plus prophylactic treatment of stenoses to that of vein grafts followed clinically.

DESIGN, PATIENTS, AND METHODS

Only studies providing information on occlusion rates were included. Mortality and limb salvage rates were also analysed but were not available from all studies.

RESULTS

2680 surveillance and 3969 non-surveillance vein grafts were analysed. There was no significant difference between the two groups with respect to presence of critical ischaemia (p=0.3) and level of distal anastomosis (p>0.5). Surveillance identified 493 stenoses in 469 (19%) grafts, 397 (16%) grafts were treated by surgery (248; 62%) and angioplasty (149; 38%). Ninety-eight (26%) grafts developed recurrent stenoses. Total number of deaths, total number of occluded grafts and number of occlusions after 30 days were significantly greater for the non-surveillance group (p<0.001; p<0.001; p<0.01). Perioperative occlusion rates were not significantly different (p=0.1). Few surveillance studies reported limb salvage rates (6 of 17). The numbers of amputations were not significantly different between the two groups (p>0.5).

CONCLUSIONS

The patency of infrainguinal vein grafts would appear to be improved as a result of surveillance. However, no improvement in limb salvage has been demonstrated.

The "ad hoc" estimation of outflow does not predict patency of infrainguinal reconstructions

OBJECTIVES

This prospective study was performed to evaluate the clinical implication of the adhoc estimation (also called SVS score) of outflow on patency of infrainguinal in situ femoropopliteal or -distal bypasses.

METHODS

The bypasses were followed with Duplex scanning at 1, 3, 6, and 12 months after surgery. Fifty-three bypasses were recruited for the study, 20 of which were performed in 17 diabetics. In 47% the adhoc scoring was < or = 4.5 and in 53% it was between 5 and 10 (1 corresponds to an excellent outflow and 10 to a blind segment).

RESULTS

Within the first 30 days eight occlusions occurred, all of which were surgically corrected. The adhoc score for these bypasses was 4.2 vs. 4.9 (NS) for those who did not occlude. During follow-up, revisions were performed in 21 cases (40%) with 30 interventions. At the end of 1 year, 68% of the bypasses were patent (80% among diabetics and 64% among non-diabetics, NS). Patency at 1 year was not influenced by the adhoc classification.

CONCLUSION

The estimation of outflow from angiography seems to be of no value in predicting graft patency in infrainguinal grafting.

Pulse-generated run-off versus dependent Doppler ultrasonography for assessment of calf vessel patency

Pulse-generated run-off (PGR) is an established technique in the assessment of calf vessel patency. Dependent Doppler ultrasonography is proposed as a fast and simple alternative. Twenty-six limbs with severe ischaemia were evaluated by PGR, dependent Doppler examination and intra-arterial digital subtraction angiography (DSA). PGR was performed and scored as previously described. Dependent Doppler ultrasonography was performed after 5 min of foot dependency and scored as for PGR. Angiograms were scored by an independent radiologist, who awarded 2 for a vessel widely patent to the ankle, 1 for a diseased vessel crossing the ankle and 0 if no vessel was visualized. Of 78 calf vessels evaluated, 59 (76 per cent) appeared patent on PGR and dependent Doppler examination but only 33 (42 per cent) appeared patent to the ankle with intra-arterial DSA. There was very good agreement between PGR and dependent Doppler for detection of patent calf vessels (kappa = 0.93). Doppler signals were biphasic in six calf vessels on dependency and in 22 vessels with PGR. PGR and dependent Doppler ultrasonography detected 26 vessels communicating with the pedal arch compared with seven detected angiographically. There was good agreement between PGR and dependent Doppler examination for diagnosis of the most suitable vessel for distal anastomosis (kappa = 0.80). The wide availability and simplicity of dependent Doppler ultrasonography mean that no patient with a critically ischaemic limb should be denied reconstructive surgery on the basis of angiographic findings alone.