Lower extremity bypass using only duplex ultrasonography: is the time now?
Imaging for lower extremity arterial bypasses continues to evolve as distal target vessels are more frequently small infragenicular arteries. For these procedures to be properly planned and executed, accurate anatomic knowledge of the lower extremity arterial system and potential venous conduits is essential. The utility of current imaging methods for planning lower extremity revascularization is examined, including the relatively recent use of duplex arterial mapping. Arteriography is a poor "gold standard" in many cases of iliac and infrainguinal arterial occlusive disease. Duplex arterial scanning can be performed successfully in patients being considered for lower extremity revascularization. Patients with isolated stenoses or short occlusions, particularly those above the inguinal ligament, may be identified in whom percutaneous endovascular therapy is appropriate, depending on their clinical presentation. Patients with more severe disease may be taken to the operating room, where the quality of the inflow is evaluated with arterial pressure measurement. If the inflow pressure is not equal to systemic pressure, arteriography with pullback pressure measurements can be performed, and the responsible lesion can be identified and appropriately treated. Once inflow obstruction has been corrected, intraoperative outflow arteriography is performed. If duplex arterial mapping does not demonstrate a distal site for bypass, arteriography should be performed, as a preoperative or intraoperative study, before considering amputation. This approach should decrease the cost and complications of lower extremity revascularization while allowing treatment planning for lower extremity vascular occlusive disease to be based on accurate anatomic and physiological data.
Walsh
D B
DB
Department of Surgery and the Noninvasive Vascular Laboratory, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
LaBombard
E
E
D000792:Angiography; D001166:Arteriovenous Shunt, Surgical / Q000379:methods*; D006801:Humans; D007866:Leg / Q000098:blood supply* / Q000000981:diagnostic imaging* / Q000601:surgery; D018616:Ultrasonography, Doppler, Duplex