Limitations of and lessons learned from clinical experience of 1,020 duplex arteriography.
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.


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.
Hingorani
Anil P
AP
Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, NY, USA.
Ascher
Enrico
E
Marks
Natalie
N
Puggioni
Alessandra
A
Shiferson
Alexander
A
Tran
Victor
V
Jacob
Theresa
T
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015901:Angiography, Digital Subtraction; D003287:Contrast Media; D003925:Diabetic Angiopathies / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D007511:Ischemia / Q000000981:diagnostic imaging* / Q000601:surgery; D035002:Lower Extremity / Q000098:blood supply* / Q000000981:diagnostic imaging; D008875:Middle Aged; D018616:Ultrasonography, Doppler, Duplex / Q000379:methods*; D018084:Ultrasonography, Interventional / Q000379:methods; D014656:Vascular Surgical Procedures / Q000379:methods*
D003287:Contrast Media