title: Comparison between angiographic and arterial duplex ultrasound assessment of tibial arteries in patients with peripheral arterial disease: on behalf of the Joint Endovascular and Non-Invasive Assessment of LImb Perfusion (JENALI) Group.
abstract: BACKGROUND
  Endovascular treatment of peripheral arterial disease (PAD) involving the tibial arteries is becoming an increasingly important part of revascularization. The current anatomical description of vessel patency in tibial arteries does not contribute effectively to therapeutic strategies. The Joint Endovascular and Non-Invasive Assessment of Limb Perfusion (JENALI) score, is a novel scoring system developed to further assess patency of tibial arteries, via both angiography and arterial duplex ultrasonography. A comparison was made between the JENALI score obtained by ultrasound and by angiography. Angiography is currently considered the gold standard of tibial artery imaging.
  
  
  METHODS
  This prospective single-center study involved 49 patients undergoing peripheral angiography for evaluation of PAD, between November 2011 and November 2012. All patients underwent a detailed ultrasound assessment of the tibial arteries ± 7 days from diagnostic angiography. Eligible patients had a Rutherford score ≥ III or abnormal ankle-brachial index values. Angiography and ultrasound were evaluated in a blinded fashion.
  
  
  RESULTS
  Average age of patients was 69.8 years. A total of 846 segments were assessed by both angiography and ultrasound. We found that 648 segments (76.6%) were deemed to be patent by angiography compared to 723 (85.5%) by ultrasound. Critical limb ischemia (CLI; Rutherford score ≥ 4) was described in 26 patients (53%). Average JENALI score for the right lower extremity was 7.0 by angiogram vs 7.7 by ultrasound. The average JENALI score of the left leg was 6.7 by angiogram vs 7.7 by ultrasound. A total of 94 lower extremities were assigned a JENALI score. Ultrasound was accurate in detecting tibial artery patency or occlusion in 80% of segments. The overall sensitivity/specificity of ultrasound detecting tibial artery patency was calculated at 93% and 40% (P<.05), respectively. Detection of patency via ultrasound was highest for the anterior tibial artery and the lowest for the peroneal artery. The angiographic and ultrasound JENALI scores better correlated with vessel patency (higher scores) than the lower angiographic and ultrasound JENALI scores.
  
  
  CONCLUSIONS
  Using the novel JENALI scoring system allowed for direct comparison between two imaging modalities. In theory, the comparison can be extended to other imaging modalities. Ultrasound imaging had a high sensitivity in detecting patent vessels confirmed by angiography. Detecting occluded segments via ultrasound was less accurate. The highest accuracy was in the more superficial arteries (ie, anterior tibial, posterior tibial), compared to the deeper peroneal arteries. Risk stratification, treatment, and patient outcomes may be future applications of the JENALI scoring system.
authors.affiliation: Metro Health Hospital, 5900 Byron Center Ave, SW, Wyoming, MI 49519 USA. Jihad.Mustapha@metrogr.org.
authors.forename: Jihad A
authors.initials: JA
authors.lastname: Mustapha
authors.forename: Fadi
authors.initials: F
authors.lastname: Saab
authors.forename: Larry
authors.initials: L
authors.lastname: Diaz-Sandoval
authors.forename: Barbara
authors.initials: B
authors.lastname: Karenko
authors.forename: Theresa
authors.initials: T
authors.lastname: McGoff
authors.forename: Carmen
authors.initials: C
authors.lastname: Heaney
authors.forename: Matthew
authors.initials: M
authors.lastname: Sevensma
mesh_terms: D000368:Aged; D000792:Angiography / Q000379:methods*; D057510:Endovascular Procedures / Q000379:methods*; D005260:Female; D006801:Humans; D007866:Leg / Q000098:blood supply*; D008297:Male; D058729:Peripheral Arterial Disease / Q000175:diagnosis* / Q000503:physiopathology / Q000601:surgery; D011379:Prognosis; D011446:Prospective Studies; D012372:ROC Curve; D015203:Reproducibility of Results; D012720:Severity of Illness Index; D016909:Tibial Arteries / Q000000981:diagnostic imaging* / Q000503:physiopathology; D018616:Ultrasonography, Doppler, Duplex / Q000379:methods*; D014654:Vascular Patency