title: Treatment planning for peripheral arterial disease based on duplex ultrasonography and computed tomography angiography: consistency, confidence and the value of additional imaging.
abstract: BACKGROUND
  Duplex ultrasonography (DUS) can be used for treatment planning for lower extremity peripheral arterial disease (PAD), but has not replaced contrast-enhanced imaging such as computed tomography angiography (CTA). We assessed DUS-based treatment planning for consistency, confidence, and the value of additional CTA among multinational surgeons.
  
  
  METHODS
  Data from 12 patients with PAD were reviewed by 2 American vascular surgeons individually and 1 Dutch vascular department by consensus. Reviewers selected treatment based on DUS first and based on added CTA second. Agreement and consistency of treatment plans was assessed using kappa statistics (κ). Imaging quality and therapeutic confidence were scored (1-5) and assessed with t-tests.
  
  
  RESULTS
  Of the 36 treatment plans formulated, additional CTA confirmed 27 (75%), changed 6 (17%), and supplemented 3 (8%) plans. The approach never changed when open revascularization was selected based on DUS (14 plans; 39%). Agreement between DUS- and CTA-based treatment planning was substantial, with a mean kappa (μκ) of 0.68, but agreement between reviewers was fair (μκ DUS, 0.24; μκ CTA, 0.23). CTA received greater average scores than DUS for quality (4.36 vs 3.29; P < .0001) and confidence (4.36 vs 3.26; P < .0001). Reviewers often expressed the need for additional imaging after DUS (mean, 63%).
  
  
  CONCLUSIONS
  PAD treatment planning based on CTA was mostly consistent with DUS-based treatment plans, although CTA was still felt to be needed to increase confidence. This observation suggests that to promote greater use of less invasive DUS imaging, not only improvement of DUS quality but also improvement of clinician confidence is required.
authors: Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Division of Vascular Surgery, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
authors: Marit S
authors: MS
authors: de Vos
authors: Division of Vascular Surgery, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
authors: Barbara J
authors: BJ
authors: Bol
authors: Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
authors: Edwin C
authors: EC
authors: Gravereaux
authors: Division of Vascular Surgery, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.
authors: Jaap F
authors: JF
authors: Hamming
authors: Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA. Electronic address: llnguyen@partners.org.
authors: Louis L
authors: LL
authors: Nguyen
mesh_terms: D000328:Adult; D000368:Aged; D000792:Angiography; D015331:Cohort Studies; D005121:Extremities / Q000098:blood supply; D005260:Female; D006801:Humans; D007383:Intermittent Claudication / Q000000981:diagnostic imaging / Q000628:therapy; D007511:Ischemia / Q000000981:diagnostic imaging / Q000628:therapy; D008297:Male; D008875:Middle Aged; D009426:Netherlands; D010347:Patient Care Planning / Q000706:statistics & numerical data; D058729:Peripheral Arterial Disease / Q000000981:diagnostic imaging* / Q000628:therapy; D010865:Pilot Projects; D014057:Tomography, X-Ray Computed; D018616:Ultrasonography, Doppler, Duplex; D014481:United States