Duplex Arteriography for Lower Extremity Revascularization
Identifieur interne : 001721 ( Istex/Corpus ); précédent : 001720; suivant : 001722Duplex Arteriography for Lower Extremity Revascularization
Auteurs : Anil P. Hingorani ; Enrico Ascher ; Natalie MarksSource :
- Perspectives in Vascular Surgery and Endovascular Therapy [ 1531-0035 ] ; 2007-03.
Abstract
Duplex arteriography may be a potential replacement of preoperative standard contrast arteriography for peripheral arterial imaging in lower extremity revascularization procedures. In patients with chronic or acute ischemia, a well-performed duplex arteriography offers several practical advantages over contrast arteriography: it is noninvasive; it does not require nephrotoxic agents; it is portable and can be done expeditiously; color flow and waveform analysis provide a better estimation of the hemodynamic significance of occlusive disease; it allows direct visualization of the entire artery and not only of the lumen thus enabling plaque characterization; with color flow and power Doppler techniques, it is possible to identify patent arteries subjected to very low flow states; and it can detect occluded arterial aneurysms thereby avoiding unnecessary attempts at thromboembolectomies. High-quality arterial ultrasonography performed by a highly skilled and well-trained vascular technologist may represent an alternative to conventional arteriography for patients in need of primary or secondary lower extremity revascularization.
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DOI: 10.1177/1531003506298080
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<record><TEI wicri:istexFullTextTei="biblStruct"><teiHeader><fileDesc><titleStmt><title xml:lang="en">Duplex Arteriography for Lower Extremity Revascularization</title><author wicri:is="90%"><name sortKey="Hingorani, Anil P" sort="Hingorani, Anil P" uniqKey="Hingorani A" first="Anil P." last="Hingorani">Anil P. Hingorani</name><affiliation><mods:affiliation>Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York,</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: ahingorani@maimonidesmed.org</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Ascher, Enrico" sort="Ascher, Enrico" uniqKey="Ascher E" first="Enrico" last="Ascher">Enrico Ascher</name><affiliation><mods:affiliation>Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Marks, Natalie" sort="Marks, Natalie" uniqKey="Marks N" first="Natalie" last="Marks">Natalie Marks</name><affiliation><mods:affiliation>Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York</mods:affiliation></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">ISTEX</idno><idno type="RBID">ISTEX:326A5F7C98199B8CD88C34650A6F276C45B87E40</idno><date when="2007" year="2007">2007</date><idno type="doi">10.1177/1531003506298080</idno><idno type="url">https://api.istex.fr/document/326A5F7C98199B8CD88C34650A6F276C45B87E40/fulltext/pdf</idno><idno type="wicri:Area/Istex/Corpus">001721</idno><idno type="wicri:explorRef" wicri:stream="Istex" wicri:step="Corpus" wicri:corpus="ISTEX">001721</idno></publicationStmt><sourceDesc><biblStruct><analytic><title level="a" type="main" xml:lang="en">Duplex Arteriography for Lower Extremity Revascularization</title><author wicri:is="90%"><name sortKey="Hingorani, Anil P" sort="Hingorani, Anil P" uniqKey="Hingorani A" first="Anil P." last="Hingorani">Anil P. Hingorani</name><affiliation><mods:affiliation>Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York,</mods:affiliation></affiliation><affiliation><mods:affiliation>E-mail: ahingorani@maimonidesmed.org</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Ascher, Enrico" sort="Ascher, Enrico" uniqKey="Ascher E" first="Enrico" last="Ascher">Enrico Ascher</name><affiliation><mods:affiliation>Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York</mods:affiliation></affiliation></author><author wicri:is="90%"><name sortKey="Marks, Natalie" sort="Marks, Natalie" uniqKey="Marks N" first="Natalie" last="Marks">Natalie Marks</name><affiliation><mods:affiliation>Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York</mods:affiliation></affiliation></author></analytic><monogr></monogr><series><title level="j">Perspectives in Vascular Surgery and Endovascular Therapy</title><idno type="ISSN">1531-0035</idno><idno type="eISSN">1521-5768</idno><imprint><publisher>Sage Publications</publisher><pubPlace>Sage CA: Los Angeles, CA</pubPlace><date type="published" when="2007-03">2007-03</date><biblScope unit="volume">19</biblScope><biblScope unit="issue">1</biblScope><biblScope unit="page" from="6">6</biblScope><biblScope unit="page" to="20">20</biblScope></imprint><idno type="ISSN">1531-0035</idno></series><idno type="istex">326A5F7C98199B8CD88C34650A6F276C45B87E40</idno><idno type="DOI">10.1177/1531003506298080</idno><idno type="ArticleID">10.1177_1531003506298080</idno></biblStruct></sourceDesc><seriesStmt><idno type="ISSN">1531-0035</idno></seriesStmt></fileDesc><profileDesc><textClass></textClass><langUsage><language ident="en">en</language></langUsage></profileDesc></teiHeader><front><div type="abstract" xml:lang="en">Duplex arteriography may be a potential replacement of preoperative standard contrast arteriography for peripheral arterial imaging in lower extremity revascularization procedures. In patients with chronic or acute ischemia, a well-performed duplex arteriography offers several practical advantages over contrast arteriography: it is noninvasive; it does not require nephrotoxic agents; it is portable and can be done expeditiously; color flow and waveform analysis provide a better estimation of the hemodynamic significance of occlusive disease; it allows direct visualization of the entire artery and not only of the lumen thus enabling plaque characterization; with color flow and power Doppler techniques, it is possible to identify patent arteries subjected to very low flow states; and it can detect occluded arterial aneurysms thereby avoiding unnecessary attempts at thromboembolectomies. High-quality arterial ultrasonography performed by a highly skilled and well-trained vascular technologist may represent an alternative to conventional arteriography for patients in need of primary or secondary lower extremity revascularization.</div></front></TEI><istex><corpusName>sage</corpusName><keywords><teeft><json:string>arteriography</json:string><json:string>surg</json:string><json:string>duplex</json:string><json:string>revascularization</json:string><json:string>vasc</json:string><json:string>tibial</json:string><json:string>preoperative</json:string><json:string>angiography</json:string><json:string>hingorani</json:string><json:string>technologist</json:string><json:string>vasc surg</json:string><json:string>ultrasound</json:string><json:string>angioplasty</json:string><json:string>duplex arteriography</json:string><json:string>infrapopliteal</json:string><json:string>ascher</json:string><json:string>ischemia</json:string><json:string>endovascular</json:string><json:string>femoral</json:string><json:string>popliteal</json:string><json:string>peroneal</json:string><json:string>visualization</json:string><json:string>ultrasonography</json:string><json:string>vasc endovasc surg</json:string><json:string>endovasc</json:string><json:string>intraoperative</json:string><json:string>vascular surgery</json:string><json:string>tibial vessels</json:string><json:string>imaging</json:string><json:string>anterior tibial artery</json:string><json:string>insufficiency</json:string><json:string>aneurysm</json:string><json:string>mellitus</json:string><json:string>magnetic resonance angiography</json:string><json:string>infrainguinal</json:string><json:string>diabetes mellitus</json:string><json:string>lower extremity revascularization</json:string><json:string>contrast arteriography</json:string><json:string>renal</json:string><json:string>anastomosis</json:string><json:string>carotid</json:string><json:string>acute ischemia</json:string><json:string>imaging modality</json:string><json:string>hemodynamic</json:string><json:string>embolectomy</json:string><json:string>lower extremity revascularization hingorani</json:string><json:string>patency</json:string><json:string>endovascular therapy</json:string><json:string>modality</json:string><json:string>distal anastomosis</json:string><json:string>duplex imaging</json:string><json:string>duplex ultrasound</json:string><json:string>calcification</json:string><json:string>graft</json:string><json:string>lesion</json:string><json:string>iliac</json:string><json:string>peroneal artery</json:string><json:string>severe calcification</json:string><json:string>renal failure</json:string><json:string>extremity</json:string><json:string>duplex ultrasonography</json:string><json:string>nephrotoxic agents</json:string><json:string>color flow</json:string><json:string>popliteal artery</json:string><json:string>inferior vena cava filters</json:string><json:string>lower extremity</json:string><json:string>renal disease</json:string><json:string>lower extremity revascularization procedures</json:string><json:string>arterial segments</json:string><json:string>distal peroneal</json:string><json:string>contrast angiography</json:string><json:string>power doppler</json:string><json:string>doppler</json:string><json:string>vascular</json:string><json:string>runoff</json:string><json:string>inflow</json:string><json:string>poor runoff</json:string><json:string>significant lesions</json:string><json:string>vascular technologist</json:string><json:string>early results</json:string><json:string>tibial artery</json:string><json:string>conventional arteriography</json:string><json:string>tibioperoneal trunk</json:string><json:string>extremity revascularization</json:string><json:string>outflow vessels</json:string><json:string>arterial ultrasonography</json:string><json:string>unnecessary attempts</json:string><json:string>iliac arteries</json:string><json:string>occlusive disease</json:string><json:string>renal insufficiency</json:string><json:string>intraoperative findings</json:string><json:string>endovascular procedures</json:string><json:string>hemodynamic significance</json:string><json:string>infrapopliteal arteries</json:string><json:string>infrapopliteal bypasses</json:string><json:string>distal aorta</json:string><json:string>rest pain</json:string><json:string>posterior approach</json:string><json:string>completion angiogram</json:string><json:string>duplex arteriographic mapping</json:string><json:string>duplex scanning</json:string><json:string>balloon angioplasty</json:string><json:string>pima indians</json:string><json:string>proximal</json:string></teeft></keywords><author><json:item><name>Anil P. Hingorani MD</name><affiliations><json:string>Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York,</json:string><json:string>E-mail: ahingorani@maimonidesmed.org</json:string></affiliations></json:item><json:item><name>Enrico Ascher MD</name><affiliations><json:string>Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York</json:string></affiliations></json:item><json:item><name>Natalie Marks MD, RVT</name><affiliations><json:string>Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York</json:string></affiliations></json:item></author><subject><json:item><lang><json:string>eng</json:string></lang><value>duplex arteriograms</value></json:item><json:item><lang><json:string>eng</json:string></lang><value>lower extremity revascularization</value></json:item></subject><articleId><json:string>10.1177_1531003506298080</json:string></articleId><language><json:string>eng</json:string></language><originalGenre><json:string>other</json:string></originalGenre><abstract>Duplex arteriography may be a potential replacement of preoperative standard contrast arteriography for peripheral arterial imaging in lower extremity revascularization procedures. 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In patients with chronic or acute ischemia, a well-performed duplex arteriography offers several practical advantages over contrast arteriography: it is noninvasive; it does not require nephrotoxic agents; it is portable and can be done expeditiously; color flow and waveform analysis provide a better estimation of the hemodynamic significance of occlusive disease; it allows direct visualization of the entire artery and not only of the lumen thus enabling plaque characterization; with color flow and power Doppler techniques, it is possible to identify patent arteries subjected to very low flow states; and it can detect occluded arterial aneurysms thereby avoiding unnecessary attempts at thromboembolectomies. High-quality arterial ultrasonography performed by a highly skilled and well-trained vascular technologist may represent an alternative to conventional arteriography for patients in need of primary or secondary lower extremity revascularization.</p></abstract><textClass><keywords scheme="keyword"><list><head>keywords</head><item><term>duplex arteriograms</term></item><item><term>lower extremity revascularization</term></item></list></keywords></textClass></profileDesc><revisionDesc><change when="2007-03">Published</change></revisionDesc></teiHeader></istex:fulltextTEI><json:item><extension>txt</extension><original>false</original><mimetype>text/plain</mimetype><uri>https://api.istex.fr/document/326A5F7C98199B8CD88C34650A6F276C45B87E40/fulltext/txt</uri></json:item></fulltext><metadata><istex:metadataXml wicri:clean="corpus sage not found" wicri:toSee="no header"><istex:xmlDeclaration>version="1.0" encoding="UTF-8"</istex:xmlDeclaration><istex:docType PUBLIC="-//NLM//DTD Journal Publishing DTD v2.3 20070202//EN" URI="journalpublishing.dtd" name="istex:docType"></istex:docType><istex:document><article article-type="other" dtd-version="2.3" xml:lang="EN"><front><journal-meta><journal-id journal-id-type="hwp">sppvs</journal-id><journal-id journal-id-type="publisher-id">PVS</journal-id><journal-title>Perspectives in Vascular Surgery and Endovascular Therapy</journal-title><issn pub-type="ppub">1531-0035</issn><publisher>
<publisher-name>Sage Publications</publisher-name>
<publisher-loc>Sage CA: Los Angeles, CA</publisher-loc>
</publisher></journal-meta><article-meta><article-id pub-id-type="doi">10.1177/1531003506298080</article-id><article-id pub-id-type="publisher-id">10.1177_1531003506298080</article-id><article-categories><subj-group subj-group-type="heading"><subject>Articles</subject></subj-group></article-categories><title-group><article-title>Duplex Arteriography for Lower Extremity Revascularization</article-title></title-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Hingorani</surname><given-names>Anil P.</given-names></name><degrees>MD</degrees><aff>Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York, <email xlink:type="simple">ahingorani@maimonidesmed.org</email></aff></contrib></contrib-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Ascher</surname><given-names>Enrico</given-names></name><degrees>MD</degrees><aff>Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York</aff></contrib></contrib-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Marks</surname><given-names>Natalie</given-names></name><degrees>MD, RVT</degrees><aff>Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York</aff></contrib></contrib-group>
<pub-date pub-type="ppub"><month>03</month><year>2007</year></pub-date><volume>19</volume><issue>1</issue><fpage>6</fpage><lpage>20</lpage><abstract><p>Duplex arteriography may be a potential replacement of preoperative standard contrast arteriography for peripheral arterial imaging in lower extremity revascularization procedures. In patients with chronic or acute ischemia, a well-performed duplex arteriography offers several practical advantages over contrast arteriography: it is noninvasive; it does not require nephrotoxic agents; it is portable and can be done expeditiously; color flow and waveform analysis provide a better estimation of the hemodynamic significance of occlusive disease; it allows direct visualization of the entire artery and not only of the lumen thus enabling plaque characterization; with color flow and power Doppler techniques, it is possible to identify patent arteries subjected to very low flow states; and it can detect occluded arterial aneurysms thereby avoiding unnecessary attempts at thromboembolectomies. High-quality arterial ultrasonography performed by a highly skilled and well-trained vascular technologist may represent an alternative to conventional arteriography for patients in need of primary or secondary lower extremity revascularization.</p></abstract><kwd-group><kwd>duplex arteriograms</kwd>
<kwd>lower extremity revascularization</kwd></kwd-group><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Other</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value>6 Original ArticlesDuplex Arteriography for Lower Extremity Revascularization SAGE Publications, Inc.200710.1177/1531003506298080 Anil P.Hingorani MD Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York, ahingorani@maimonidesmed.org EnricoAscher MD Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York NatalieMarks MD, RVT Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York Address correspondence to: Anil P. Hingorani, MD, Division of Vascular Surgery, Maimonides Medical Center, 4802 10th Avenue, Duplex arteriography may be a potential replacement of preoperative standard contrast arteriography for peripheral arterial imaging in lower extremity revascularization procedures. In patients with chronic or acute ischemia, a well-performed duplex arteriography offers several practical advantages over contrast arteriography: it is noninvasive; it does not require nephrotoxic agents; it is portable and can be done expeditiously; color flow and waveform analysis provide a better estimation of the hemodynamic significance of occlusive disease; it allows direct visualization of the entire artery and not only of the lumen thus enabling plaque characterization; with color flow and power Doppler techniques, it is possible to identify patent arteries subjected to very low flow states; and it can detect occluded arterial aneurysms thereby avoiding unnecessary attempts at thromboembolectomies. High-quality arterial ultrasonography performed by a highly skilled and well-trained vascular technologist may represent an alternative to conventional arteriography for patients in need of primary or secondary lower extremity revascularization. duplex arteriograms lower extremity revascularization ontrast arteriography (CA) remains the gold standard imaging modality for patients in need C o f lower extremity revascularization proce- dures despite its association with local and systemic complications. Encouraged by recent technological advances in duplex ultrasonography, coupled with the increased patient demand for less invasive alterna- tives, several authors have expressed an increasing interest in the use of duplex arteriography (DA) as a potential replacement of preoperative standard CA for peripheral arterial imaging. Hence, we find that DA is being investigated for this purpose.1-3 Although some authors have demonstrated an acceptable correlation between arteriography and DA,4-12 others have been less enthusiastic and continue to advocate preopera- tive or prebypass arteriography.13-16 Some of the fac- tors that may explain these discrepant results include: (1) use of older duplex equipment, (2) experience of the vascular technologist(s), (3) lack of formal training and protocols for DA, (4) commitment in terms of time and effort to perfect the technique, (5) reluctance of the surgeon to give up the visual effect of a complete, uninterrupted study as provided by arteriography, and (6) severe calcification preventing adequate vessel insonation and other local barriers making DA less feasible in some of these patients. In an effort to explore the use of DA for patients undergoing lower extremity revascularizations, we have used DA since 1998. In addition, some of the techniques that we have used to obtain adequate data from DA for the lower extremity revasculariza- tion even in disadvantaged situations are considered. This experience with duplex arteriography along with extensive endovascular experience has formed the basis for much of our experience with duplex-guided angioplasty. Duplex Arteriography At our institution, from January 1, 1998, to January 1, 2005, 906 patients (51% men) requiring lower extrem- ity revascularization underwent 1020 duplex arteri- ograms. An attempt to image from the distal aorta to the pedal arteries was made in all the patients. The 7 selection of optimal inflow and outflow bypasses anastomotic sites and angioplasty sites was based on a schematic drawing following DA examination. For bypasses, inflow disease was also assessed by intraop- erative pressure gradient (IPG) between donor and radial arteries. Completion arteriography of the run off vessels was obtained correlating well with the pre- operative findings. Indications for the examinations included tissue loss (409), rest pain (221), claudica- tion (310), acute ischemia (74), popliteal aneurysm (45), superficial femoral artery aneurysm (2), abdom- inal aortic aneurysm (10), and failing bypass (55). Duplex Ultrasonography The vascular ultrasound tests were all performed on either an ATL HDI 3000 or ATL HDI 5000 duplex scanner by 6 registered vascular technologists. The arterial segments starting from mid–abdominal aorta to the pedal arteries were studied in cross-sectional and longitudinal planes. The test begins by placing the patient in the lateral decubitus position opposite to the side of interest with slight ipsilateral knee and hip flexure for insonation of the distal aorta and the ipsilateral common and exter- nal iliac arteries. This position improves the ultrasound field of view by shifting the gas-containing bowels away from the probe. Next, the patient is placed in the supine position with mild genuflection and thigh abduction for visualization of the common, superficial and deep femoral arteries. While the patient is in this same position, the above-knee popliteal artery segment is evaluated from a medial approach and the below- knee segment from a posterior approach. The exam continues by moving the probe medially to insonate the posterior tibial artery and its plantar branches. The patient is then returned to the original position for visu- alization of the tibio-peroneal trunk and peroneal arter- ies, as well as the origin of the anterior tibial artery. This is accomplished by placing the probe just posteriorly to the lower border of the fibula. The remainder of the anterior tibial artery is visualized by positioning the probe between the tibia and the fibula. Finally, the dor- salis pedis artery and its metatarsal branches are insonated with the patient in the supine position. During DA, we routinely perform venous mapping to identify usable veins for harvest, thereby avoiding the additional time and energy needed in pursuit of a vein of good quality and caliber. If no usable vein is identified and a bypass to the tibial vessels is required, the diameter and quality of the tibial veins may be measured for a possible prosthetic bypass with a distal fistula. Finally, examination of the subclavian-axillary segment may be performed as a possible inflow source for debilitated patients with severe aorto-iliac disease. This is accomplished without the risk of an additional thoracic aortogram or the time needed for an additional thoracic magnetic resonance angiogram. A variety of scanheads are used to obtain high- quality B-mode, color and power Doppler images as well as reliable velocity spectra. Curvilinear 5-2 MHz and phased array 3-2 MHz probes are used for aorto- iliac scanning. A linear 7-4 MHz probe is used for visualization of the femoral, popliteal, and tibial ves- sels. The high resolution of the compact linear 10-5 MHz scanhead allows better visualization of superfi- cial arteries on the ankle and foot. A linear 15-5 MHz probe allows high-quality imaging of superficial struc- tures. A peak systolic velocity (PSV) ratio ≥2 reflects a lesion with ≥50% stenosis; a PSV ratio ≥3 is used to confirm a ≥70% stenosis. Any discrepancies are com- municated to the operating surgeon. The arterial seg- ments are classified as normal or mildly diseased (<50%), significantly stenosed (≥50%), occluded, or not visualized. Vessel wall thickness and degree of cal- cification are reported to aid in the choice of anasto- mosis sites. A more precise evaluation of arterial size, length and degree of narrowing, as well as plaque characteristics, are performed for single focal or sequential lesions suitable for balloon angioplasty and/or stent placement. A color-coded map of the arte- rial tree is drawn to facilitate reading by the sur- geon.8,12 In general, however, color and power Doppler are primarily used, and B-mode and velocity spectra are used to supplement these data especially in the presence of long lesions or multiple lesions. Because the status of the branches of the arter- ies can also add valuable data for the surgeon, visu- alization of as many tibial and pedal branches as possible, including malleolar, plantar, tarsal, and deep plantar arteries and branches of the named vessels, is also performed during DA. We found that the high-frequency probe (10-15 MHz) can be espe- cially useful in this portion of the protocol. Contrast Arteriography Standard percutaneous preoperative CA with DSA was obtained when DA was not able to provide ade- quate imaging of arterial segments essential for limb revascularization or severely disadvantaged runoff by ultrasound (n = 102 [10%]). 8 Figure 1. Duplex arteriogram of distal terminal branches of peroneal artery. Intraoperative Evaluation Completion arteriography or duplex was performed in all cases to evaluate patency of the distal anastomosis and runoff status. The aorto-iliac segment was evalu- ated at the completion of the procedure by measuring the pressure gradient between the distal anastomosis and radial arteries in patients undergoing infrain- guinal bypasses. A gradient >20 mm Hg of systolic pressure warranted on-table angiography and repair of the inflow lesions. All patients underwent duplex imaging of the entire bypass postoperatively. Results The ages ranged from 30 to 98 years old with a mean of 73 ± 11 (SD) years. Fifty percent of the patients were diabetic. Prior procedures had been performed in 262 patients. DA was performed by 6 technolo- gists (4 of whom have medical degrees). DA was performed intraoperatively in 205 patients and the remainder preoperatively in preparation for an open revascularization.18,19 The resultant procedures based on 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), debridement (4), amputation (8) and no intervention Figure 2. Duplex arteriographic mapping (left) and comple- tion angiogram of bypass to dorsalis pedis (right). (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. The reasons for these were to extensive ulcers (6), edema (10), severe arterial wall calcification (64), uncooperative patient (6), low flow (8), obesity (12) multiple previous sur- geries (15), poor visualization of the origin of anterior tibial artery (1), and very poor runoff (18). Factors associated with an increased need to obtain CA included DM (P < .001), infrapopliteal calcifi- cation (P < .001), older age (P = .01), and limb- threatening ischemia (P < .001). Factors not associated with the need to obtain CA included which technolo- gist performed the examination, whether the technol- ogist has a medical degree, or whether the patient underwent previous revascularization. Lessons Learned Our experience has documented the progression of preoperative DA evolving into an integral part of the revascularization procedure itself. This incorpora- tion of DA into the revascularization procedure is predicated on the need to accurately assess the entire arterial tree from the aorta to the pedal vessels before, during, and at the end of the procedure.17-19 While the results of these interventions have already been described, the purpose of this series was to focus upon some of the lessons that we have learned during this process. 9 While this experience clearly demonstrates the feasibility of duplex arteriography, as with any technol- ogy, it is important to appreciate its limitations. When severe tibial vessel wall calcification or extremely low flow situations are encountered (PSV< 20 cm/sec, or volume flow of < 20 cc/min), DA can be unreliable and alternative imaging modalities need to be employed. The key difference between using DA and preopera- tive CTA or MRA is that DA can alert the technician and the surgeon that it has become unreliable, whereas we have not been able to identify the factors that sug- gest when CTA or MRA are no longer supplying reli- able data.20-23 The technologist can identify the areas that have severe calcification and where adequate visualization was not obtained or if extremely low flow was encountered. Based on this experience, we sug- gest that about 90% of lower extremity revascular- ization procedures can be performed based upon preoperative DA alone. Fundamental to the implementation of DA is the training method for the technologist and the surgeon interpreting the results and the application of the information obtained. It is crucial that the accuracy of the results of each technologist be assured with at least the first 50 examinations being confirmed with another imaging modality before relying on DA as a sole imaging modality.24 Part of the process also includes training each technologist by bringing him/her to the operating room to appreciate the anatomy, the details of the intended procedures, and what information needs to obtained for the procedure to take place. During the process of setting up these protocols, the interventionalist also has to be familiar with the data obtained, to ensure of its accuracy and application. This training process necessitates a change of mentality for the technologist and the interventionalist. Rather than just describing the dis- ease, the technologist needs to present the informa- tion required to reach treatment options. Inherent to this technique is a continuous quality assurance process that needs to be maintained with the constant feedback between the surgeon and the technician performing duplex arteriography of expected findings, the actual intraoperative findings, and what interven- tions were performed. A number of the issues with duplex arteriography may necessitate some nonstandard methods of resolu- tion. When patients experience severe ischemic pain that precludes the completion of the examination, pre- medication with analgesics can be helpful for a repeat exam. Additionally, because the examination does take the cooperation of the patient, having a family member present during the examination of a confused elderly patient can sometimes allow the examination to be completed. Visualization of the iliac arteries can sometimes be better accomplished by having the patient fast. Leg elevation for 24 to 48 hours can decrease calf edema, allowing adequate visualization of the tibial vessels. While insonation in the area of open ulcers or excessive scarring may not be possible, this also would not be an area that one would want to perform an anastomosis. Therefore, even if there is local poor skin condition, severe obesity, edema, or excessive depth of the vessel (such as the tibioperoneal artery and the ori- gin of the anterior tibial artery), sufficient accurate information can, at times, still be obtained to complete the needed intervention. For example, if a claudicant is found to have a patent popliteal artery and one ves- sel runoff, but the other tibial vessels were unable to be fully assessed, one may decide to perform femoral- popliteal bypass even though the tibial vessels were not completely assessed. If a diabetic with gangrene is found to have a patent dorsalis pedis artery and an adequate conduit, but the anterior tibial artery is too calcified to visualize, one may chose to perform a bypass to the dorsalis pedis as the anterior tibial artery will probably be a much more difficult artery to per- form the distal anastomosis to as these vessels identi- fied to have severe calcification by DA were found to be rock-like upon exploration.25 If one prefers to per- form a bypass to a clearly patent dorsalis pedis rather than to a peroneal artery in the presence of an ade- quate conduit, lack of information on the peroneal artery may not really change the treatment plan. If the wall of the vessels where an anastomosis is to be performed is found to be thickened or calcified with DA, one may chose to perform the anastomosis in another area. This vessel may be patent and be identified with CA, computed tomographic angiogra- phy, or magnetic resonance angiography as an ade- quate vessel for the anastomosis. However, operative attempts of intervening at these sites can often lead to further unplanned exploration for an adequate site for the anastomosis. It is important to note the advantages of the portability of the duplex machine itself. Because DA examinations can be performed at the bedside, in the operating room, or in the holding area, time spent transporting the patient and the personnel required is significantly reduced. Additionally, obtaining the CA or magnetic resonance angiography and their inter- pretation can entail a delay in the definitive treatment of a severely ischemic limb in a debilitated patient, as 10 Figure 3. Severely calcified anterior tibial with lumen not able to be assessed. well as take a toll on the operative team. With DA, once the patient is identified to need urgent revas- cularization, the machine and technician can be brought to any part of the hospital for an abbreviated directed examination. Because DA is not just a luminal technology, it can be used to assess the actual disease of the vessel. High-resolution duplex imaging can assess the lumi- nal diameter and thickness of the wall down to approximately 1/10th of a millimeter. This can be important, not only in the selection of appropriate balloons and stents, but also especially with cutting balloons. In addition, DA has the ability to more accu- rately assess the chronic nature of the occlusion. It is possible to differentiate between an isolated chronic superficial femoral artery (SFA) occlusion and an acute embolism with little underlying disease or acute thrombosis with severe underlying atherosclerotic dis- ease. Aneurysmal vessels with partial thrombosis may have little to no luminal dilatation and may be unde- tectable by CA. Similarly, ulcerated and irregular plaques that may be a source of embolization are also poorly assessed by CA. High-resolution DA more clearly depicts these plaques. Consequently, we have found this imaging modality particularly valuable in determining patient management as compared to other technologies. Furthermore, the hemodynamic information obtained using DA may alter patient management. Volume flow measurements can help assess whether the visualized lesion is hemodynamically significant and determine whether repair of the lesion may be beneficial. For example, a poorly visualized iliac plaque with little change in the ratio of peak systolic velocities (<2) may suggest that the lesion may not be of clinical significance. Lesions that are poorly visualized due to severe calcification with elevated ratios distal to the obscured lesion suggest a hemodynamically significant lesion. Other luminal imaging modalities do not read- ily furnish details of inadequately visualized lesions or of lesions of questionable hemodynamic significance. With CA, the hemodynamic significance of a moder- ate lesion is often judged subjectively rather than on objective data. During DA, we routinely perform a venous map- ping to identify usable veins for harvest, thereby elim- inating the additional time and energy needed in pursuit of a vein of good quality and caliber. If no usable vein is identified and a bypass to the tibial ves- sels is required, the diameter of the tibial veins may be measured for a possible prosthetic bypass with a distal fistula. Finally, examination of the subclavian-axillary segment may be performed as a possible inflow source for debilitated patients with severe aorto-iliac disease. This is accomplished without the risk of an additional thoracic aortogram or the time needed for an addi- tional thoracic magnetic resonance angiography. Overall, our most common problem with DA has been with calcification. However, as we have cited before, some techniques can be used to obtain the necessary information even with severely calcified vessels, such as using multiple projections and using Son oCT.26 Although each individual field of view is limited, we have demonstrated that the vessels from the aorta to the pedal vessels can be visualized using duplex arteriography. While the role of contrast- enhanced DA has not been explored, the data on the use of contrast-enhanced duplex examinations for the carotid arteries and aortic endoleaks makes this a possible future adjunct.27-31 During our experience, we noted that the duration of examination became much shorter with increased experience. In our ini- tial experience, the entire examination took us as long as 90 minutes. By the end of our experience, the entire examination could take as little as 25 minutes. These data are based on our experience with pre- operative duplex arteriography and represent an exten- sion of our use of duplex imaging to become an integral part of the intervention itself. To perform duplex-guided angioplasties, one needs extensive expe- rience with preoperative DA. Furthermore, because duplex imaging is also being used for duplex-guided thrombin injections of arterial pseudoaneurysms, endovenous interventions of the greater saphenous 11 Figure 4. Duplex arteriographic mapping (A), completion angiogram of bypass to common plantar artery (B), and skin marking (C). vein, placement of inferior vena cava filters, carotid angioplasties, and lower extremity angioplasty, we pro- pose that this new field be termed “Interventional Ultrasonography.”32-45 Accordingly, we submit that DA can be used for evaluation of the lower extremity arter- ies in patients being evaluated for lower extremity revascularization. The advantages, limitations, and early results of the technique suggest that further study is warranted. The Technology The turn of the millennium has been marked by an accelerated technological progress that stimulated the development of less invasive treatment and diagnostic procedures. Accordingly, CA has been challenged by the development of magnetic resonance angiog- raphy, contrast tomography angiography, and duplex arteriography. In the past few years, computer technology improvements related to the ultrasound industry have produced scanners with higher definition B- mode image and more refined color-flow features. Nonetheless, duplex ultrasonography's most popular feature remains the hemodynamic assessment by velocity spectral waveform PSV ratio that directly measures the degree of arterial narrowing. However, the presence of collateral branches, tapering or dilatation of adjacent arterial segments, arterial bifurcation or tortuosity, presence of close sequen- tial lesions, and inaccuracies in the Doppler angle 12 may affect the velocity-waveform spectra. Therefore, a combined B-mode/color-flow and hemodynamic assessment is desirable. Power Doppler helps to out- line the residual lumen and quantify the degree of arterial narrowing, particularly in the presence of color bleeding, exacerbated color flashing produced by tight stenosis, or low-flow situations. Inflow and outflow site selection of infrainguinal bypass based on CA involves visualization of an ade- quate inflow with unobstructed runoff. Thereby, precise estimation of sequential stenoses may be irrelevant for surgical decision-making. Similarly, the information obtained by duplex ultrasonography can be drawn into a diagram to help surgeons' visu- alization of significant lesions and formulation of revascularization strategy. Prior Studies Previous literature examining DA primarily focused on comparing DA with CA.46-49 However, most of these studies attempted to compare the predicted bypass based on DA as compared to that predicted by angiog- raphy. Because the variation in the choice of proce- dure between surgeons given the same angiographic data has been well documented, the conclusions that can be drawn from these comparison studies between DA and CA remain questionable.50 In addition, because the vascular technologists performing these examinations in these studies would not be experi- enced with insonation of the tibial and pedal arteries and have no opportunity to learn from the angiogram or intraoperative findings, the very basis of these com- parison studies remains unrealistic and artificial. Limitations Poor visualization of vessels with extremely calcified vessel walls, skin quality problems such as severe dermatitis, open ulcers, heavy scarring, severe lym- phedema, and severe hyperkeratosis are some of the problems associated with DA, as well as rest pain, noncompliant patients, and excessive edema. Addi- tionally, we encountered difficulty visualizing the iliac arteries due to colostomy, marked iliac tortuosity, recent abdominal surgery, ascites, morbid obesity, or gas interposition in a few of our patients. To circumvent the problem of severe calcification, we have found increasing the gain, persistence, and sensitivity and using power Doppler and SonoCT tech- nology quite useful. Lack of patient cooperation may be one limitation to accurate DA, particularly for the iliac and infrapopliteal segments. Often, with limited visualization of the iliacs but with normal common femoral waveforms, it was elected to proceed to revas- cularization realizing that an intraoperative balloon angioplasty of the iliacs may be needed. Nevertheless, 10% of our patients were not able to have adequate information derived from DA and did require preoper- ative contrast angiography despite these attempts. Our evolving experience also demonstrates some of the nuances of the DA examination. We have noted that failure of visualization of all segments of the arte- rial tree in every patient has not posed a significant issue. Incomplete visualization of the iliac vessels has led to a graft pressure gradient that resulted in an intraoperative balloon angioplasty and placement of a stent in the iliac arteries from the proximal anastomo- sis of the bypass in 5 incidences. In these 5 cases, no common femoral artery waveforms abnormalities were detected consistent with our prior published data sug- gesting that these are not reliable.3 These patients also had SFA disease, making other noninvasive tech- niques less reliable for detection of these occult iliac lesions. Nevertheless, due to this limitation, the sur- geon using DA as a sole preoperative imaging tool needs to be able to perform these endovascular proce- dures during the revascularization if needed. Because our policy is to perform the inflow angioplasty at the same time as the lower extremity revascularization and the expertise and tools necessary to perform endovas- cular procedures are readily available, this has not been an issue at our institution. Furthermore, incomplete visualization of the crural and pedal vessels does not always have a major effect on the course of the procedure. For example, if a surgeon prefers to perform a bypass to the distal anterior tibial artery rather than to the dis- tal peroneal and the distal peroneal was too calci- fied to insonate, the lack of data on the distal peroneal may have little impact on the planning of the proce- dure. In general, our policy to not perform a femoral- distal bypass for claudication means that in the presence of severe SFA disease with at least one ves- sel runoff and insignificant iliac artery disease, a femoral-popliteal bypass will be planned even if the other two tibial arteries could not be completely evaluated. Nevertheless, when difficulties in the evaluation of the crural and pedal vessels are encountered and the status of these vessels is necessary, additional tech- niques can be employed. In very low flow situations 13 (PSV of < 20 cm/sec) such as in the tibial vessels with acute ischemia or cardiogenic shock, setting the pulse repetition frequency at 150-350 Hz and using the low wall filter, the highest persistence and highest sensi- tivity for the color flow imaging, can be beneficial. At times, distal compression can augment flow and demonstrate patency of tibial vessels. When the tibial vessels are severely calcified, we have found power Doppler and Sono CT to be useful. In addition, examining the vessels in transverse sec- tion, changing the angle, and increasing the gain can at times allow visualization of the vessel. The depth of the tibioperoneal trunk, origin of the proximal per- oneal and posterior arteries, and the SFA at Hunter's canal may necessitate the use of a lower frequency probe for visualization. However, this tends to sacrifice details and the resolution making these areas difficult to interpret. In these cases, velocity spectral analysis can also be a useful adjunct. In difficult arterial seg- ments, manipulation of the leg, using a different probe, or utilizing a variety of approaches may be nec- essary. For example, the medial approach may help visualize the proximal peroneal, the medial or posterior approach may assist in visualizing the mid peroneal artery, and the lateral or posterior approach may facil- itate the imaging of the distal peroneal and its branches. Thus, the tibial vessels can be adequately evaluated by using a variety of approaches and angles. The most difficult infrapopliteal segments to visu- alize that we encountered were the first portion of the anterior tibial artery and the bifurcation of the tibioperoneal trunk. This is often due to the depth of these areas. Most of the nonvisualized segments were localized between occluded segments. Therefore, non- visualization of these segments was not relevant for surgical decision-making. Contrary to the belief that the peroneal artery is difficult to image, we were able to visualize it using a variety of techniques with vari- ous approaches (medial, lateral and posterior). Using these techniques, even its continuation from the tibioperoneal trunk can be assessed. The origin of the anterior tibial artery deserves special attention, as collaterals in this area may be mistaken for a patent proximal anterior tibial artery. Careful examination of the origin of the vessels and tracing the vessels distally often can solve some of these issues. In addition, identification of the two adjacent veins can help distinguish between a large collateral and the vessel. Despite these techniques, if patency of vessels that were not visualized well was deemed crucial, an angiogram will need to be obtained before the procedure is attempted. Advantages Invasive contrast angiography remains the gold stan- dard imaging modality in planning these revascular- izations. This is regardless of the findings that contrast angiography may not detect outflow vessels that may be more clearly visualized with duplex or magnetic resonance angiography as occurs in very low flow situations with acute or severe chronic ischemia.10,51 DA, on the other hand, has the capa- bility to detect these vessels with very low flow (<20 cm/sec). The visualization of these outflow vessels may result in the performance of lower extremity revascularizations that ultimately achieve limb sal- vage. Moreover, since biplanar arteriography is not the standard for the entire arterial tree, eccentric lesions, especially in the iliacs, may go undetected utilizing contrast angiography. Finally, while MRA does have certain clear advantages over CA, we have noted that as many as 25% of patients are unable to complete their preoperative MRAs due to schedul- ing difficulties, claustrophobia, metal implants, or pacemakers. The advantages of DA as compared to other imag- ing tools include the identification of the softest por- tion of the vessel wall that can be marked on the skin before the intended procedure. Skin marking of the most suitable site for outflow anastomosis, particularly for infrapopliteal segments, may limit incision size and eliminate extensive arterial dissection in search of a soft arterial segment. Information of a noncalcified arterial segment is promptly conveyed to the surgeon, important arterial branches may be spared, and long incision-related complications reduced. While a target vessel may be patent using luminally-based imaging tools, the vessel may be severely calcified in long seg- ments as in the diabetic and end stage renal disease population. We have found that preoperative localiza- tion of the softest portion of the vessel by DA can accurately identify the most advantageous anasto- motic site, thus decreasing the risk of damage to the artery by clamping or incomplete proximal control with a tourniquet due to concomitant severe SFA cal- cification. Thus, DA can be an invaluable aid to the surgeon in determining the anastomotic site of choice. The Duplex Arteriography Team While prior studies have demonstrated the reliabil- ity of DA,8,12,13 it is highly operator dependent. We require an experienced technician whose capabilities 14 are well known to the surgical staff. Our DA techni- cians are MD/RVTs who each undergo a specialized training protocol including examination of the patient by DA and angiography. The variances encountered between both modalities are then reviewed. In addi- tion, any differences in DA and intraoperative completion angiography are analyzed by all the sur- geons and technologists resulting in a close relation- ship. Before each procedure, each case is discussed to afford the surgeon a complete picture of the findings rather than to have the surgeon merely review the mapping. Thus, the intricacies and nuances of the actual quality of the arteries and veins are presented to the surgeon as an adjunct to the mapping and images taken during the examination. For example, the thickness and characteristics of the target vessels can be more effectively communicated by verbal exchange as compared to written details or a drawing. This type of data serves to further accentuate the advantages of DA over luminally based imaging modalities, as this type of information is not available otherwise. Areas that are not well visualized should be identified as such for the surgeon to decide if this area is crucial. DA demands a high level of technical profi- ciency and understanding by the technician of the anatomy, hemodynamics, and appreciation of the intended revascularization. Knowledge and experi- ence of the technologist do play an important role. Details of exact location of disease with relation to the surgical anatomy are also necessary. For exam- ple, identifying disease in the above-, behind-, and below-knee popliteal artery is a concept that must be mastered for DA to be effective. To facilitate these goals, DA technologists at our institution freely visit the operating room to gain insight into the operative procedures. In an attempt to develop a training period at our institution, the first 50 examinations of a new tech- nologist are confirmed with CA or repeated DA examination by an established DA technologist. In the initial stages, a prospective comparative study needs to demonstrate that the DA examinations being performed are as effective as invasive CA in delineating the arterial anatomy.4 In an effort to facilitate the advancement of our DA protocol, every completion angiogram is reviewed with the technol- ogist who performed the examination, as are the iliac angioplasties. The characteristics of the proxi- mal and distal arteries, vein conduit, or tibial vein in the case when an adjunctive arteriovenous fistula is performed are discussed and any discrepancies are reviewed. DA technologists visit the operating room to witness the intraoperative findings first hand. In this manner, the constant feedback becomes the cornerstone for the continual improvement in the quality of the DA examinations. The present data confirm our previous belief that DA can also be used as the only preoperative imaging technique for patients with lower limb ischemia when performed by a well-qualified, expe- rienced registered vascular technologist under the supervision of a vascular surgeon. This is an operator- dependent test that demands the use of different scanners and constant optimization of the image by an operator that has mastered ultrasound technol- ogy and hemodynamics. Shortened Protocol The role for a shortened focused protocol also needs to be explored. Is it necessary to visualize all the ves- sels from the aorta to the pedal vessels in every case? For example, the need to scan all the tibial vessels for patients with claudication with severe iliac dis- ease and no with no significant femoral disease may be questioned if the surgeon will only perform an inflow procedure for these types of patients. Thus, the DA protocol needs to be tailored for each sur- geon, as a complete examination may not be absolutely necessary or additional exams may need to be per- formed in certain types of patients depending on the clinical approach of the operating team. In the presence of a previous patent bypass graft, DA focuses on identifying significant lesions above the proximal anastomosis, evaluating the graft itself for significant lesions, and assessing the best patent artery available for a possible jump graft. Scanning of the arterial segments between the proximal and distal anastomosis adds very little useful information and may be skipped. Previous occluded bypass grafts are registered, and a complete mapping is performed. Machines DA has further emphasized the need to keep up with rapidly advancing duplex technology, as older machines have decreased resolution, less penetration, and increased error on the diameter reduction measure- ments, lack power imaging, and demonstrate more artifacts. Some earlier investigators attempted to per- form DA with less than adequate technology, which may have affected the results.9,11,13,14,15 As the technol- ogy and our knowledge have advanced, so too have our 15 results.5,15 Therefore, our experience with DA in this patient population continues to evolve as the available technology advances.53 Renal and Diabetic Patients It has been well documented that patients with dia- betes mellitus and/or chronic renal insufficiency are at increased risk for developing contrast-induced nephropathy when subjected to CA despite the use of non-ionic contrast media.54-57 Although the renal function in most patients with contrast-induced renal failure will return to baseline, a few patients may require hemodialysis and most will have their pro- posed arterial reconstruction delayed. Some series have suggested that up to 10% of diabetic patients will have contrast-induced renal failure and up to 12% of patients with chronic renal insufficiency will signifi- cantly worsen their renal function following CA.3, 58, In addition, the significant osmotic load associated with dye injection poses a risk for fluid overload in patients on hemodialysis. Yet the gold standard imag- ing modality for lower limb ischemia continues to be invasive CA even in the presence of diabetes mellitus and chronic renal failure. More recently, several investigators have attempted to validate duplex arterial mapping as a reliable alternative to CA.1,4,60 Although some of these studies achieved excellent correlation between DA and CA, few surgeons have actually performed infrainguinal bypasses without preoperative or pre- bypass CA.3 In the present section, we focus on our experience with DA in 145 patients who had 180 lower limb arterial bypasses and who were at risk of developing or worsening their renal failure if given nonionic contrast media. From January 1998 to November 2000, lower extremity DAs were performed in 145 patients with diabetes mellitus and/or chronic renal failure before 180 arterial reconstructions. Eighty-six procedures were performed on 65 patients with diabetes alone, 30 on 22 patients with diabetes and chronic renal insuf- ficiency (CRI), and 16 on 13 patients with CRI alone. Patient ages ranged from 45 years to 98 years (mean 73 ±10 years). Indications for surgery were severe claudication in 20 (15%), rest pain in 28 (21%), nonhealing ischemic ulcers in 39 (30%), and limb gangrene in 45 (34%). Preoperative CA was performed in 16 procedures due to extremely poor runoff based on DA and limited visualization of outflow vessels. Adequacy of the inflow was confirmed by intraoperative pressure measurements. Postbypass CA or duplex imaging was obtained to verify the patency of the runoff. The DA procedure time averaged 50 ± 12 min- utes (range, 35-90 minutes). The distal anastomosis was to the popliteal artery in 65 cases (49%) and to the tibial and pedal arteries in 67 (51%). Cumulative patency rates at 1 and 3 months were 94% and 83%, respectively. Intraoperative findings confirmed the preoperative DA findings with the exception of one where the distal anastomosis was placed proximal to a significant stenosis requiring an extension graft. The use of high-quality arterial ultrasonography presents a safe and reliable option to preoperative lower extremity CA for many patients with diabetes or impaired kidney function. The ease of use and favorable patient outcomes achieved by this imaging modality may rival the use of contrast angiography for these patients. This imaging modality can offer results compa- rable to those achieved with conventional invasive CA while at the same time reducing associated risks. The advantages of avoiding or limiting the use of CA to decrease the incidence of postprocedure renal insufficiency for the diabetic patient and those patients with CRI are self-evident. This complica- tion also results in substantially increased lengths of stay, additional specialty consults, and higher costs. In addition, it can also produce suffering for the patient and their family. Moreover, an analysis of natural history studies indicates that 23% to 63% of patients with diabetes will have progressive renal insufficiency with 10% to 35% winding upon dialy- sis.61-65 Of the patients with CRI, up to 28% will require eventual dialysis.66,67 It remains unclear whether the administration of intra-arterial dye may result in additional long-term complications in these high-risk patients with peripheral vascular disease. Acute Ischemia Over the past three decades, the management of acute lower limb ischemia has evolved from simple embolec- tomies performed with local anesthesia to highly chal- lenging arterial reconstructions. Some of the factors accounting for this dramatic development include a more aggressive approach at limb salvage in the elderly patient by well-trained vascular surgeons, decreased prevalence of rheumatic heart disease and a sub- stantial increase in the use of warfarin sulphate for cardiac arrhythmias. Accordingly, many of these patients presenting with acutely ischemic limbs will 16 have underlying multisegmental occlusive arterial disease rather than a simple embolus obstructing a healthy vessel. Although the clinical diagnosis of an ischemic leg can often be made without difficulties, the anatomical pattern of the inflow, the outflow and the occluded arterial segment may at times be impossible to ascertain by standard preoperative imaging modali- ties. Invasive CA has been advocated by some authors for patients presenting with acute ischemia.1,2 However, it has some limitations particularly when compared to duplex ultrasound: (1) it delineates the patent arterial lumen only, (2) it fails to identify throm- bosed popliteal aneurysms, (3) it fails to visualize an outflow source in very low-flow situations, (4) it requires potentially nephrotoxic agents, and (5) it delays prompt treatment. Lastly, there are few retro- spective reports on the importance of preoperative arte- riography in patients with acute ischemia. Conversely, relying solely on a medical history and a physical exam- ination without any preoperative imaging technique may subject patients to unnecessary attempts at embolectomies or thrombectomies and may signifi- cantly prolong the operation. This would be quite undesirable in this often high-risk population with mul- tiple cardiovascular risk factors. Furthermore, avoid- ance of nephrotoxic agents, visualization of low flow arteries and a more expeditious exam are some of the advantages of DA that are particularly important in these often sick subset of patients presenting with acute lower limb(s) ischemia. The purpose of this sec- tion was to focus whether DA can also be used effec- tively in the setting of acute ischemia. From January 1998 to February 2001, 68 patients were admitted to our institution with 87 instances of acute lower limb(s) ischemia and underwent 87 oper- ations. There were 34 men and 34 women whose age ranged from 51 to 95 years (mean 72 ± 12.5). There were 44 cases of acute arterial occlusions and 43 cases of bypass graft thromboses. In the former group the most proximal occluded site was the aorta in 1 case, common iliac in 4 cases, external iliac in 15 cases and infrainguinal arteries in 24 cases. In the latter group, there were 4 suprainguinal grafts, 24 bypasses to the popliteal artery and 15 bypasses to infrapopliteal arteries. All patients had DA as their initial diagnostic study. The duplex protocol varied according to the pulse exam. In patients with a good femoral pulse but absent popliteal pulse, attempts were made to visual- ize the ipsilateral femoral-popliteal segment and the proximal third of the infrapopliteal arteries. This was extended to the pedal arteries in cases of proximal occlusion. When the femoral pulse was absent, the protocol included visualization of the distal aorta, bilateral iliac, and common femoral arteries. This exam was extended into the deep and superficial femoral-popliteal segments in cases of proximal occlu- sion. None of these cases had preoperative or preby- pass CA. Intraoperative arterial pressures to confirm the adequacy of the inflow tract and arteriography to assess the runoff were performed in 78% of the cases at the end of the procedure. DA was not completed in 5 of the 87 cases because of severe arterial calcification (3), patient uncooperativeness (1), or obesity (1). DA correctly predicted the extent of the occluded arterial segment in 80 of 82 cases (98%). Of the 44 cases of arterial occlusions 7 were treated by thromboembolectomies alone, thromboembolectomies and patch angioplasties in 14 cases, thromboembolectomies and iliac balloon angioplasties with stents in 4 cases. In the remaining 19 cases a variety of bypasses were required to restore unobstructed flow after an attempted embolectomy. DA correctly identified all 7 cases (100%) that required embolectomy alone and 13 of the 14 cases (93%) of thrombectomy and patch angioplasty, and 2 of 4 cases (50%) of thromboembolectomies with iliac balloon angioplasty and stents. In addition DA predicted the necessity for bypass operations in 15 of 16 cases (94%) with significant underlying occlu- sive disease and for 3 of 3 (100%) thrombosed popliteal aneurysms. The 1-month arterial patency rate for the 25 embolectomy cases was 65% and 1- month graft patency rates were 59% for 15 femoral- popliteal bypasses and 62% for 24 infrapopliteal bypasses. The time spent to perform DA varied from 20 to 50 minutes (mean 30 minutes). A well-performed DA offers several practical advantages over CA in this subset of patients: (1) it is noninvasive; (2) it does not require nephrotoxic agents; (3) it is portable and it can be done expedi- tiously; (4) color flow and waveform analysis provide a better estimation of the hemodynamic significance of occlusive disease; (5) it allows direct visualization of the entire artery and not only of the lumen thus enabling plaque characterization; (6) with color flow and power Doppler techniques it is possible to iden- tify patent arteries subjected to very low flow states; and (7) it can detect occluded arterial aneurysms thereby avoiding unnecessary attempts at throm- boembolectomies. Most of the patients in this series had their DA performed during regular hours because it was not possible to have the technologist(s) available at all 17 Figure 5. Example of duplex arteriographic mapping. times. Except for the time of the day there was no other factor differentiating those patients with acute ischemia who underwent DA from those who did not. Regardless of its obvious limitations, this experience demonstrates the advantages of DA in helping the sur- geon plan the surgical approach and avert unnecessary thrombectomies and embolectomies that can further contribute to the high mortality and morbidity in patients with acute lower limb ischemia. This experience correlates with our belief that high-quality arterial ultrasonography performed by a highly skilled and well-trained vascular technologist may represent an alternative to conventional arteriog- raphy for patients in need of primary or secondary lower extremity revascularization. The technologist needs to be trained to understand vascular pathology, hemodynamics, and ultrasound technology to per- form an accurate DA. Limitations inherent to the technique and very poor runoff observed on ultra- sonographic examination may necessitate additional preoperative imaging modalities in certain patients. Despite these techniques, there were two cases in which a jump graft was performed due to a missed dis- tal lesion. One stenosis in the distal anterior tibial artery was missed, and a large collateral was mistaken for the distal posterior tibial artery in a patient with extremely low flow. Both of these occurred early in the course of our experience, were detected by routine completion angiography, and were remedied with a jump graft. Both patients seemed to have no compli- cations from the procedures. While these cases help illustrate the limitations of DA, the cases seem quite infrequent. These types of limitations need to be weighed against the potential benefits of the DA pro- tocol and the limitations of CA. 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</ref-list></back></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Duplex Arteriography for Lower Extremity Revascularization</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Duplex Arteriography for Lower Extremity Revascularization</title></titleInfo><name type="personal"><namePart type="given">Anil P.</namePart><namePart type="family">Hingorani</namePart><namePart type="termsOfAddress">MD</namePart><affiliation>Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York,</affiliation><affiliation>E-mail: ahingorani@maimonidesmed.org</affiliation></name><name type="personal"><namePart type="given">Enrico</namePart><namePart type="family">Ascher</namePart><namePart type="termsOfAddress">MD</namePart><affiliation>Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York</affiliation></name><name type="personal"><namePart type="given">Natalie</namePart><namePart type="family">Marks</namePart><namePart type="termsOfAddress">MD, RVT</namePart><affiliation>Division of Vascular Surgery, Maimonides Medical Center, Brooklyn, New York</affiliation></name><typeOfResource>text</typeOfResource><genre type="other" displayLabel="other"></genre><originInfo><publisher>Sage Publications</publisher><place><placeTerm type="text">Sage CA: Los Angeles, CA</placeTerm></place><dateIssued encoding="w3cdtf">2007-03</dateIssued><copyrightDate encoding="w3cdtf">2007</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><physicalDescription><internetMediaType>text/html</internetMediaType></physicalDescription><abstract lang="en">Duplex arteriography may be a potential replacement of preoperative standard contrast arteriography for peripheral arterial imaging in lower extremity revascularization procedures. In patients with chronic or acute ischemia, a well-performed duplex arteriography offers several practical advantages over contrast arteriography: it is noninvasive; it does not require nephrotoxic agents; it is portable and can be done expeditiously; color flow and waveform analysis provide a better estimation of the hemodynamic significance of occlusive disease; it allows direct visualization of the entire artery and not only of the lumen thus enabling plaque characterization; with color flow and power Doppler techniques, it is possible to identify patent arteries subjected to very low flow states; and it can detect occluded arterial aneurysms thereby avoiding unnecessary attempts at thromboembolectomies. High-quality arterial ultrasonography performed by a highly skilled and well-trained vascular technologist may represent an alternative to conventional arteriography for patients in need of primary or secondary lower extremity revascularization.</abstract><subject><genre>keywords</genre><topic>duplex arteriograms</topic><topic>lower extremity revascularization</topic></subject><relatedItem type="host"><titleInfo><title>Perspectives in Vascular Surgery and Endovascular Therapy</title></titleInfo><genre type="journal">journal</genre><identifier type="ISSN">1531-0035</identifier><identifier type="eISSN">1521-5768</identifier><identifier type="PublisherID">PVS</identifier><identifier type="PublisherID-hwp">sppvs</identifier><part><date>2007</date><detail type="volume"><caption>vol.</caption><number>19</number></detail><detail type="issue"><caption>no.</caption><number>1</number></detail><extent unit="pages"><start>6</start><end>20</end></extent></part></relatedItem><identifier type="istex">326A5F7C98199B8CD88C34650A6F276C45B87E40</identifier><identifier type="DOI">10.1177/1531003506298080</identifier><identifier type="ArticleID">10.1177_1531003506298080</identifier><recordInfo><recordContentSource>SAGE</recordContentSource></recordInfo></mods></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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