Can duplex scan arterial mapping replace contrast arteriography as the test of choice before infrainguinal revascularization? Reese A. Wain, MD, George.

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Presentation transcript:

Can duplex scan arterial mapping replace contrast arteriography as the test of choice before infrainguinal revascularization? Reese A. Wain, MD, George L. Berdejo, BA, RVT, William N. Delvalle, BA, RVT, Ross T. Lyon, MD, Luis A. Sanchez, MD, William D. Suggs, MD, Takao Ohki, MD, Evan Lipsitz, MD, Frank J. Veith, MD Journal of Vascular Surgery Volume 29, Issue 1, Pages 100-109 (January 1999) DOI: 10.1016/S0741-5214(99)70352-6 Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 1 Sample bilateral lower extremity duplex arterial map. The duplex mapping forms are a graphical representation of the lower extremity vasculature from the inguinal ligament through the feet. The common femoral (CFA), deep femoral (DFA), superficial femoral (SFA), above knee popliteal (AKP), below knee popliteal (BKP), anterior tibial (ATA), peroneal (PER), and posterior tibial (PTA) arteries are each seen, as is the tibioperoneal trunk (TPT) and the pedal vessels (not labeled). Arterial stenoses and occlusions corresponding to the patient's pattern of disease are drawn on the form during the duplex study. Occlusions are denoted by filling in the entire lumen of the relevant segment, whereas stenoses are filled in less completely. An asterisk (*) next to a stenotic segment represents a more than 50% stenosis. Note that the AKP is divided into proximal and distal halves for imaging and mapping purposes. In this example, more than 50% stenoses have been documented within the right SFA and TPT. The right CFA, BKP, and ATA are less severely diseased, and the distal PTA and the entire PER are occluded. On the left side, the SFA and the proximal AKP are occluded. The distal AKP, BKP, and infrapopliteal vessels are free of significant disease. Journal of Vascular Surgery 1999 29, 100-109DOI: (10.1016/S0741-5214(99)70352-6) Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 2 Examination of a 79-year-old man with rest pain in the right foot. A, This preoperative arteriogram reveals a patent deep femoral artery (DFA) and an occlusion of the proximal superficial femoral artery (SFA). The below-knee popliteal (BKP) artery is patent, the tibioperoneal trunk (TPT) is severely diseased, and the posterior tibial artery (PTA) has straight line flow to the foot. Note that the peroneal and anterior tibial arteries are occluded. B, Color flow is seen on the duplex image of the patent proximal SFA, whereas the occluded distal SFA does not exhibit color flow. C, Blood flow velocities of 40 cm/s in the BKP and 142 cm/s in the TPT are revealed by means of spectrum analysis. The increase in velocity confirms the presence of a more than 50% TPT stenosis. D, Flow in 2 anterior tibial veins (ATV) is revealed by means of a color flow image of the proximal calf; however, color flow cannot be elucidated within the anterior tibial artery (ATA), which is therefore occluded at this level. E, Distally, the reconstitution of the ATA is confirmed by means of color flow within it. F, No flow disturbances and a widely patent lumen are revealed by means of a color flow image of the PTA. Journal of Vascular Surgery 1999 29, 100-109DOI: (10.1016/S0741-5214(99)70352-6) Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 2 Cont'd G, The arterial map that was created based on these duplex findings. Note that all arterial occlusions and stenoses seen on the preoperative angiogram were also imaged by duplex. This patient underwent femoral-PTA bypass grafting, which was the procedure he was predicted to require based on the duplex arterial mapping results. Journal of Vascular Surgery 1999 29, 100-109DOI: (10.1016/S0741-5214(99)70352-6) Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions

Fig. 3 Examination of an 80-year-old woman with gangrenous left toes. A, The findings of this patient's preoperative arteriogram (bottom) were corroborated by means of the arterial mapping (top). The patient had a tibioperoneal trunk occlusion and a reconstituted peroneal (PER) artery in the mid-calf, which fills the proximal dorsalis pedis artery through small collaterals. Based on arterial mapping, the blinded observer could not predict whether the patient would require bypass graft to the DPA or to the PER. Based on the angiogram and the small PER-to-DPA collaterals, the decision was made to perform bypass grafting to the DPA. B, The distal anastomosis to the DPA is demonstrated by means of the intraoperative completion study. Journal of Vascular Surgery 1999 29, 100-109DOI: (10.1016/S0741-5214(99)70352-6) Copyright © 1999 Society for Vascular Surgery and International Society for Cardiovascular Surgery, North American Chapter Terms and Conditions