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J VASC ENDOVASC SURG 2010;17(Suppl. 1 to No.

3):19-24

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Role of Duplex ultrasound in the management
of infrageniculate surgical revascularization

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RV O G. BALDINO, P. MORTOLA, A. CHIAMA, T. SCIUTTO, P. CASSOLA, A. GORI

IC
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Aim. The objective of the study was to determine whether the Department of Vascular Surgery, E.O. Ospedali Galliera
long and short term results of patients undergoing duplex ultra- Genoa, Italy
sound as the sole pre-operative imaging method for infra-
AM
geniculate arterial surgical reconstruction are comparable to
the results of cases performed with angiographic imaging.
Methods. Between January 2005 and June 2009, 50 consecu-
tive patients with critical limb ischaemia (CLI) underwent
duplex ultrasound arterial mapping (DUAM) before under- the non-inferiority goal of this pre-operative approach was
going infragenicular surgical revascularisation. The vascu- achieved.
lar ultrasound tests were all performed using a Toshiba SSA-
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Conclusion. In selected cases, high quality arterial ultra-


770A Aplio 80 duplex scanner. The aortoiliac, femoral- sonography performed by skilled operators offers an accurate,
popliteal and infrageniculate arterial segments were studied reliable alternative to pre-operative arteriography before infra-
to obtain high quality B-mode, colour and power Doppler, genicular surgical revascularisation, and can accurately iden-
Advanced Dynamic Flow (ADF) images as well as velocity tify the best distal anastomotic site. Poor visualisation of high-
spectra. The vessels were classified as being normal or mild- ly calcified vessels, as well as the presence of extensive and
ly diseased (< 50%), moderately diseased (50-70%), severely open ulcers, severe oedema and obesity are some of the limi-
diseased (70-99%), occluded, or not visualised. Infragenicular tations associated with DUAM.
surgical reconstruction was based on DUAM without pre-
operative contrast arteriography (CA) in 17 (35%) patients. KEY WORDS: Vascular diseases – Ultrasonography, Doppler, Duplex
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Intraoperative completion arteriography with an OEC 9600 - Diagnostic imaging.


mobile unit was carried out, nonetheless, to evaluate patency
of the distal anastomosis and runoff status. Post-operative
duplex was performed at 1, 3, and 6 months, and then every
T raditionally, contrast angiography (CA) has been
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6 months afterwards.
Results. The selected revascularisation strategy and the ultra- the mainstay of pre-operative lower extremity vas-
sound-predicted artery site of distal anastomosis were used in cular imaging. Significant evidence was gathered to jus-
all of the cases. The 30 day mortality rate was 5.9% in DUAM tify ultrasound (US) based revascularisation in the
patients. After a mean follow-up of 21 months, limb salvage infrapopliteal segment.1-11 Duplex ultrasonography is
was achieved by 94.1% of patients in the DUAM-group; pri- painless, well tolerated by patients and cheaper than
mary patency rate was 58.8%, while mortality during follow-
up was 18%, mainly due to malignancy (11%). Outcomes in the angiography. CA is costly, invasive and may be asso-
DUAM-group patients were comparable to the CA-group, thus ciated with local and systemic complications, and
moreover, the technical limitations include both fail-
ure to provide hemodynamic information and failure
Corresponding author: G. Baldino, Department of Vascular Surgery,
E.O. Ospedali Galliera, Genoa, Italy. to demonstrate patency of low-flow distal arteries.12, 13
E-mail: giuseppe.baldino@galliera.it Other non invasive techniques, such as magnetic

Vol. 17 - Suppl. 1 to No. 3 THE ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 19
BALDINO INFRAGENICULATE SURGICAL REVASCULARIZATION

resonance angiography (MRA) or computed tomog- TABLE I.—Patient’s characteristics.


raphy angiography (CTA) provide suboptimal results Demographic
in evaluating patients with severely diseased DUAM CA Overall P

ME F
data
infrapopliteal arteries.9, 14-18 MRA requires cooperative
patients and is contraindicated in the presence of pace- Female 7 (41.2%) 9 (27.3%) 16 (32.0%) NS
makers, recent surgery, claustrophobia and severe hip Male 10 (58.8%) 24 (72.7%) 34 (68.0%) NS
and knee contraction. The aim of the study was to Mean age 73.8 (50-93 yrs) 75.1 (51-94 yrs) 74.5 (50-94 yrs) NS
evaluate whether duplex ultrasound arterial mapping DUAM: Duplex ultrasound arterial mapping; CA: contrast angiography; NS: not
(DUAM) could selectively replace angiography in significant.

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patients with critical limb ischaemia (CLI) requiring

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surgical infrapopliteal revascularisation for diffuse
atherosclerotic arterial disease (TASC type C and D TABLE II.—Comorbidities and risk factors.

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lesions) while providing short and long term results that Comorbidities
DUAM CA Overall P
are comparable to those achieved by using angio- and risk factors
graphic pre-operative imaging.19 Diabetes mellitus 6 13 19
(35.3%) (39.4%) (38%) NS
Hypertension 10 27 37
Materials and methods (58.8%) (81.8%) (74%) NS
CAD 8 11 19
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(47.0%) (33.3%) (38%) NS


Between January 2005 and June 2009, 300 patients Atrial fibrillation 1 5 6
were admitted to the Galliera Hospital Vascular Surgery (5.9%) (15.2%) (12%) NS
Department, Genoa, Italy for CLI. All patients under- COPD 2 7 9
(11.8%) (21.2%) (18%) NS
went DUAM before undergoing surgical or endovas- Chronic renal failure 3 16 19 <0.05
cular treatment: 50 of them were eligible for infra- (17.6%) (48.5%) (38%) (0.033)
genicular surgical revascularisation. Dyslipidemia 10 24 34
A clinical diagnosis of CLI was confirmed in all (58.8%) (72.7%) (68%) NS
Hyperhomocysteinaemia 12 24 36
patients by ankle pressure measurement <50 mm Hg (70.6%) (72.7%) (72%) NS
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obtained by cuff-manometry or, when arteries were Smokers 3 7 10


extremely calcified, by pole test measurement based on (17.6%) (21.2%) (20%) NS
hydrostatic pressure derived by leg elevation.19-21 Ex smokers 7 14 21
(41.2%) (42.4%) (42%) NS
All vascular US tests were performed under the
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supervision of the operating surgeon, using a Toshiba DUAM: Duplex ultrasound arterial mapping; CA: contrast angiography; NS: not
significant; CAD: coronary artery disease; COPD: chronic obstructive pulmonary
SSA-770A Aplio 80 Duplex scanner (Toshiba Corp., disease.
Tokyo, Japan). A 6-11 MHz linear array transducer
was used to visualise femorodistal arteries and the
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iliac segment in thinner patients. A 2-6 MHz curved low it more proximally. The vessels were classified as
array transducer was employed to visualise the aor- being normal or mildly diseased (<50%) in the pres-
toiliac segment, the superficial femoral artery at the ence of a peak systolic velocity (PSV) ratio <2; mod-
adductor canal, the tibioperoneal trunk and the prox- erately diseased (50-70%) with a PSV ratio >2, severe-
imal anterior tibial artery. The aortoiliac, femoral- ly diseased (70-99%) in the presence of a PSV ratio
popliteal and infrageniculate arterial segments were > 3, occluded, or not visualised.3, 8, 9, 15, 16 Pre-opera-
studied to obtain high quality B-mode, colour and
tive duplex evaluation included measuring arterial
power Doppler, Advanced Dynamic Flow (ADF)
images as well as velocity spectra. In some cases, size, vessel wall thickness, length and degree of steno-
aortoiliac imaging required preparing the patient so as sis or occlusion. This information was used to more
to avoid artefacts caused by bowel interposition. We precisely establish the best anastomotic site. Hand-held
found that extremity rotation and repositioning may Doppler insonation of the foot arch or dorsalis pedis
be useful to improve femoral, popliteal and tibial artery and proximal compression of the calf vessel at
artery imaging. In practice, it was often easier to iden- the ankle using the fingers can sometimes be a useful
tify the infragenicular vessel at the ankle and to fol- test to identify which artery is feeding the foot arch,

20 THE ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY September 2010


INFRAGENICULATE SURGICAL REVASCULARIZATION BALDINO

TABLE III.—Type of revascularization. TABLE IV.—Results.


N. Results (21 months) DUAM CA Overall P

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Femoroperoneal bypass Reversed vein 3 Limb salvage 16 (94.1%) 19 (57.6%) 35 (70%) <0.01
In situ vein 2 (0.0076)
Composite sequential 4 Primary patency 10 (58.8%) 16 (48.5%) 26 (52%) NS
Femorotibial bypass (posterior tibial) Reversed vein 3 Secondary patency — 18 (54.5%) 28 (56%) —
In situ vein 2
Composite sequential 1 Minor amputation 2 (11.8%) 4 (12.1%) 6 (12%) —
30 day mortality 1 (5.9%) 3 (9.1%) 4 (8%) —
Femorotibial bypass (anterior tibial) Reversed vein 2
Overall mortality 3 (17.6%) 6 (18.2%) 9 (18%) NS

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and should thus be the preferred distal anastomotic
DUAM: Duplex ultrasound arterial mapping; CA: contrast angiography; NS: not
significant.

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site.22
Evaluation of the autogenous conduits (diameter, bypass or concomitant coronary artery disease
length and collaterals) was also part of the pre-opera- (CAD).23
tive imaging: venous resources were accurately iden- All patients underwent duplex surveillance follow-
tified and carefully mapped due to their relevance up programmes which included examinations at 1, 3,
when deciding which kind of reconstruction to per- and 6 months after surgery, and then every 6 months
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form. afterwards.
The average time required to perform each DUAM Statistical analysis was performed using the χ2 test.
examination was about 60 minutes.
After DUAM evaluation, pre-operative CA was per-
formed in 33 (65%) cases, while the remaining 17 Results
(35%) patients underwent infragenicular surgical revas-
cularisation without additional imaging. All interventions in the DUAM-group were carried
Arterial lesions were classified according to the out as had been planned by pre-operative US: the cho-
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TransAtlantic Inter-Society Consensus (TASC) 2007 sen revascularisation strategy and US predicted artery
criteria.19 Five (29.4%) cases were classified as TASC site of anastomosis were used in all cases.
C and 12 (70.6%) were classified as TASC D. The 30 day mortality rate was (5.9%) in DUAM
Indication for surgery was rest pain in 7 cases patients (one death was due to multi organ failure -
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(41.1%), tissue loss in 2 (11.8%) and non-healing ulcer MOF), and 9.1% in the CA-group (3 deaths were relat-
in 8 patients (47.1%) (TASC 2007).19 ed to cardiac complications).
The patients’ characteristics are summarised in The mean follow-up was 21 months (range 2 – 54
Tables I and II. months).
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Distal anastomosis was to the peroneal artery in 9 The limb salvage rate was 94.1% in DUAM patients
cases (52.9%), and to the tibial arteries in 8 (47.1%); and 57.6% in the CA-group (p<0.05), and the minor
the specific procedures that were performed are shown amputation rate was similar in the two groups (11.8%
in Table III. in the DUAM-group vs 12.1% in the CA-group) (Table
Intraoperative completion arteriography with an IV).
OEC 9600 mobile unit (OEC Medical Systems, Salt Primary patency rate was comparable in both groups
Lake City, Utah, USA) was carried out in all cases to (58.8% in the DUAM-group — 48.5% in the CA-
evaluate patency of the distal anastomosis, runoff sta- group). Three patients in the DUAM-group required
tus and correct graft tunnelisation. additional endovascular procedures because they devel-
In agreement with Dutch Bypass Oral anticoagu- oped asymptomatic, tight stenoses in the venous graft
lants or Aspirin (BOA) Study Group data, we admin- which was detected by US surveillance. Two patients
istered anticoagulation treatment (Warfarin or low in the CA-group were re-admitted for acute limb
molecular weight heparin) to all patients with venous ischaemia due to graft thrombosis: one underwent
graft, which was associated with antiplatelet drugs hybrid surgery (surgical thrombectomy and endovas-
(ASA or clopidogrel) in case of composite sequential cular recanalisation of the pedal artery), while the sec-

Vol. 17 - Suppl. 1 to No. 3 THE ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 21
BALDINO INFRAGENICULATE SURGICAL REVASCULARIZATION

ond patient was successfully treated with loco region- DUAM in this arterial district at our institution. On
al thrombolysis. Lastly, the secondary patency rate in the basis of this experience we started to selectively
the CA-group was 54.5%. replace CA with DUAM before infragenicular surgi-

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Overall mortality during the follow-up period was cal revascularisation in order to avoid complications
18% in both groups. Two patients in the DUAM-group associated with arteriography (4-9%), including
died of malignancy, and one of MOF, while 5 patients haematoma, anaphylaxis, false aneurysms, arteriove-
in the CA-group died of cardiovascular disease and nous fistula and renal failure, as well as to reduce costs
one of renal failure. and length of hospital stay.32-36
Our findings demonstrate that in selected cases,

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DUAM is at least as good as CA for pre-operative
Discussion planning of infrapopliteal bypass, and comparable
outcomes in both DUAM- and CA-group patients con-

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Appropriate management of CLI requires prompt firmed the non-inferiority of this pre-operative dye-
surgical or endovascular treatment to prevent limb less imaging approach.
loss. The Bypass versus Angioplasty in Severe Some of the limitations associated with DUAM
Ischaemia of the Leg (BASIL) Trial randomised 452 that may lead to not-diagnostic studies include; poor
CLI patients to undergo either bypass surgery or angio- visualisation of highly calcified vessels, extensive
plasty.24 The primary end point of amputation-free and open ulcers and the presence of dressings obscur-
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survival did not differ between treatment groups at 1 ing the visualisation of the underlying vasculature,
year, but the patients had been pre-selected as candi- severe oedema, dermatitis, hyperkeratosis, and mor-
dates for either therapy and constituted only 30% of the bid obesity.
entire CLI population.25 CLI revascularisation must
DUAM relies heavily on technology that has only
be individualised: patients with TASC A and B lesions
recently become available in top level duplex ultra-
should initially be offered angioplasty. Treatment of
sound instruments. Power Doppler is useful in low-
TASC C and D lesions depends on the patient’s char-
flow velocity small vessel imaging and, in most cas-
acteristics; endovascular treatment should be taken
into consideration in selected high-risk patients, par- es, is able to overcome the problem of severe vessel cal-
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ticularly if the available vein conduit is poor, if med- cification. The latest US technology, such as B-flow
ical co-morbidities are significant, or if life expectan- (GE ultrasound Milwaukee, WI, USA) or ADF
cy is less than 2 or 3 years. Bypass is the best option (Toshiba Corp., Tokyo, Japan), provides more sensitive
for most patients with TASC C and D lesions and for direct imaging of blood flow in stenotic arterial seg-
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long segment tibial disease in reasonable risk patients ments with increased flow velocity, and has improved
with good vein conduit.24, 25 the ability to image the lumen-vessel wall interface at
Traditionally, CA has been the gold standard for low- the site of greatest stenosis.
er limb arterial diagnostic examination. The use of Although the limitations of duplex US tibial vessel
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DUAM in lower limb arterial imaging was first report- imaging are well known, this diagnostic technique
ed by Jager et al. in 1985.26 Although comparisons offers clear advantages in terms of cost and portabil-
between US and CA have produced mixed results, sev- ity. Furthermore, its advantages are that it is not inva-
eral authors reported the feasibility of surgical and sive, it is very well tolerated by patients, it is less
endovascular revascularisation to infragenicular and expensive than CA, it can be repeated as needed with-
foot arteries based primarily on DUAM.1-11, 27, 28 out any additional risk while avoiding ionising radia-
The Maimonides Medical Centre experience showed tion and contrast media, and it provides functional
that DUAM could appropriately select patients for data.29-31
surgical or for endovascular treatment, thus limiting the The crucial points are that inadequate US exami-
role of CA to interventional procedures, but such a nations must be identified, and that a single imaging
program requires specific training of an ultrasound/ modality must not be the basis for leg amputation.
surgery team.1, 3, 5, 8, 9, 15, 16 Although CA remains the gold standard in
We first decided to perform infragenicular endovas- infrapopliteal vessel visualisation, surgery should not
cular revascularisation based on DUAM alone, and be ruled out on the basis of angiography alone, since
this was the initial step in the validation process of CA can miss patent distal calf vessels with proximal

22 THE ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY September 2010


INFRAGENICULATE SURGICAL REVASCULARIZATION BALDINO

For the time being, CA continues to act as the gold


standard for tibial artery imaging, but fails to provide
information about the hemodynamic significance of

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various arterial lesions. DUAM is also mandatory pri-
or to ruling out surgery on the basis of CA alone, and
successful infragenicular surgical revascularisations
using DUAM alone have been described. The cost of
a DUAM scan (about ? 75) is appreciably lower than
that of a CA (? 500), CTA (? 260) or MRA (? 365)

A
examination.

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Conclusions

In selected cases, high quality arterial ultrasonogra-


phy performed by skilled operators offers a reliable
alternative to pre-operative arteriography before infra-
genicular surgical revascularisation, and can accurate-
MIN O

ly identify the best distal anastomotic site. Our find-


Figure 1.—Algorithm for the diagnosis and treatment of CLI. ings demonstrate that in selected cases, DUAM is at
least as good as CA for the pre-operative planning of
infrapopliteal bypass. Poor visualisation of highly cal-
occlusion.12, 13 Figure 1 shows our algorithm for the cified vessels, as well as the presence of extensive and
diagnosis and treatment of CLI. open ulcers, severe oedema and obesity are some of the
We have had limited and unsatisfactory experience limitations associated with duplex arterial mapping.
with MRA in the evaluation of infragenicular arterial
disease. The literature data also reports the suboptimal
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results of this technique which requires a high level of References


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24 THE ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY September 2010