Master Title Ultrasound for Initial Evaluation of Lower Extremity Arterial Occlusive Disease: WHY? Gregory L. Moneta MD Professor and Chief Knight Cardiovascular Institute Division of Vascular Surgery Oregon Health & Science University Portland, Oregon USA Lower Extremity Artery: Left foot ulceration Physiologic Testing Ankle Brachial Index Exercise Testing Segmental Pressures/Waveforms Phylesmography (Pulse Volume Recordings) 1
Left leg claudication Sudden Onset left lower leg and foot pain Left foot ulceration Left foot ischemic pain 2
Misconceptions: Lower Extremity Arterial Duplex Scanning Right Leg Claudication • Time consuming • Difficult • Adds little to physiologic testing 2016:OHSU Lower Extremity Vascular Lab Reality of Modern Arterial Duplex Scanning Arterial Testing • Efficient / Practical • $ CTA / MRA • Still do ABIs to establish presence of • Accurate disease. • More information than • Rare exercise testing for unclear cases physiologic testing. claudication. • More accurate than • Almost no segmental pressure studies. physiologic testing. • Better follow-up info. • More than 2000 lower extremity arterial duplex studies. • Techs prefer it to physiologic testing. Cannon Beach, Oregon 3
Duplex Mapping (Clinical Categories from History/Physical Exam) • 150 patients with duplex and angiography CFA Mid AT • Group A: No significant occlusive disease • Group B: Aortoiliac occlusive disease Mid Peroneal Proximal SFA • Group C: Infrainguinal occlusive disease • Group D: Multilevel occlusive disease Mid PT Mid Popliteal Duplex Mapping Duplex Mapping Indication for Angiography Clinical Classification of Occlusive Disease 4
Duplex Mapping: Proximal Arteries Duplex Mapping: Tibial Arteries • Visualization • Visualization • Distinguish <50% vs. >50% stenosis • Predict continuous patency to the ankle (PSV, velocity ratios, waveform analysis) • Overall and according to clinical disease • Distinguish stenosis from occlusion category • Overall and according to disease category Duplex Mapping Duplex Mapping 5
Duplex Mapping: Suprageniculate Duplex Mapping: Suprageniculate Arteries (Sensitivity/Specificity/PPV/NPV) (Sensitivity/Specificity/PPV/NPV) Duplex Mapping: Tibial Arteries Duplex Mapping: Stenosis vs. Occlusion (Sensitivity/Specificity/PPV/NPV for predicting continuous patency) (Iliacs, Superficial Femoral, Popliteal) In 98% of comparisons duplex successfully distinguished stenosis from occlusion! 6
Duplex vs Segmental Pressures Duplex vs. Segmental Pressures Technical Success: Examination of Iliac-Femoral-Popliteal Arteries •Angiography 100% •Segmental Pressures 100% •Duplex Mapping 99.8% Duplex vs Segmental Pressures Duplex vs Segmental Pressures Sensitivities and Positive Predictive Values (50-100% Specificities and Negative Predictive Values Stenosis, 151 Extremities) (50-100% Stenosis, 151 Extremities) Arterial Segment Sensitivity (%) PPV (%) Arterial Segment Sensitivity (%) PPV (%) SDP ADM SDP ADM SDP ADM SDP ADM Iliac/CFA 86 97 77 93 Iliac/CFA 59 88 72 94 Proximal SFA 80 100 65 92 Proximal SFA 73 95 85 100 Distal SFA/Popliteal 56 99 60 86 Distal SFA/Popliteal 48 78 45 98 SFA / Popliteal 53 100 55 83 SFA / Popliteal 85 93 83 100 7
Duplex vs Segmental Pressures Duplex vs Segmental Pressures Missed 50-100% Stenosis By SDP and ADM in Total Agreement with Angiography Patients/Limbs With (A) and Without (B) Diabetes, Renal (151 Limbs) Failure or Previous Vascular Surgery Segmental Doppler Pressures Arterial Duplex Mapping Arterial Segment Segmental Pressures Arterial Duplex 52 (34%) 123 (82%) A(%) B(%) P-value A(%) B(%) P-value Iliac/CFA 33 43 0.712 13 3 0.007 Proximal SFA 32 22 0.468 7 8 0.789 P < 0.0001 Distal SFA/Popliteal 50 33 0.348 25 10 0.316 ABI and Progression of Atherosclerosis ABI and Progression of Atherosclerosis •114 patients • ABI is relatively insensitive to detect •193 extremities progression of atherosclerosis •Mean follow-up: 3.3 years • Duplex is better •76% of arteries initially patent by angiography 8
ABI and Progression of Atherosclerosis ABI and Progression of Atherosclerosis Duplex Mapping: Conclusions • Highly accurate Coffin Nails • Better than segmental pressures and ABI • Preferred initial examination for evaluation of PAD 9
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