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