Aortoiliac Reconstructive Surgery Based Upon The Results Of Duplex

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Eur J Vasc Endovasc Surg 16, 383-389 (1998) Aortoiliac Reconstructive Surgery Based Upon the Results of Duplex Scanning E. S. van der Zaag, D. A. Legemate*, T. Nguyen, R. Balm and M. J. H. M. Jacobs Department of Vascular Surgery, Academic Medical Centre, Amsterdam, The Netherlands Objective: to evaluate whether duplex scanning can replace angzography m patzents operatedfor aortodiac obstructzve &sease. Design: retrospectzve. Materials and methods: between January 1995 and October 1996, 44 patzents underwent vascular surgery of the aortodzac tract The study population was &v~ded into two groups; patzents operated upon the results of duplex scanning only and patTents who also underwent angwgraphy prior to surgery. The add#zonal value of angzography and the dzfferences between both groups concermng unexpected peroperatzvefindings, early postoperatwefailures and the need for ad&tzonal radwlog~caI or surgzcal interventzons m the first three postoperatwe months were studied Results: Duplex scan group: 22 patients were operated upon the results of duplex scanning only In two patlents surgzcal strategy had to be changed. Early postoperatzve graft occluswn occurred m one case. A haemodynamwally szgn¢cant graft stenoszs wzthm 3 months of surgery occurred m one patzent. Duplex/angwgraphy group 22 patzents underwent both duplex scanning and ang~ography. Szx patzents underwent &agnostzc angzography after failed duplex scanning In 10 patzents angzography was part of percutaneous translummal angzoplasty prior to surgery In sm patients angzograms were performed after successful duplex scanning Angiography faded m two patzents and added mformatzon m four of 16 patzents. Unexpected findings at operatwn occurred m four patzents Graft stenoszs wzthin 3 months was detected m three patwnts Conclusion: after successful duplex scanning mformatzon obtained by ang~ography has only a hmzted impact on therapeutzc deciswn-makmg In the majority of patzents vascular reconstructive surgery of aorto&ac arterzes can be planned based on duplex scanning only. Key Words" Aortodzac obstructzve dzseases; Duplex scanning, Angzography; Chmcal nnpact. Introduction Table 1. Surgery for aortoiliac obstructive disease. Treatment W h e n patients are selected for aortoiliac reconstructive surgery based u p o n the results of duplex scanning, additional angiography is usually still p e r f o r m e d to plan the definitive surgical approach. However, duplex scanning m a y replace diagnostic angiography because b o t h the aortoiliac and femoropopliteal arteries can be accurately assessed. In a recent meta-analysis, based on results of both convenhonal and colour-coded duplex scanning, w e reported a pooled sensitivity of 80% and specificity of 95% for the detection of stenosis greater than 50% in the aortoihac arteries. If duplex scanning has to differentiate between open or occluded aortoiliac arteries, the sensitivity becomes even greater than Aortobl-lhac bypass AortoblfemoraI bypass Ihoblfemoral bypass Ihofemoral bypass Femorofemoral crossover bypass Endarterectomy of the fllactract Total Duplex group Anglography group Total 3 5 1 5 7 0 4 0 8 10 3 9 1 13 17 1 0 1 22 22 44 90% and these figures m a y be higher if colour-coded duplex scanning is used. ~'2In view of the high accuracy of duplex scanning c o m p a r e d to angiography, the need for preoperative angiography must be questioned. Several reports describe the potential of duplex scan- * Please address all correspondence to D A Legemate, Department of Vascular Surgery, G4-105, Academic Medical Centre, Umvers~ty 3 10 of Amsterdam, Melbergdreef 9, 1105 AZ Amsterdam-Zmdoost, The n m g in clinical decision-making. - If a lesion can Netherlands be treated b y percutaneous transluminal angioplasty 1078-5884/98/0110383+07 $12 00/0 © 1998 W B Saunders Company Ltd E, S. van der Zaag et aL 384 Table 2. Preoperative work-up in patients operated for aortoiliac obstructive disease. n Duplex scan group Anglography group Lesion 22 22 Anglography St * Occ -~ Diagnostic Interventlonal Add mformatzon Decisive for surgical strategy 5 3 17 19 15 12 1§ 10 0 10 6 • Stenoms t Occlusion $ Intraoperatlve anglogram for successlve femorocrural bypass § Intraoperatlve translummal dilatation of superficml femoral artery Table 3. Treatment strategy in patients treated for bilateral aortoiliac obstructive disease. Case Duplex scanning Aortolliac Strategy Dmcrepancy between duplex and anglography Treatment change Unexpected fmdmgs at operatlon 1 L* R Stenosls Occlusion PTA EIA+ Iliofemoral bypass No Progression of occlusion No No No No 2 L R Stenosls Occlusion PTA CIA Ihofemoral bypass No No No No No No 3 L R Occluston Stenosls Ihofemoral bypass PTA EIA No Stenosls < 5 0 % $ No Procedure abandoned Yes§ No 4 L Occlusion No No No R Stenoszs Femorofemoral crossover bypass PTA EIA No No No L = Left/R = Right i- Percutaneous translummal angloplasty of the external flmc artery (EIA)/common fllac artery (CIA) $ After multlplane views and mtra-arterml pressure measurements § Due to calclficatzonof the arterial wall end-to-side anastomosls is converted into end-to-end anastomosis Table 4. Treatment strategy in patients operated within 6 months after percutaneous transluminal angioplasty. Case Duplex scan Aortoflzac tract Strategy Discrepancy between Treatment duplex and change anglography Duplex survezllance Strategy Unexpected findings at operatzon 1. 2 3 Stenosls Stenosls Stenosls PTA EIA* PTA EIA PTA CIA No Thrombolysm PTA Aorta blf. Reoccluslon Reoccluslon Reocclusion Occlusion Occlusion Stenosis PTA EIA PTA EIA PTA EIA No No No Reoccluslon Reoccluslon Restenosls Ihofemoral bypass Ihofemoral bypass Aortoblfemoral bypass Ihofemoral bypass Ihofemoral bypass Ihofemoral bypass No No Yest 4 5 6 No Acute occlusion Leslon extentlon into aorta No No No No No Yes$ * Percutaneous translummal angloplasty of the external lhac artery (EIA)/common fllac artery (CIA) -t Due to calcification of the aorta the proximal anastomosis m retrnplanted more proximally $ Due to perlvascular clcatnsatlon of the common fllac artery as a result of prior operation, the lhofemoral bypass is converted into a femorofemoral crossover bypass. (PTA), d u p l e x s c a n n i n g c a n correctly select these p a t i e n t s i n o v e r 80% of cases. 3-7 O n l y three s t u d i e s , h o w e v e r , d e s c r i b e the role of d u p l e x s c a n n i n g i n p l a n n i n g s u r g i c a l a p p r o a c h . 8-I° A theoretical d e c i s i o n a n a lysls s h o w e d a g o o d a g r e e m e n t b e t w e e n a s u r g e o n ' s decision based on duplex scanning versus that based o n a n g i o g r a p h y . 8 T w o s t u d i e s d e s c r i b e d the u s e of d u p l e x s c a n n i n g as the sole i m a g i n g m o d a l i t y i n a selected, s m a l l n u m b e r of p a t i e n t s . I n o n e of these, all Eur I Vasc Endovasc Surg Vol 16, November 1998 p a t i e n t s also u n d e r w e n t o n - t a b l e a n g l o g r a p h y prxor to s u r g e r y a n y w a y . 9'1° I n o u r h o s p i t a l the d e c i s i o n to s c h e d u l e a p a t i e n t for a PTA is r o u t i n e l y b a s e d u p o n the r e s u l t s of d u p l e x s c a n n i n g only, a n d i n a n i n c r e a s i n g n u m b e r of p a t i e n t s surgical r e c o n s t r u c t i o n s are p e r f o r m e d w i t h o u t a n g i o g r a p h y . This a p p l i e s m a i n l y to r e c o n s t r u c t i o n s of the aortolliac tract, as a s s e s s m e n t of the c r u r o p e d a l outflow is n e c e s s a r y for f e m o r o d i s t a l b y p a s s e s a n d d u p l e x Preoperative Duplex-scanning 385 months. The remaining 44 patients consisted of 28 men and 16 women ranging in age from 29 to 82 n Operation Restenosls Remtervenhon years. The indications for operation were disabhng Unexpected <3 months <3 months claudication in 29 patients, rest pain m 14 patients and findings* lschaemic ulceration in one patient. The results of Duplex scan 22 2 1 1 duplex scanning and angiograms were collected and group analysed. Anglography 22 4 3 0 group Duplex scanning was performed with a HewlettPackard sonos 1000 or 2000. The aortolliac segments, * Intraoperahve findings which changed surgical strategy, common femoral and the orifice of both the deep and superficial femoral arteries were routinely examined scanning of these arteries is, as yet, insufficiently val- on both sides (with a 3.5-4.5 MHz probe). Femoidated. 1 In a retrospective study we analysed the con- ropopliteal outflow of the affected limb was also astribuhon of duplex scanmng to the work-up and sessed, whereas crural arteries were not investigated. clinical decision-making in pahents operated for aorto- Peak systolic velocity (PSV) ratios were used to grade iliac obstructive disease, to determine whether angio- stenoses; a lesion with a PSV-ratio greater than or graphy was needed after successful duplex scanning, equal to 2.5 or occlusion was considered as haemodynamically significantJ 1'12The results of duplex scanning, including the length of the lesions, were drawn Patients and Methods on an anatomical line diagram, providing the vascular surgeon with a road map to plan the surgical technique. All patients referred to our vascular laboratory for Intra-arterial digital subtraction angiographyvia retaortoiliac duplex investigation between January 1995 rograde femoral puncture was performed using the and October 1996 were identified. Aortoiliac re- Seldingertechnique. Stenoses were graded based upon construchve surgery was performed in 47 of these cross-sectional diameter reduction and considered patients. Only those patients who were operated haemodynamically significant if greater than 50%. within 6 months after duplex examinahon were ana- Monoplane views were taken routinely. When the lysed. In three patients this time span exceeded 6 results of the duplex scan were not in accordance with Table 5. Intraoperative findings and clinical outcome in patients operated for aortoiliac obstructive disease. Interventionneeded ] J Aortoihacand femoropophtealduplexscan PTAindicated Aortoiliac surgery indicated Results of duplex scan unequivocal I Femoropophteal surgeryindicated L_ Resultsof duplexscanequivocal [ / Angiography Schedule for PTA Schedule for surgery ] Schedule for surgery/~ Fig. 1. Algonthrn of preoperahve work-up m pahents w~th peripheral arterial obstructive disease. Eur J Vasc Endovasc Surg Vol 16, November 1998 E.S. van der Zaag et al. 386 RIGHT PSV Aorta 63 Ratio EDV LEFT PSV Coehac SMA SMA Renal CIAprox 180 mid 195 mid &st 230 dlst EIAprox ! CIAprox 184 EIAprox 101 mid 160 mid 82 IIA prox L IIA prox dlst 135 dist 85 CFAprox 110 CFAprox 69 DFA 90 40 DFA 50 SFA33 cm 100 35 SFA34 cm 65 30 cm 25 2O 22 cm cm 88 am 18 cm 15 80 10 5 cm 10 cm I- 85 0 [ L 50 am 19 cm 45 cm 10 cm cm PA EDV Coeliac Renal 23 cm Ratio Aorta 46 am 60 PA 35 TPT 50 TPT 30 ATA 55 ATA 32 PTA PTA PA PA CIA = Common lliac artery CFA = Common femoral artery PA = Popliteal artery IIA = Internal lllac artery DFA = Deep femoral artery TPT = %bloperoneal trunk EIA = External ihac artery SFA = Superficial femoral artery ATA = Anterior tlblal artery Fig. 2. Results of duplex scanning reported on a standard data sheet the m o n o p l a n e a n g i o g r a p h y , m u l t i p l a n e v i e w s w e r e m a d e or i n t r a - a r t e n a l f e m o r a l p r e s s u r e m e a s u r e m e n t s w e r e p e r f o r m e d : a n a b s o l u t e p e a k systolic b r a c h i a l f e m o r a l p r e s s u r e g r a d i e n t g r e a t e r t h a n 20 m m H g at rest, or a d r o p m f e m o r a l to b r a c h i a l i n d e x g r e a t e r t h a n 15% after a d m i n i s t r a t i o n of p a p a v e r i n e , w a s cons i d e r e d h a e m o d y n a m i c a l l y significant. ~2 Based o n p r e o p e r a t i v e w o r k - u p , the s t u d y p o p u latlon was divided retrospectively into a duplex scan Eur J Vasc Endovasc Surg Vol 16, November 1998 g r o u p (those w h o w e r e o p e r a t e d o n w i t h o u t a d d i t i o n a l a n g i o g r a p h y ) a n d a n a n g i o g r a p h y g r o u p (those w h o had both duplex scanning and additional anglog r a p h y ) . The r e s u l t s of a n g l o g r a p h y w e r e c o m p a r e d w i t h d u p l e x s c a n n i n g to assess the a d d i t i o n a l v a l u e of a n g i o g r a p h y . Surgical r e p o r t s w e r e r e v i e w e d to detect differences b e t w e e n b o t h g r o u p s c o n c e r n i n g the o c c u r r e n c e of u n e x p e c t e d m t r a o p e r a t l v e f i n d i n g s a n d c h a n g e s of the s u r g i c a l a p p r o a c h . Blood systolic a n k l e Preoperative Duplex-scanning pressure, results of duplex surveillance and the occurrence of reinterventions (PTA or surgery) were reviewed to detect &fferences m chnical outcome between both groups in the course of the first 3 postoperative months. The Wilcoxon paired-test was used to compare pre- and postoperative blood systolic ankle pressure measurements, Results Preoperatwe work-up Duplex scan group. Based on the results of the duplex scan, 22 patients underwent vascular reconstructive surgery of the aortoiliac tract without addihonal angiography (Table 1). The median hme between duplex examination and operahon was 60 days (range: 2-135 days), Anglography group The other 22 patients underwent duplex scanning as well as angiography before operation (Table 1). For this group of pahents the median time between duplex examination and operation was 52 days (range: 1-126 days). There were no complicahons after angiography. In 12 patients addihonal angiography was performed solely for &agnostic reasons and in 10 patients angiography was part of percutaneous treatment prior to surgery (Table 2). Of the 12 diagnostic angiographies, six were necessary because duplex scanning failed due to obesity The other six patients underwent an angiogram after successful duplex scanning. In four pahents this diagnostic angiogram added no new informahon regarding the surgical strategy. In two patients the guidewire could not pass the atherosclerotic lesion in both groins and angiography failed. In these patients the final deosion (for an aortobifemoral bypass) was therefore based on duplex scanning alone Of the 10 patients who had percutaneous treatment prior to surgery, four were scheduled for a combination of both percutaneous and surgical treatment for bilateral aortoiliac obstructive &sease based on duplex scanning only (Table 3). The other six patients had to be operated after early graft stenosis of PTA of the aortoiliac tract, Both the patient selection for percutaneous treatment and detection of early failures were based on the information of duplex scanning (Table 4). Four of these 10 angiograms performed during percutaneous treatment did add new information which changed the percutaneous approach, but did not affect the surgical strategy 387 Intraoperativefindmgs Duplex scan group. In two patients the surgical strategy had to be changed, as unexpected findings occurred during operation (Table 5). In the first case, endarterectomy of the occluded external iliac artery was extended into the common ihac artery, as a pinpoint stenosis was detected intraoperatively in the common lhac artery. In the second case a patient received a femorofemoral crossover bypass instead of a combmation of an endarterectomy of the common femoral artery and a transluminal dilatation of a stenosls of the lpsilateral common ihac artery, because the entire iliac tract appeared to be calcified and virtually occluded, making it unsuitable for percutaneous treatment Two of the 22 patients underwent on-table angiography for complementary outflow reconstructions, which was already scheduled preoperatively, one, to assess the suitability of the crural arteries for successive distal bypass surgery and one because of a translummal dilatation of a stenosis m the superficial femoral artery Angiography group. In this group of patients four unexpected findings occurred during operation (Table 5). In two patients the proximal end of the graft had to be anastomosed more proximally because of excessive calcification. In one, the option of an end-to-side anastomosls was converted into an end-to-end anastomosis because of unexpected dilatation of the abdominal aorta. In the final patient the common iliac tract could not be explored because of excessive scarring after previous vascular reconstructive surgery and the planned lliofemoral bypass was converted into a femorofemoral crossover bypass. Climcal outcome Duplex scan group. Early failure of one graft occurred (Table 5). One hour after imtial surgery, duplex scanning confirmed acute thrombosis of the graft and a surgical thrombectomy was successfully performed. All patients recovered well after surgery and median ankle-brachial indices rose from 54% (range: 0-109%) preoperatively to 75% (range: 45-111%) postoperativey (n = 15, p<0.05). In one patient, duplex surveillance detected a haemodynamicallysignificantgraftstenosis during the 3 months following surgery. Angiography group. There were no early failures of surgical treatment in this patient group (Table 5). Eur J Vasc Endovasc Surg Vol 16, November 1998 E, S. van der Zaag et aL 388 Median ankle to brachial indices rose f r o m 35% (range: 0-56%) u p to 77% (range: 27-100%) p o s t o p e r a t : v e l y (n = 14, p<0.05). In three patients h a e m o d y n a m i c a l l y significant graft stenoses w e r e detected within 3 months. Because of persistent rest p a i n due to infrainguinal obstructive arterial d:sease, one patient u n d e r w e n t distal b y p a s s surgery 1 w e e k after init:al aortobifemoral b y p a s s surgery, Discussion This s t u d y shows that in a considerable n u m b e r of patients w i t h aortoiliac obstruct:ve disease reconstructive surgery can be p e r f o r m e d on the basis of duplex scanning only. Preoperative a n g i o g r a p h y w a s m a i n l y p e r f o r m e d as p a r t of a p e r c u t a n e o u s ratervention (10/44) or because of inability to visualise the entire aortoiliac tract (6/44). Six out of 44 patients u n d e r w e n t a diagnost:c a n g i o g r a p h y after successful duplex scanning. These examinations w e r e p r o b a b l y p e r f o r m e d out of habit, although there m i g h t h a v e b e e n a w e l l - f o u n d e d reason w h i c h can be difficult to discern in a retrospective s t u d y like this. In b o t h groups, u n e x p e c t e d findings occurred w h : c h required a change in surgical strategy. N o significant differences w e r e found, however, b e t w e e n the g r o u p s a n d there w a s no difference in the n e e d for add:tional intervention d u r i n g the 3 m o n t h s following surgery, O v e r the past years the use of duplex scanning has radically changed the pre-interventlonal w o r k - u p in our patients. An algorithm of our current w o r k - u p is s h o w n in Fig. 1. Duplex examinations are not requested in our vascular laboratory if no intervention is considered. Diagnostic a n g i o g r a p h y is always asked for w h e n d u p l e x scanning s h o w s that the pat:ent needs a f e m o r o & s t a l b y p a s s or if it is not clear w h e t h e r a PTA m i g h t be possible. H o w e v e r , s o m e p a p e r s indicate that in selected cases femorodistal b y p a s s surgery m i g h t be possible w i t h o u t additional angiography. 9':3":4 If the duplex examination is p e r f o r m e d according to a s t a n d a r d protocol b y well trained vascular technologists a n d results are r e p o r t e d on a data sheet w h i c h combines information on changes in cross-sectional area b a s e d on PSV-ratios, a n d w i t h an anatomical line d r a w i n g in w h i c h length a n d localisation of lesions are precisely indicated (Fig. 2), the vascular surgeon can p l a n the surgical a p p r o a c h w : t h o u t the n e e d for angiography. Duplex scanning of the renal, the inferior mesenteric and internal iliac arteries is t i m e - c o n s u m m g and for the inferior mesenteric a n d internal iliac arteries insufficiently validated. Therefore these arteries are not routinely scanned. H o w e v e r , for m o s t patients Eur J Vasc Endovasc Surg Vol 16, November 1998 treated for obstructive aortoiliac disease, reformation concerning the p a t e n c y of inferior mesenteric a n d internal iliac arteries is not essential w h e n planning the surgical technique. The technologist and vascular surgeon should discuss the (abnormal) results of duplex scanning or u n e x p e c t e d intraoperative findings, to i m p r o v e the diagnostic performance. A p r e o p e r a t i v e w o r k - u p b a s e d on duplex scanning alone is beneficial for the patient as it is p e r f o r m e d in the outpat:ent clinic and excludes the discomfort a n d risks of u n n e c e s s a r y angiography. In conclusion, this s t u d y s h o w s that after successful duplex scanning information obtained b y a n g i o g r a p h y has only a limited i m p a c t on therapeutic decisionm a k i n g w h e n aorto:liac reconstructive surgery is needed. A n g i o g r a p h y should be reserved for those patients in w h o m the results of d u p l e x scanning are equivocal. References 1 KOELEMAYMJW, HARTOGDEN D, PRINS MH, KROMHOUTJG, LEGEMATEDA, JACOBSMJHM. 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Bt J Sttrg 1996, 83 1725-1728 10 ELSMANBHP, LEGEMATEDA, HEIJDENVANDERFHWM, Vos DE HJ, MALIWPTHM, EIKELBOOMBC Impact of ultrasonographlc duplex scanning on therapeut:c dec:s:on making m lower-hrnb arterml dmease Br J Surg 1995, 82 630-633 11 LEGEMATEDA, TEEUWENC, HOENEVELDH, ACKERSTAFFRGA, EIKELBOOM BC Spectral analys:s criteria m duplex scanning of Preoperative Duplex-scanning 389 aortolhac and femoropophteal arterial dxsease Ultrasound Med comparison with anglography Eur J Vasc Endovasc Surg 1996, Bzol 1991, 17 769-776 12 300-303 12 LEGEMATEDA, TEE~JWENC, HOENEVELD H, EIKELBOOMBC Value 14 KOELEMAY MJW, LEGEMATE DA, VAN GURP J, PONSON AE, of duplex compared with anglography and pressure measureREEKERSJA, JACOBSMJHM Colour duplex scanning and pulsement m tile assessment of aortollxac arterial lesions Br J S u r g generated run-off for assessment of pophteal and cruropedal 1991; 78 1003-1008 artenes before peripheral bypass surgery. Br J Surg 1997, 84 13 KARACAGILS, LOTBERGAM, GRANBOA, LORELIUSLE, BERGQVIST 1115-1119 D Value of duplex scanmng m evaluation of crural and foot arteries m hmbs with severe lower-hmb lschaemla A prospective Accepted27 January I998 Eur J Vasc Endovasc Surg Vol 16, November 1998