The Role of Color Doppler Ultrasound Arterial Mapping for Decision Making in the Treatment of Patients with Lower Extremity Peripheral Arterial Disease

Ali Babaei Jandaghi, Zahra Mardanshahi, Ahmad Alizadeh, Iraj Baghi, Hossein Hemmati, Narges Tabarzan Baboli, Shabnam Alizadeh Arasi, Amin Keshavarzzirak

Department of Cardiology, Heshmat Hospital, Guilan University of Medical Sciences, Rasht, Iran.
Department of Radiology, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran.
Department of Vascular Surgery, Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran.
Department of Vascular Surgery, Razi Hospital, Guilan University of Medical Sciences, Rasht, Iran.

DOI: 10.4236/ss.2013.410081                

Abstract

Purpose: To assess the efficacy of color Doppler imaging for decision making in the treatment of patients with lower extremity peripheral arterial disease (PAD) compared to digital subtraction angiography (DSA). Materials and Methods: Color Doppler scan was done on patients suspected for lower limb PAD, a day prior to the DSA which was done by a vascular surgeon. Also, for the patients who were candidates for endovascular intervention based on the color Doppler arterial mapping results, endovascular interventions were performed at the same time if the DSA findings are correlated with the color Doppler map. The grading for evaluated segments was normal, insignificant stenosis (<50%), hemodynamically significant stenosis (≥50%) and occlusion. We yielded the diagnostic efficacy indices of Doppler for detecting arterial stenosis in each 18 different arterial segments below the renal arteries including, infrarenal aorta, common and external iliac, common femoral, superficial femoral (proximal, middle and distal segments), deep femoral, popliteal artery, tibioperoneal trunk, anterior and posterior tibial arteries (proximal, middle and distal segments) and peroneal artery (proximal and distal segments). Then, we yielded the kappa agreement between Doppler and DSA findings considering the grade of stenosis in 18 arterial segments separately. Results: Totally 115 lower extremities (2045 arterial segments) were evaluated in 90 patients [mean age: 60.8 ± 8.9 (range: 47 - 84 years old)] of which 68 (75.6%) were men. The sensitivity of color Doppler for all arterial segments was 90% or higher except for common iliac artery, distal segment of superficial femoral artery and proximal segments of anterior and posterior tibialis and peroneal arteries. However, the specificity was 89% or higher, in all arterial segments. Kappa agreement was 0.72 or higher in all segments (All P-Values < 0.001). Conclusion: This study suggests that considering excellent capability of color Doppler sonography in the evaluation of lower extremity arterial disease, color Doppler arterial mapping is sufficient for decision making in the treatment of these patients and can reduce the rate of diagnostic angiography.

Keywords

Lower Extremity; Peripheral Arterial Disease; Color Doppler Sonography; Arterial Mapping; Digital Subtraction Angiography

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	K. A. Jager, D. J. Phillips, R. L. Martin, et al., “Noninvasive Mapping of Lower Limb Arterial Lesions,” Ultrasound in Medicine and Biology, Vol. 11, No. 3, 1985, pp. 515-521. http://dx.doi.org/10.1016/ 0301-5629(85)90164-4
[2]	T. R. Kohler, D. R. Nance, M. M. Cramer, et al., “Duplex Scanning for Diagnosis of Aortoiliac and Femoropopliteal Disease: A Prospective Study,” Circulation, Vol. 76, No. 5, 1987, pp. 1074-1080. http://dx.doi.org/10.1161/01.CIR.76.5.1074
[3]	B. L. Thiele and D. E. Strandness Jr., “Accuracy of Angiographic Quantification of Peripheral Atherosclerosis,” Progress in Cardiovascular Diseases, 1983, Vol. 26, No. 3, pp. 223-236. http://dx.doi.org/10.1016/0033-0620(83)90007-5
[4]	H. B. Slot, L. Strijbosch and J. M. Greep, “Interobserver Variability in Single-Plane Aortography,” Surgery, Vol. 90, No. 3, 1981, pp. 497-503.
[5]	M. Pemberton, S. Nydahl, T. Hartshorne, et al., “Can Lower Limb Vascular Reconstruction Be Based on Color Duplex Imaging Alone?” European Journal of Vascular & Endovascular Surgery, Vol. 12, No. 4, 1996, pp. 452-454. http://dx.doi.org/10.1016/S1078-5884(96)80013-X
[6]	B. H. Elsman, D. A. Legemate, F. H. van der Heijden, et al., “Impact of Ultrasonographic Duplex Scanning on Therapeutic Decision Making in Lower-Limb Arterial Disease,” British Journal of Surgery, Vol. 82, No. 5, 1995, pp. 630-633.
[7]	C. G. Koshy, B. R. Chacko and S. N. Keshava, “Diagnostic Accuracy of Color Doppler Imaging in the Evaluation of Peripheral Arterial Disease as Compared to Digital Subtraction Angiography,” Vascular Disease Management, Vol. 6, No. 1, 2009, pp. 2-9.
[8]	E. Favaretto, C. Pili, A. Amato, et al., “Analysis of Agreement between Duplex Ultrasound Scanning and Arteriography in Patients with Lower Limb Artery Disease,” Journal of Cardiovascular Medicine, Vol. 8, No. 5, 2007, pp. 337-341. http://dx.doi.org/10.2459/01.JCM.0000268124.51543.b2
[9]	A. Krnic, N. Vucic and Z. Sucic, “Duplex Scanning Compared with Intra-Arterial Angiography in Diagnosing Peripheral Arterial Disease: Three Analytical Approaches,” Vasa, Vol. 35, No. 2, 2006, pp. 86-91. http://dx.doi.org/10.1024/0301-1526.35.2.86
[10]	S. Aly, K. Sommerville, M. Adiseshiah, et al., “Comparison of Duplex Imaging and Arteriography in the Evaluation of Lower Limb Arteries,” British Journal of Surgery, Vol. 85, No. 8, 1998, pp. 1099-1102. http://dx.doi.org/10.1046/j.1365-2168.1998.00786.x
[11]	T. Leiner, A. G. Kessels, P. J. Nelemans, et al., “Peripheral Arterial Disease: Comparison of Color Duplex US and Contrast-Enhanced MR Angiography for Diagnosis,” Radiology, Vol. 235, 2005, pp. 699-708. http://dx.doi.org/10.1148/radiol.2352040089
[12]	J. F. Polak, M. I. Karmel, J. A. Mannick, et al., “Determination of the Extent of Lower-Extremity Peripheral Arterial Disease with Color-Assisted Duplex Sonography: Comparison with Angiography,” American Journal of Roentgenology, Vol. 155, No. 5, 1990, pp. 1085-1089. http://dx.doi.org/10.2214/ ajr.155.5. 2120939
[13]	J. Fontcuberta, A. Flores, A. Orgaz, M. Doblas, J. Gil, I. Leal, R. Rodriguez, J. Maria and M. Dolores, “Reliability of Preoperative Duplex Scanning in Designing a Therapeutic Strategy for Chronic Lower Limb Ischemia,” Annals of Vascular Surgery, Vol. 23, No. 5, 2009, pp. 577-582. http://dx.doi.org/10.1016/j.avsg. 2008.07.011
[14]	G. K. Chiramel, R. C. Binita, N. K. Shyamkumar, S. Edwin and A. Sunil, “Decision Making in the Treatment of Peripheral Arterial Disease—A Single-Institution Comparative Study Using Information from Color Doppler and Digital Subtraction Angiogram Studies,” Indian Journal of Radiology and Imaging, Vol. 21, No. 4, 2011, pp. 294-297. http://dx.doi.org/10.4103/0971-3026.90694
[15]	World Medical Association, “Declaration of HelsinkiEthical Principles for Medical Research Involving Human Subjects,” 2012. http://www.wma.net/en/30publications/10policies/b3/index.html
[16]	A.-M. Lofberg, S. Karacagil, A. Hellberg, A. Bostrom, C. Ljungman and G. ostholm, “The Role of Duplex Scanning in the Selection of Patients with Critical Lower-Limb Ischemia for Infrainguinal Percutaneous Transluminal Angioplasty,” CardioVascular and Interventional Radiology, Vol. 24, No. 4, 2001, pp. 229-232. http://dx.doi.org/10.1007/s00270-001-1786-7
[17]	J. A. Grassbaugh, P. R. Nelson, E. M. Rzucidlo, M. L. Schermerhorn, M. F. Filinger, R. J. Powell, et al., “Blinded Comparison of Preoperative Duplex Ultrasound Scanning and Contrast Arteriography for Planning Revascularization at the Level of Tibia,” Journal of Vascular Surgery, Vol. 37, No. 6, 2003, pp. 1186-1190. http://dx.doi.org/10.1016/S0741-5214(03)00328-8
[18]	J. Q. Alexander, S. M. Leos and S. G. Katz, “Is Duplex Ultrasonography an Effective Single Modality for the Preoperative Evaluation of Peripheral Vascular Disease?” American Surgeon, Vol. 68, No. 12, 2002, pp. 1107-1110.
[19]	E. Ascher, A. Hingorani, N. Markevich, W. Yorkovich, R. H. Shutzer, T. Jacob, et al., “Role of Duplex Arteriography as the Sole Preoperative Imaging Modality Prior to Lower Extremity Revascularization Surgery in Diabetic and Renal Patients,” Annals of Vascular Surgery, Vol. 18, No. 4, 2004, pp. 433-439. http://dx.doi.org/10.1007/s10016-004-0058-x