THE ADDITIONAL VALUE OF INTRAOPERATIVE ANGIOGRAPHY IN INFRAGENICULAR RECONSTRUCTION

Objective: To evaluate the ability of preoperative intraarterial digit al subtraction angiography (IADSA) to predict the feasibility of infra genicular reconstruction and site of the distal anastomosis. Design: P rospect ive study. Setting University Hospital Materials: 45 patients with 50 ischaemic limbs, considered potential candidates for infrageni cular reconstruction Chief Outcome Measures: Pre-reconstruction intrao perative angiography (IOA) was used as the gold standard. Analysis of angiograms was performed blindly and independently by a single observe r. In patients who ultimately underwent primary amputation, exploratio n and attempted angiography of the crural and ankle vessels was perfor med to verify the IADSA findings. Main Results: There was 87% accuracy (kappa = 0.66) between IADSA and IOA in diferentiating between a norm al stenosed and occluded tibial artery and there was 86% accuracy (kap pa = 0.67) in determining the adequacy of run-off into the pedal arch. IADSA had a positive predictive value of 100% to determine the feasib ility of reconstruction but a negative predictive value of only 73%. A fter excluding those patients that IADSA deemed non-reconstructable, I ADSA had a positive predictive value of 97% to determine the correct a rtery and 92% to determine the correct segment of artery for distal an astomosis. Conclusions: IADSA could not determine when reconstruction was not possible, but in those deemed reconstructable by IADSA, the su rgeon can confidently expose the appropriate artery at the appropriate level knowing the pedal run-off status in 86% of patients. IADSA shou ld not be used to exclude reconstruction (i.e. pre-reconstruction IOA is still required in these patients) but for the remainder, IADSA can be used to plan surgical strategy without recourse to IOA.