Endovascular surgery based solely on noninvasive preprocedural imaging

Purpose: Conventional pre-endovascular procedural evaluation uses both noni nvasive testing and diagnostic arteriography. Diagnostic and therapeutic pr ocedures often must be performed separately because of concerns about exces sive contrast administration or inappropriate location of vascular access f or the interventional procedure. We wanted to determine if patients could s uccessfully undergo endovascular procedures based on noninvasive modalities alone. Methods: One hundred nineteen consecutive patients requiring intervention f or lower-extremity ischemia were evaluated by means of physical examination s and segmental pressure measurements. Patients then underwent magnetic res onance angiography (MRA) to image native vessels or duplex scanning for fai ling bypass grafts. Suitable patients underwent endovascular procedures wit h "road map" arteriography, which was compared with preoperative duplex sca nning or MRA findings. Costs of the conventional and noninvasive approaches were compared, on the basis of estimated hospital cost schedule. Results: Sixty consecutive endovascular procedures were performed in 56 pat ients (105 lesions angioplastied), either atone (30, 50%) or in combination (30, 50%) with another vascular reconstruction. Completely noninvasive eva luation was accomplished in 43 procedures (72%), either by means of duplex scanning (11, 18%) or MRA (32, 53%). Conventional arteriography (CA) was re quired in 2 patients (3%) because of MRA contraindications and in 1 patient because of complex previous arterial reconstruction. fourteen patients had earlier CAs. The findings of the noninvasive modalities were confirmed in every case by means of intraoperative arteriography, and no additional lesi ons were revealed (no false positive or negative studies). After endovascul ar interventions, the mean patient ankle-brachial index (ABI) improved from 0.64 +/- 0.03 to 0.81 +/- 0.03 (P <.001) and the mean limb-status category improved from 3.4 +/- 0.2 to 0.8 +/- 0.2 (P <.001). There were 4 initial t echnical failures (7%), 1 morbidity (1%), and no mortalities. The noninvasi ve approach was less costly than if preprocedural diagnostic CA had been us ed, allowing $551 saved for each duplex scanning case and $235 saved for ea ch MRA case. If the cost of a short-stay unit after a diagnostic arteriogra m was included, the savings were greater: $695 saved for each duplex scanni ng case and $379 saved for each MRA case. Conclusion: Endovascular procedures can be performed based on preprocedural noninvasive modalities alone. for patients requiring endovascular procedur es, knowledge of the arterial anatomy before obtaining arterial access avoi ds the need for additional punctures or sessions leg, antegrade puncture fo r femoral angioplasty after retrograde puncture for the diagnostic arteriog ram). This approach is less costly than performing preprocedural diagnostic arteriography and avoids the hazards of arterial puncture and nephrotoxic contrast agents.