The use of duplex ultrasound arterial mapping as an alternative to conventional arteriography for primary and secondary infrapopliteal bypasses

BACKGROUND: For more than 1 decade, duplex ultrasonography has been investi gated as a potential replacement for invasive contrast arteriography (CA) p rior to Tower extremity revascularization. While some authors advocate the reliability of this methodology for infrainguinal imaging, revascularizatio ns based on duplex ultrasonography alone are seldom reported. Our initial e xperience with duplex ultrasound arterial mapping (DUAM) for primary and se condary infrapopliteal bypasses performed without preoperative CA is report ed in this series. METHODS: Twenty-eight infrapopliteal bypasses based on DUAM alone (26) and combined DUAM and CA (2) were performed. Indications for surgery were tissu e loss in 22 cases and rest pain in 6. Eight patients (29%) had at least 1 previous ipsilateral revascularization. A schematic anatomical drawing base d on DUAM helped the selection of optimal inflow and outflow bypass sites. Bypasses originated from the femoral arteries in 17 cases, external iliac i n 3, and popliteal in 4, and from a previous graft in 4. The distal anastom osis was to the dorsalis pedis in 12 cases, posterior tibial in 7, anterior tibial in 6, and peroneal in 3. RESULTS: DUAM revealed unobstructed inflow in 24 cases, significant iliac s tenosis in 1, and in 3 cases imaging was not possible owing to obesity. A p ressure gradient of 15 mm Hg between donor and radial artery confirmed the stenosis diagnosed by DUAM, and was successfully treated with balloon angio plasty and stent placement. A single infrapopliteal runoff artery was ident ified by DUAM in 22 cases, 2 in 4 cases, and 3 in 2 cases. Preoperative CA was performed in 2 instances because of severe arterial calcification. Comp letion arteriography matched the run-off status predicted by DUAM in 25 out of 26 cases (96%). DUAM missed a significant anterior tibial artery stenos is that required a distal graft extension. One-, 3-, and 6-month patency ra tes were 96%, 85%, and 62%, respectively. Limb salvage rate was 86%. CONCLUSIONS: This early experience shows that DUAM may be a safe alternativ e to invasive conventional arteriography for the majority of patients (89%) presenting with critical ischemia and in need of infrapopliteal bypasses. Am J Surg. 1999;178:162-165. (C) 1999 by Excerpta Medica, Inc.