Lower-extremity revascularisation without preoperative contrast arteriography in 185 cases: Lessons learned with duplex ultrasound arterial mapping

Purpose: we have previously reported our experience with lower-extremity du plex ultrasound arterial mapping (DUAM) compared to contrast arteriography (CA) to predict lower-extremity bypass sites. The present study evaluates a rterial revascularisation procedures for chronic limb ischaemia based on DU AM. Materials and methods: from January 1998 to July 1999, 195 patients (128 me n, 67 women) underwent 211 lower- extremity revascularisation procedures ba sed on DUAM. Indications for surgery were tissue loss, severe claudication, rest pain and popliteal aneurysm in 57%, 25%, 14% and 4% of the limbs, res pectively. The mean age was 72 +/- 12 years and risk factors such as diabet es, hypertension, tobacco use, coronary artery and end-stage renal disease were present in 53%, 58%, 53%, 50% and 12% of the patients, respectively. P revious revascularisation procedures had been performed in 23% of the limbs . Preoperative evaluation consisted of DUAM alone (185) or of a combination of DUAM and CA (29 limbs). CA was deemed necessary due to a combination of technical difficulties that jeopardised adequate sonographic imaging and p resence of disadvantaged run-off for medico-legal reasons. DUAM consisted o f direct imaging of all major arteries from the distal aorta to the pedal c irculation. Optimal inflow and outflow bypass anastomotic sites were select ed according to a diagram based on DUAM. Adequacy of the inflow was additio nally assessed by common-femoral-artery waveform and confirmed by intraoper ative pressure measurements. Post-bypass CA was obtained to verify patency of the run-off. Results: DUAM procedure time averaged 75 +/- 26 min. For patients who under went only DUAM, the distal anastomosis was to the popliteal artery in 91 ca ses and to tibial or pedal arteries in 58 cases. Distal anastomosis was pro ximal to a significant lesion in two cases that required jump grafts. Cumul ative patency rates at 1 and 3 months for popliteal bypasses were 96% and 9 0%, and for infrapopliteal bypasses 90% and 83%, respectively. Inflow proce dures to the femoral artery, patch and balloon angioplasties accounted for the remaining 40 cases. Four primary amputations were performed after CA co nfirmed DUAM findings. Conclusions: contrary to general belief, these data show that high-quality arterial ultrasonography represents a safe alternative to preoperative CA, even for infrapopliteal bypasses. This non-invasive approach may be especia lly useful for patients with contrast allergy or impaired renal function.