A Prospective Observational Parallel Group Comparison Study Comparing Duplex Ultrasound Arterial Mapping (DUAM) As Sole Investigative Tool For Angioplasty With Magnetic Resonance Angiography (MRA) Or Conventional Angiography (CA)

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Abstract 15

Aoife Lowery, MB BCh, B. Mahendran, B.J. Manning, N. Hynes, E. Andrews, D. Courtney, S. Sultan
Western Vascular Institute, Galway, Ireland.

Although DUAM has been accurate in the evaluation of lower extremity arterial disease, MRA and CA are commonly performed prior to intervention. The aim of this study is to compare clinical and haemodynamic outcome in patients with critical lower limb ischaemia (CLI) following Endovascular revascularisation (EvR) based solely on preoperative DUAM with those based on CA or MRA.
Between Oct 2002- Mar 2004, 334 patients were admitted with PVD. 137 had CLI, of these 86 patients underwent EvR as primary procedure for CLI. 73% of patients had rest pain, 38% had ulcers and 7% with gangrene. Aorto-iliac and infra-inguinal revascularisation were 25% and 75% respectively. Lesions with diameter reduction of >60% of arterial lumen and with peak systolic velocity of >180cm/sec were considered significant. DUAM identified the characteristics of plaque, calcification and echolucency of intra-luminal occlusive material especially in acute cases, thereby identifying those patients who are unsuitable for management by angioplasty. Outcome measures were symptom relief, increase in ABI and Duplex scan at day 1 and week 6. Patency of angioplasty site, limb salvage, morbidity, mortality and length of stay were compared between patients treated based on findings by DUAM alone or with MRA or CA. Nonparametric t test, Mann-Whitney U test and Chi square were used for statistical analysis.
ABI at day 1 - DUAM vs CA (p=0.746) vs MRA (p = 0.034*) and week 6 - DUAM vs CA (p=0.43) vs MRA (p=0.03*). Primary patency at day1 & week 6 for DUAM was 100% & 96.3% compared to 100% & 92% for CA and 85% & 78% for MRA groups. The primary patency rate was lowest in the MRA group p= 0.03* at day1 and p=0.04* at week 6. Increase in ABI’s were comparable between DUAM and CA however, significantly poor result in the MRA group could be attributed to different management protocol. The limb salvage rates at Week 6 were 100%, 100% and 96% for DUAM, CA and MRA respectively. There was no significant difference in procedure related mortality or morbidity at six weeks. The number of hospital admissions per case was lower and the length of hospital stay was significantly shorter in the DUAM group p<0.0001.
Successful Endovascular revascularisation in CLI requires achieving adequate inflow to a normal target vessel. MRA overestimated the degree of stenosis with venous contamination of tibial vessel imaging. However, CA outline accurately the lower extremity arterial tree. All treated significant lesions were preoperatively identified by DUAM. Therefore, we believe that DUAM is superior to CA or MRA, as a sole non-invasive inexpensive bedside investigative tool.