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Lower Extremity Arterial Evaluation: Are Segmental Arterial Blood Pressures Worthwhile?

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Lower Extremity Arterial Evaluation: Are Segmental Arterial Blood Pressures Worthwhile? View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Elsevier - Publisher Connector Lower extremity arterial evaluation: Are segmental arterial blood pressures worthwhile? Steven S. Gale, MD, Robert P. Scissons, RVT, Sergio X. Salles-Cunha, PhD, Steven M. Dosick, MD, Ralph C. Whalen, MD, John P. Pigott, MD, and Hugh G. Beebe, MD, Toledo, Ohio Purpose: Physiologic observations with blood flow waveform analysis and pressure mea- surements can document the severity of lower extremity arterial disease. Segmental blood pressures (SEGPs) taken at the thigh, calf, and ankle are commonly used, but their utility has seldom been studied. We quantified improvements in accuracy compared with arteriography when ankle pressures alone (ABI) or SEGP data were added to veloc- ity waveforms obtained by Doppler ultrasound. Methods: Continuous-wave Doppler velocity waveforms were recorded at common femoral (CFA), popliteal (POP), and dorsal pedal and posterior tibial (TIB) arterial lev- els. Systolic SEGP data were obtained with appropriately sized upper thigh, upper calf, and ankle cuffs. Waveforms, waveforms plus ABI, and waveforms plus SEGP data from 81 patients were randomly interpreted by 14 technologists or physicians from four insti- tutions blinded to clinical and arteriographic data. Arteriograms were assigned negative or significant, severe (≥75% diameter stenosis) values for four segments: iliofemoral (CFA), superficial femoral (SFA), popliteal (POP), and infrapopliteal (TIB) arteries. A total of 9072 segmental interpretations were analyzed. Results: Compared with arteriography, the accuracy of waveform analysis was 83% for severe disease at and proximal to the CFA, 79% for SFA disease, 64% for POP disease, and 73% for TIB disease. Adding ABI improved the accuracy significantly (p < 0.01) to 88% (CFA), 86% (SFA), 70% (POP), and 85% (TIB). Accuracy was inferior when SEGP data replaced ABI: 86% (CFA), 85% (SFA), 70% (POP), and 80% (TIB). Conclusions: ABIs significantly improved Doppler waveform accuracy at all levels. Com- pared with ABI, the addition of segmental pressure to waveform data failed to improve accuracy. Pressure measurements above the ankle may lack cost effectiveness and clinical utility. (J Vasc Surg 1998;27:831-9.) Modern, noninvasive peripheral arterial evaluation of disease location and severity, follow-up of disease in the vascular laboratory combines physiologic mea- progression, and quantification of effects of therapy surements and duplex ultrasound imaging.1 Blood are the main objectives of such physiologic assessment. flow and pressure observations have been the founda- As ultrasound duplex imaging evolved,8-11 improved, tion of physiologic assessment.1-7 Analysis of flow direct, noninvasive visualization of arterial segments velocity waveforms and measurements of systolic may have rendered the indirect, segmental pressure blood pressure at various levels of the extremity are the measurement method obsolete for the purpose of traditional components of a basic protocol. Estimation disease localization.12 The issue of segmental pres- sure use, however, remains controversial.13 In con- trast, flow velocity measurement and flow waveform From the Jobst Vascular Center. analysis have remained an integral part of a duplex Presented at the Twenty-first Annual Meeting of the Midwestern ultrasound examination. Vascular Surgical Society, Chicago, Ill., Sep. 12–13, 1997. As the cost effectiveness of all medical proce- Reprint requests: Hugh G. Beebe, MD, Jobst Vascular Center, dures becomes more intensely scrutinized and reim- 2109 Hughes Drive suite 400, Toledo, Ohio 43606. bursement is reduced, vascular laboratory protocols Copyright © 1998 by the Society for Vascular Surgery and Inter- national Society for Cardiovascular Surgery, North American should optimize useful medical information at the Chapter. lowest possible cost. Segmental pressures are com- 0741-5214/98/$5.00 + 0 24/6/88135 monly used, but their utility has rarely been studied. 831 JOURNAL OF VASCULAR SURGERY 832 Gale et al. May 1998 Table I. Noninvasive lower extremity arterial eval- sion was given by 52 patients (64%). There were 40 uation indications diabetic patients (49%), and 39 patients (48%) had Condition Patients positive cardiac histories. Indications commonly accepted for Medicare reimbursement were docu- Gangrene 7 (9%) mented for all noninvasive studies (Table I). A stan- Ischemic ulcer 22 (27%) dard exam consent form was signed by the patient or Rest pain 23 (28%) Embolization (blue toe) 3 (4%) legal representative before vascular laboratory and Claudication 26 (32%) arteriographic exams. Interpreting panel. Data sets were mailed to 15 physicians and 30 technologists who were inter- viewed by phone and showed interest in the project. The rationale for this study is based on the fol- Of these, 19 were able to complete at least one full lowing assumptions: ultrasound may be able to data set. A total of 14 participants from four institu- replace diagnostic arteriography in selected cases;14,15 tions completed the reading of all three data sets: one in skilled hands, femoropopliteal ultrasound imaging vascular surgeon, one radiologist (also a registered can be performed faster and with less patient discom- vascular technologist [RVT]), a biomedical engineer fort than segmental pressure measurements; Doppler (PhD, RVT), and 11 vascular technologists. Experi- waveform analysis is an integral component of the ence with noninvasive vascular testing averaged 11 duplex ultrasound examination, just as significant as years (range, 1 to 22 years). Participants used their color flow, B-mode imaging, and velocity measure- own criteria for interpreting segmental pressures and ments; and continuous-wave Doppler waveform flow waveform data. There were no instructions, for analysis provides basic information similar to that example, to compare pressures measured at one site obtained with the duplex Doppler technology regard- with those for levels above or below or with pressures ing occlusive disease proximal to the site of observa- of the contralateral extremity. There were no instruc- tion. We therefore tested the null hypothesis that tions about how to interpret triphasic, biphasic, interpretation accuracy of physiologic noninvasive monophasic, or flat waveforms. There were no assessment, compared with arteriography, is instructions regarding which ankle-brachial indices unchanged when ankle pressure alone or segmental (ABIs), posterior tibial or anterior tibial, should be pressure data were added to the velocity waveform used in the interpretation of results. Individual inter- information obtained with continuous-wave Doppler. preters’ criteria were also used to identify total or par- For this purpose, we designed a randomized, multi- tial arterial incompressibility and medial calcification. center, blinded-interpretation study. Interpreters were assumed to be experienced and able to apply that experience to data obtained during METHODS an Intersocietal Commission for Accreditation of Patient population. Patients were randomly Vascular Laboratories certified vascular laboratory selected among those having standard segmental activity. pressure and waveform examinations (n = 826) and Noninvasive physiologic examination. All tests arteriograms between January 20, 1994, and Janu- were performed by experienced technologists with ary 19, 1996. Alphabetical order determined ran- the patient supine after a period of rest, history tak- domization. Patients with incomplete readings of ing, and a brief physical examination. A continuous- the arteriograms and those for whom the noninva- wave ultrasound transducer (Parks model 1052, sive and the arteriographic examination dates were Beaverton, Ore.) was employed to obtain velocity more than 2 months apart were excluded from this waveforms at the common femoral (CFA), popliteal study. A total of 81 patients were entered: 41 (POP), and posterior tibial and dorsal pedal (TIB) women (51%) and 40 men (49%). The number 81 arteries. The CFA waveform was obtained at the was selected arbitrarily to strike a balance between groin crease, the POP waveform at the mid-position the quantity of examinations entered in the study crease of the popliteal fossa, the posterior tibial and a manageable number of examinations for vol- waveform at the level of the medial malleolus, and untary interpretation. The average age was 71 years the dorsal pedal waveform was obtained at mid-foot. (range, 40 to 94 years). At the time of the noninva- Arm, upper calf, and ankle systolic pressures were sive test, 31 patients (38%) were nonsmokers, 22 measured with a 12 cm cuff. Ankle pressures were (27%) were actively smoking, and 28 (35%) had measured independently with the Doppler transduc- smoked cigarettes in the past. A history of hyperten- er aimed at the distal posterior tibial and dorsal pedal JOURNAL OF VASCULAR SURGERY Volume 27, Number 5 Gale et al. 833 arteries. ABIs were calculated separately for the pos- terior tibial and dorsal pedal (anterior tibial) arteries with the assistance of the calculator of an automated cuff inflator (Parks model 1105, Beaverton, Ore.). A tapered 24 cm cuff (Hokanson, Inc., Bellevue, Wash.) was employed for thigh pressure measure- ments. Placement of this cuff was optimized for patient comfort as far proximally on the thigh as pos- sible. A single thigh pressure value was obtained. Auscultation of the distal arterial signal was per- formed primarily at the loudest tibial
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