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Utility of Magnetic Resonance Arteriography for Distal Lower Extremity Revascularization

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Utility of Magnetic Resonance Arteriography for Distal Lower Extremity Revascularization CORE Metadata, citation and similar papers at core.ac.uk Provided by Elsevier - Publisher Connector Utility of magnetic resonance arteriography for distal lower extremity revascularization Thomas S. Huber, MD, PhD, Martin R. Back, MD, R. James Ballinger, MD, PhD, William C. Culp, MD, Timothy C. Flynn, MD, Paul S. Kubilis, MS, and James M. Seeger, MD, Gainesville, Fla. Purpose: Magnetic resonance arteriography (MRA) of the lower extremities affords several possible advantages over conventional contrast arteriography (CA). We hypothesized that MRA of the infrageniculate vessels was sufficiently accurate to replace CA before revascularization procedures in patients with limb-threatening ischemia. Methods: Fifty-three extremities in 49 patients were prospectively evaluated before at- tempted infrageniculate revascularization procedures with preoperative infrageniculate time-of-flight MRA (cost, $170/study) and standard contrast arteriography (cost, $1310/study) of the aortoiliac and runoff vessels. Independent operative plans were formulated based on the MRA and CA results before the revascularization procedure. Intraoperative, prebypass arteriograms (IOA; cost, $46/study) were obtained in all patients to confirm the adequacy of the distal runoff. The preoperative plans formulated by the results of MRA and CA were compared with the actual procedure performed based on the IOA. All arteriograms (CA, MRA, IOA) were reviewed after the operation by two independent reviewers, and the number of patent vessel segments and those with < 50% stenosis was determined. Results: Revascularization procedures were performed in 44 of 53 extremities (83%), and amputation was performed in nine extremities (17%) because of an absence of a suitable bypass target. The CA and MRA were equally effective in predicting the optimal operative plans as determined from IOA (CA, 42 of 53 [77%] vs MRA, 40 of 53 [75%]; p = 0.79). More patent vessel segments were seen on CA than MRA (reviewer A, 229 vs 174, kappa = 0.32; reviewer B, 321 vs 314, kappa = 0.46); however, a comparable number of segments were seen ifthe vessels of the foot were excluded. The accuracy (reviewer A, 78% vs 68%, p = 0.003; reviewer B, 75% vs 67%, p = 0.003) and sensitivity (reviewer A, 69% vs 51%, p = 0.001; reviewer B, 68% vs 46%, p = 0.0001) of CA relative to IOA were superior to those of MRA, although the specificity was comparable (reviewer A, 86% vs 90%, p = 0.31; reviewer B, 82% vs 87%, p = 0.52). The combination of MRA and IOA would have resulted in the optimal operative plan in 51 of the 53 cases (96%) and was comparable with CA and IOA (53 of 53; 100%; p = 0.50). Substitution of MRA and IOA for CA and IOA could potentiaUy have saved an estimated $60,420. Conclusions: The combination of MRA and IOA provides an accurate, cost-efficient strategy for visualization of the infrageniculate vessels before revascularization procedures. (J Vasc Surg 1997;26:415-24.) From the Section ofVascular Surgery (Drs. Huber, Back, Flynn, Supported in part by a Clinical Research Small Grants Award from and Seeger), the Section of Magnetic •esonance Imaging (Dr. Be Shands Hospital at the University of Florida College of Ballinger), and the Section of Interventional Radiology (Dr. Medicine. Culp), University ofFlorida College of Medicine; the Section of Presented at the Twenty-first Annual Meeting of The Southern Vascular Surgery (Drs. I-tuber, Back, Flynn, and Seeger), the Association for Vascular Surgery, Coronado, Calif., Jan. 22-25, Section of Magnetic Resonance Imaging (Dr. Ballinger), and 1997. the Section of Interventional Radiology (Dr. Culp), Gainesville Reprint requests: Thomas S. Huber, MD, PhD, Section of Vascular Veterans Administration Medical Center; and the Division of Surgery, Department of Surgery, University of Florida CoUege of Biostatistics (P. S. Kubilis), Department ofStatistics, University Medicine, PO Box 100286, Gainesville, FL 32610-0286. of Florida College of Liberal Arts and Sciences. 24/6/82583 415 JOURNAL OF VASCULAR SURGERY 416 Huber et al. September 1997 The clinical utility of magnetic resonance arte- of the vasculature to allow accurate operative plan- riography (MRA) for lower extremity arterial revas- ning in paticnts with limb-threatening ischemia. cularization remains unresolved. The technique of_ fers several practical and theoretical advantages over PATIENTS AND METHODS conventional contrast arteriography (CA). Specifi- Study design. Patients with limb-threatening cally, MRA is noninvasive and does not require intra- ischemia who were undergoing evaluation for infra- vascular contrast; therefore, the potential complica- geniculate arterial revascularization were prospec- tions associated with CA as a result of both the tively enrolled in the study. All patients underwent vascular access and the contrast agent are avoided. standard preoperative evaluation including both Furthermore, MRA has been reported to provide time-of-flight MRA of the infrageniculate vessels and better visualization of the distal arterial vasculature >4 CA of the aortoiliac and runoff vessels. Operative and may be more cost-effective,s8 plans were formulated independently on the basis of The widespread application of MRA in patients the CA and the MRA results by the attending sur- with peripheral vascular occlusive disease is contin- geon, and the most suitable distal bypass target was gent on adequate visualization of the vasculature selected. An amputation was planned if no bypass necessary for successful bypass procedures. However, target could be identified. An intraoperative arterio- the studies that have examined the adequacy of MRA gram (IOA) was performed before revascularization for lower extremity revascularization procedures or amputation, and the optimal procedure was se- have reported contradictory results. Owen et al. 1 lected on the basis of the results of the "gold" stan- reported that MRA of the vessels below the adductor dard, IOA. 11 The actual procedure performed and canal was superior to CA and facilitated revascular- the optimal bypass target selected were compared ization in 17% of the patients who had been deemed with those predicted by the preoperative CA and unreconstructable by CA. Hoch et al.7 compared MRA. All three imaging studies (CA, MRA, IOA) digital subtraction arteriography (DSA) with MRA were subsequently reviewed after surgery by two for patients undergoing infrainguinal revasculariza- independent vascular surgeons in a blinded fash- tion and concluded that MRA alone was sufficient. ion. The number of patent vessel segments and the Carpenter et al. ó and Cambria et al.8 have extended number of segments with <50% stenosis were de- these observations and have reported series of lower termined during the postoperative review. In addi- extremity revascularization procedures using MRA as tion, a post hoc analysis was performed to derer- the sole imaging technique. In contrast, Snidow et mine whether the site of cannulation for the IOA al. 9 reported that the treatment plan generated by that was selected on the basis of the CA or MRA the MRA (aorta and runoff vessels) matched that results would have resulted in the optimal opera- from the CA only 41% of the time. Similarly, Quinn tive plan. et al.10 reported that femoral MRA could replace CA Patients. A total of 53 extremities in 49 patients only 57% of the time. were prospectively enrolled in the study from the Critical analysis of these respective series empha- Gainesville Veterans Administration Hospital (49 ex- size several limitations in the current application of tremities) and the Shands Hospital at the University MRA for patients with peripheral vascular occlusive of Florida (four extremities). During the study pe- disease. First, the accuracy and thus the clinical utility riod, a total of 158 infrageniculate revascularization of MRA may vary with the anatomic level (infrapop- procedures (study extremities, 53 of 158 [34%]) liteal > femoropopliteal > aortoiliac). Second, there were performed at the two study institutions (VA, is a significant leaming curve associated with the 68; University, 90). Scheduling conflicts between generation, interpretation, and äpplication of the the CA and the MRA accounted for the primary MRA images, sa~ and thus the findings from these reason that patients were not enrolled in the study seminal series may be restricted to select centers of because the magnetic resonance scanner was only excellence.~,7,8 Lastly, the MRA technique has been available during the late evening hours. The patient validated primarily by comparison with preoperative demographics reflect the secondary and tertiary clin- CA, which may be inappropriate in light of the ical practices at the Veterans Administration and lmown limitations of CA to visualize the complete University hospitals, respectively (Table I). Notably, distal vasculature in the presence ofmultilevel occlu- the majority of the patients were male and diabetic, sive disease? ,1°,i2,13 and a significant portion had undergone previous This study was designed to determine whether ipsilateral lower extremity revascularization proce- infrageniculate MRA provides sufficient visualization dures. Rest pain and tissue loss (grade II and III JOURNAL OF VASCULARSURGERY Volume 2ö, Number3 Huber et al. 417 chronic ischemia 14) were the operative indications in Table I. Patient demographics (n = 5 3) 94% of the cases. Age (yr) 68 -4- 10 The distal bypass targets for revascularization Sex (male) 96% were selected based on standard principles.
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