J VASC ENDOVASC SURG 2010;17(Suppl. 1 to No.

3):19-24

ED F
Role of Duplex ultrasound in the management
of infrageniculate surgical revascularization

A
RV O G. BALDINO, P. MORTOLA, A. CHIAMA, T. SCIUTTO, P. CASSOLA, A. GORI

IC
NE O
Aim. The objective of the study was to determine whether the Department of Vascular Surgery, E.O. Ospedali Galliera
long and short term results of patients undergoing duplex ultra- Genoa, Italy
sound as the sole pre-operative imaging method for infra-
AM
geniculate arterial surgical reconstruction are comparable to
the results of cases performed with angiographic imaging.
Methods. Between January 2005 and June 2009, 50 consecu-
tive patients with critical limb ischaemia (CLI) underwent
duplex ultrasound arterial mapping (DUAM) before under- the non-inferiority goal of this pre-operative approach was
going infragenicular surgical revascularisation. The vascu- achieved.
lar ultrasound tests were all performed using a Toshiba SSA-
R

Conclusion. In selected cases, high quality arterial ultra-

770A Aplio 80 duplex scanner. The aortoiliac, femoral-
popliteal and infrageniculate arterial segments were studied
to obtain high quality B-mode, colour and power Doppler,
Advanced Dynamic Flow (ADF) images as well as velocity
spectra. The vessels were classified as being normal or mild-
ly diseased (< 50%), moderately diseased (50-70%), severely
diseased (70-99%), occluded, or not visualised. Infragenicular
surgical reconstruction was based on DUAM without pre-
operative contrast arteriography (CA) in 17 (35%) patients.
P
sonography performed by skilled operators offers an accurate,
reliable alternative to pre-operative arteriography before infra-
genicular surgical revascularisation, and can accurately iden-
tify the best distal anastomotic site. Poor visualisation of high-
ly calcified vessels, as well as the presence of extensive and
open ulcers, severe oedema and obesity are some of the limi-
tations associated with DUAM.
KEY WORDS: Vascular diseases – Ultrasonography, Doppler, Duplex

Intraoperative completion arteriography with an OEC 9600 - Diagnostic imaging.

mobile unit was carried out, nonetheless, to evaluate patency
of the distal anastomosis and runoff status. Post-operative
duplex was performed at 1, 3, and 6 months, and then every
T raditionally, contrast angiography (CA) has been
MI

6 months afterwards.
Results. The selected revascularisation strategy and the ultra-
sound-predicted artery site of distal anastomosis were used in
all of the cases. The 30 day mortality rate was 5.9% in DUAM
patients. After a mean follow-up of 21 months, limb salvage
was achieved by 94.1% of patients in the DUAM-group; pri-
mary patency rate was 58.8%, while mortality during follow-
up was 18%, mainly due to malignancy (11%). Outcomes in the
DUAM-group patients were comparable to the CA-group, thus
Corresponding author: G. Baldino, Department of Vascular Surgery,
E.O. Ospedali Galliera, Genoa, Italy.
E-mail: giuseppe.baldino@galliera.it
the mainstay of pre-operative lower extremity vas-
cular imaging. Significant evidence was gathered to jus-
tify ultrasound (US) based revascularisation in the
infrapopliteal segment.1-11 Duplex ultrasonography is
painless, well tolerated by patients and cheaper than
angiography. CA is costly, invasive and may be asso-
ciated with local and systemic complications, and
moreover, the technical limitations include both fail-
ure to provide hemodynamic information and failure
to demonstrate patency of low-flow distal arteries.12, 13
Other non invasive techniques, such as magnetic

Vol. 17 - Suppl. 1 to No. 3 THE ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 19
 BALDINO INFRAGENICULATE SURGICAL REVASCULARIZATION

resonance angiography (MRA) or computed tomog- TABLE I.—Patient’s characteristics.

raphy angiography (CTA) provide suboptimal results Demographic
in evaluating patients with severely diseased DUAM CA Overall P

ME F
data
infrapopliteal arteries.9, 14-18 MRA requires cooperative
patients and is contraindicated in the presence of pace- Female 7 (41.2%) 9 (27.3%) 16 (32.0%) NS
makers, recent surgery, claustrophobia and severe hip Male 10 (58.8%) 24 (72.7%) 34 (68.0%) NS
and knee contraction. The aim of the study was to Mean age 73.8 (50-93 yrs) 75.1 (51-94 yrs) 74.5 (50-94 yrs) NS
evaluate whether duplex ultrasound arterial mapping DUAM: Duplex ultrasound arterial mapping; CA: contrast angiography; NS: not
(DUAM) could selectively replace angiography in significant.

A
patients with critical limb ischaemia (CLI) requiring

VA O
surgical infrapopliteal revascularisation for diffuse
atherosclerotic arterial disease (TASC type C and D TABLE II.—Comorbidities and risk factors.

DIC
lesions) while providing short and long term results that Comorbidities
DUAM CA Overall P
are comparable to those achieved by using angio- and risk factors
graphic pre-operative imaging.19 Diabetes mellitus 6 13 19
(35.3%) (39.4%) (38%) NS
Hypertension 10 27 37
Materials and methods (58.8%) (81.8%) (74%) NS
CAD 8 11 19
MIN O

(47.0%) (33.3%) (38%) NS

Between January 2005 and June 2009, 300 patients Atrial fibrillation 1 5 6
were admitted to the Galliera Hospital Vascular Surgery (5.9%) (15.2%) (12%) NS
Department, Genoa, Italy for CLI. All patients under- COPD 2 7 9
(11.8%) (21.2%) (18%) NS
went DUAM before undergoing surgical or endovas- Chronic renal failure 3 16 19 <0.05
cular treatment: 50 of them were eligible for infra- (17.6%) (48.5%) (38%) (0.033)
genicular surgical revascularisation. Dyslipidemia 10 24 34
A clinical diagnosis of CLI was confirmed in all (58.8%) (72.7%) (68%) NS
Hyperhomocysteinaemia 12 24 36
patients by ankle pressure measurement <50 mm Hg (70.6%) (72.7%) (72%) NS
R

obtained by cuff-manometry or, when arteries were Smokers 3 7 10

extremely calcified, by pole test measurement based on (17.6%) (21.2%) (20%) NS
hydrostatic pressure derived by leg elevation.19-21 Ex smokers 7 14 21
(41.2%) (42.4%) (42%) NS
All vascular US tests were performed under the
ER

supervision of the operating surgeon, using a Toshiba DUAM: Duplex ultrasound arterial mapping; CA: contrast angiography; NS: not
significant; CAD: coronary artery disease; COPD: chronic obstructive pulmonary
SSA-770A Aplio 80 Duplex scanner (Toshiba Corp., disease.
Tokyo, Japan). A 6-11 MHz linear array transducer
was used to visualise femorodistal arteries and the
P

iliac segment in thinner patients. A 2-6 MHz curved
array transducer was employed to visualise the aor-
toiliac segment, the superficial femoral artery at the
adductor canal, the tibioperoneal trunk and the prox-
imal anterior tibial artery. The aortoiliac, femoral-
popliteal and infrageniculate arterial segments were
studied to obtain high quality B-mode, colour and
power Doppler, Advanced Dynamic Flow (ADF)
images as well as velocity spectra. In some cases,
aortoiliac imaging required preparing the patient so as
to avoid artefacts caused by bowel interposition. We
found that extremity rotation and repositioning may
be useful to improve femoral, popliteal and tibial
artery imaging. In practice, it was often easier to iden-
tify the infragenicular vessel at the ankle and to fol-
low it more proximally. The vessels were classified as
being normal or mildly diseased (<50%) in the pres-
ence of a peak systolic velocity (PSV) ratio <2; mod-
erately diseased (50-70%) with a PSV ratio >2, severe-
ly diseased (70-99%) in the presence of a PSV ratio
> 3, occluded, or not visualised.3, 8, 9, 15, 16 Pre-opera-
tive duplex evaluation included measuring arterial
size, vessel wall thickness, length and degree of steno-
sis or occlusion. This information was used to more
precisely establish the best anastomotic site. Hand-held
Doppler insonation of the foot arch or dorsalis pedis
artery and proximal compression of the calf vessel at
the ankle using the fingers can sometimes be a useful
test to identify which artery is feeding the foot arch,

20 THE ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY September 2010

 INFRAGENICULATE SURGICAL REVASCULARIZATION BALDINO

TABLE III.—Type of revascularization. TABLE IV.—Results.

N. Results (21 months) DUAM CA Overall P

ME F
Femoroperoneal bypass Reversed vein 3 Limb salvage 16 (94.1%) 19 (57.6%) 35 (70%) <0.01
In situ vein 2 (0.0076)
Composite sequential 4 Primary patency 10 (58.8%) 16 (48.5%) 26 (52%) NS
Femorotibial bypass (posterior tibial) Reversed vein 3 Secondary patency — 18 (54.5%) 28 (56%) —
In situ vein 2
Composite sequential 1 Minor amputation 2 (11.8%) 4 (12.1%) 6 (12%) —
30 day mortality 1 (5.9%) 3 (9.1%) 4 (8%) —
Femorotibial bypass (anterior tibial) Reversed vein 2
Overall mortality 3 (17.6%) 6 (18.2%) 9 (18%) NS

A
VA O
and should thus be the preferred distal anastomotic
DUAM: Duplex ultrasound arterial mapping; CA: contrast angiography; NS: not
significant.

DIC
site.22
Evaluation of the autogenous conduits (diameter,
length and collaterals) was also part of the pre-opera-
tive imaging: venous resources were accurately iden-
tified and carefully mapped due to their relevance
when deciding which kind of reconstruction to per-
MIN O
bypass or concomitant coronary artery disease
(CAD).23
All patients underwent duplex surveillance follow-
up programmes which included examinations at 1, 3,
and 6 months after surgery, and then every 6 months

form. afterwards.
The average time required to perform each DUAM Statistical analysis was performed using the χ2 test.
examination was about 60 minutes.
After DUAM evaluation, pre-operative CA was per-
formed in 33 (65%) cases, while the remaining 17 Results
(35%) patients underwent infragenicular surgical revas-
cularisation without additional imaging. All interventions in the DUAM-group were carried
Arterial lesions were classified according to the out as had been planned by pre-operative US: the cho-
R

TransAtlantic Inter-Society Consensus (TASC) 2007
criteria.19 Five (29.4%) cases were classified as TASC
C and 12 (70.6%) were classified as TASC D.
Indication for surgery was rest pain in 7 cases
ER
sen revascularisation strategy and US predicted artery
site of anastomosis were used in all cases.
The 30 day mortality rate was (5.9%) in DUAM
patients (one death was due to multi organ failure -

(41.1%), tissue loss in 2 (11.8%) and non-healing ulcer
in 8 patients (47.1%) (TASC 2007).19
The patients’ characteristics are summarised in
Tables I and II.
P
MOF), and 9.1% in the CA-group (3 deaths were relat-
ed to cardiac complications).
The mean follow-up was 21 months (range 2 – 54
months).

Distal anastomosis was to the peroneal artery in 9
cases (52.9%), and to the tibial arteries in 8 (47.1%);
the specific procedures that were performed are shown
in Table III.
Intraoperative completion arteriography with an
OEC 9600 mobile unit (OEC Medical Systems, Salt
Lake City, Utah, USA) was carried out in all cases to
evaluate patency of the distal anastomosis, runoff sta-
tus and correct graft tunnelisation.
In agreement with Dutch Bypass Oral anticoagu-
lants or Aspirin (BOA) Study Group data, we admin-
istered anticoagulation treatment (Warfarin or low
molecular weight heparin) to all patients with venous
graft, which was associated with antiplatelet drugs
(ASA or clopidogrel) in case of composite sequential
The limb salvage rate was 94.1% in DUAM patients
and 57.6% in the CA-group (p<0.05), and the minor
amputation rate was similar in the two groups (11.8%
in the DUAM-group vs 12.1% in the CA-group) (Table
IV).
Primary patency rate was comparable in both groups
(58.8% in the DUAM-group — 48.5% in the CA-
group). Three patients in the DUAM-group required
additional endovascular procedures because they devel-
oped asymptomatic, tight stenoses in the venous graft
which was detected by US surveillance. Two patients
in the CA-group were re-admitted for acute limb
ischaemia due to graft thrombosis: one underwent
hybrid surgery (surgical thrombectomy and endovas-
cular recanalisation of the pedal artery), while the sec-

Vol. 17 - Suppl. 1 to No. 3 THE ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 21
 BALDINO
ond patient was successfully treated with loco region-
al thrombolysis. Lastly, the secondary patency rate in
the CA-group was 54.5%.
ME F
Overall mortality during the follow-up period was
18% in both groups. Two patients in the DUAM-group
died of malignancy, and one of MOF, while 5 patients
in the CA-group died of cardiovascular disease and
one of renal failure.
VA O
Discussion
DIC
Appropriate management of CLI requires prompt
surgical or endovascular treatment to prevent limb
loss. The Bypass versus Angioplasty in Severe
Ischaemia of the Leg (BASIL) Trial randomised 452
CLI patients to undergo either bypass surgery or angio-
plasty.24 The primary end point of amputation-free
MIN O
survival did not differ between treatment groups at 1
year, but the patients had been pre-selected as candi-
dates for either therapy and constituted only 30% of the
entire CLI population.25 CLI revascularisation must
be individualised: patients with TASC A and B lesions
should initially be offered angioplasty. Treatment of
TASC C and D lesions depends on the patient’s char-
acteristics; endovascular treatment should be taken
into consideration in selected high-risk patients, par-
R
ticularly if the available vein conduit is poor, if med-
ical co-morbidities are significant, or if life expectan-
cy is less than 2 or 3 years. Bypass is the best option
for most patients with TASC C and D lesions and for
ER
long segment tibial disease in reasonable risk patients
with good vein conduit.24, 25
Traditionally, CA has been the gold standard for low-
er limb arterial diagnostic examination. The use of
P
DUAM in lower limb arterial imaging was first report-
ed by Jager et al. in 1985.26 Although comparisons
between US and CA have produced mixed results, sev-
eral authors reported the feasibility of surgical and
endovascular revascularisation to infragenicular and
foot arteries based primarily on DUAM.1-11, 27, 28
The Maimonides Medical Centre experience showed
that DUAM could appropriately select patients for
surgical or for endovascular treatment, thus limiting the
role of CA to interventional procedures, but such a
program requires specific training of an ultrasound/
surgery team.1, 3, 5, 8, 9, 15, 16
We first decided to perform infragenicular endovas-
cular revascularisation based on DUAM alone, and
this was the initial step in the validation process of
22 THE ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY
INFRAGENICULATE SURGICAL REVASCULARIZATION
DUAM in this arterial district at our institution. On
the basis of this experience we started to selectively
replace CA with DUAM before infragenicular surgi-
cal revascularisation in order to avoid complications
associated with arteriography (4-9%), including
haematoma, anaphylaxis, false aneurysms, arteriove-
nous fistula and renal failure, as well as to reduce costs
and length of hospital stay.32-36
Our findings demonstrate that in selected cases,
A
DUAM is at least as good as CA for pre-operative
planning of infrapopliteal bypass, and comparable
outcomes in both DUAM- and CA-group patients con-
firmed the non-inferiority of this pre-operative dye-
less imaging approach.
Some of the limitations associated with DUAM
that may lead to not-diagnostic studies include; poor
visualisation of highly calcified vessels, extensive
and open ulcers and the presence of dressings obscur-
ing the visualisation of the underlying vasculature,
severe oedema, dermatitis, hyperkeratosis, and mor-
bid obesity.
DUAM relies heavily on technology that has only
recently become available in top level duplex ultra-
sound instruments. Power Doppler is useful in low-
flow velocity small vessel imaging and, in most cas-
es, is able to overcome the problem of severe vessel cal-
cification. The latest US technology, such as B-flow
(GE ultrasound Milwaukee, WI, USA) or ADF
(Toshiba Corp., Tokyo, Japan), provides more sensitive
direct imaging of blood flow in stenotic arterial seg-
ments with increased flow velocity, and has improved
the ability to image the lumen-vessel wall interface at
the site of greatest stenosis.
Although the limitations of duplex US tibial vessel
imaging are well known, this diagnostic technique
offers clear advantages in terms of cost and portabil-
ity. Furthermore, its advantages are that it is not inva-
sive, it is very well tolerated by patients, it is less
expensive than CA, it can be repeated as needed with-
out any additional risk while avoiding ionising radia-
tion and contrast media, and it provides functional
data.29-31
The crucial points are that inadequate US exami-
nations must be identified, and that a single imaging
modality must not be the basis for leg amputation.
Although CA remains the gold standard in
infrapopliteal vessel visualisation, surgery should not
be ruled out on the basis of angiography alone, since
CA can miss patent distal calf vessels with proximal
September 2010
 INFRAGENICULATE SURGICAL REVASCULARIZATION
ME F
VA O
DIC
MIN O
Figure 1.—Algorithm for the diagnosis and treatment of CLI.
occlusion.12, 13 Figure 1 shows our algorithm for the
diagnosis and treatment of CLI.
We have had limited and unsatisfactory experience
with MRA in the evaluation of infragenicular arterial
disease. The literature data also reports the suboptimal
R
results of this technique which requires a high level of
cooperation from patients and currently does not seem
to be able to provide adequate information on
ER
infrapopliteal arteries, at least not in the CLI patient
population. The presence of a pacemaker, recent
surgery, claustrophobia, and/or severe hip and knee
contraction are also major contraindications for MRA.
P
The presence of metal clips or knee prostheses and
venous overlap may lead to not-diagnostic studies. In
conclusion, the tendency to over-estimate lesion sever-
ity in tibial vessels remains an important practical lim-
itation, and MRA does not yet appear to be a stand-
alone modality for tibial vessel imaging.37-43
CTA is a potentially powerful diagnostic tool: the
technique is straightforward but visualisation of crur-
al vessels is significantly limited in the presence of
heavy wall calcifications, and sofware removal of these
calcifications may result in over-estimation of the degree
of stenosis. Although comparative studies between CA
and CTA have shown close agreement in assessing
lower extremity arterial disease, most of the discrep-
ancies are observed in below-knee vessels.9, 17, 18
Vol. 17 - Suppl. 1 to No. 3 THE ITALIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY
BALDINO
For the time being, CA continues to act as the gold
standard for tibial artery imaging, but fails to provide
information about the hemodynamic significance of
various arterial lesions. DUAM is also mandatory pri-
or to ruling out surgery on the basis of CA alone, and
successful infragenicular surgical revascularisations
using DUAM alone have been described. The cost of
a DUAM scan (about ? 75) is appreciably lower than
that of a CA (? 500), CTA (? 260) or MRA (? 365)
A
examination.
Conclusions
In selected cases, high quality arterial ultrasonogra-
phy performed by skilled operators offers a reliable
alternative to pre-operative arteriography before infra-
genicular surgical revascularisation, and can accurate-
ly identify the best distal anastomotic site. Our find-
ings demonstrate that in selected cases, DUAM is at
least as good as CA for the pre-operative planning of
infrapopliteal bypass. Poor visualisation of highly cal-
cified vessels, as well as the presence of extensive and
open ulcers, severe oedema and obesity are some of the
limitations associated with duplex arterial mapping.
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