Journal of Vascular Surgery
Volume 39, Issue 1 , Pages 169-175, January 2004

Preoperative high-frequency duplex scanning of potential pedal target vessels☆

  • W.J Hofmann, MD

      Affiliations

    • Department of Vascular Surgery, Salzburg, Vienna, Austria
    • Corresponding Author InformationReprint requests: Wolfgang J. Hofmann, MD, Landesklinik für Gefässchirurgie, Müllner Hauptstrasse 48, A-5020 Salzburg, Austria
    • ,
  • J Walter, MD

      Affiliations

    • Department of Vascular Surgery, Salzburg, Vienna, Austria
    • ,
  • A Ugurluoglu, MD

      Affiliations

    • Department of Vascular Surgery, Salzburg, Vienna, Austria
    • ,
  • M Czerny, MD

      Affiliations

    • Department of Cardiothoracic Surgery, General Hospital Vienna, University of Vienna, Vienna, Austria
    • ,
  • R Forstner, MD

      Affiliations

    • Department of Radiology, St John's Hospital, Salzburg, Vienna, Austria
    • ,
  • H Magometschnigg, MD

      Affiliations

    • Department of Vascular Surgery, Salzburg, Vienna, Austria

Received 28 February 2003; accepted 23 June 2003.

Article Outline

Abstract 

Objective

The aim of this prospective study conducted at a tertiary referral center was to evaluate the efficacy of high-frequency duplex scanning in the preoperative evaluation of potential pedal target vessels.

Material and methods

The study population consisted of thirty-three consecutive diabetics suffering critical limb ischemia, with indications of infra-popliteal occlusive disease. Duplex ultrasound was performed by an angiologist unaware of any prior imaging procedures. The pedal vessels were divided into four segments. The inner diameter-, the grade of calcification (on a scale from 1-to-3), the maximal systolic velocity, and the resistance index ([V.max syst–V min syst]/V max syst), were assessed by using a 13-MHz probe, and the pedal target vessel best suited for surgery was identified.

Results of duplex scanning were compared to (1) the results of selective digital subtraction angiography (DSA) and contrast-enhanced magnetic resonance angiography (CE-MRA) studies interpreted by two radiologists, (2) the site of distal anastomosis predicted by a vascular surgeon according to DSA and CE-MRA studies, (3) the definitive site of distal anastomosis, and (4) early postoperative results (patency at three months).

Results

Duplex scanning depicted significantly more pedal vascular segments than selective DSA- (P = .004, McNemar test). Agreement in predicting the site of distal anastomosis expressed as κ value as follows: duplex versus DSA/CE-MRA, κ 0.71;-DSA/CE-MRA versus definitive anastomosis, κ 0.67; -and duplex versus definitive anastomosis κ 0.82.

Two patients were excluded from surgery as all three imaging modalities failed to demonstrate a pedal target vessel. Two patients had exploratory dissection of a pedal vessel (according to CE-MRA findings) that turned out to be occluded (as predicted by duplex scanning). In one patient the operation had to be terminated due to lack of autologous bypass material. In 31 patients who underwent pedal artery bypass, the resistance index could not be correlated to the run-off as assessed by intra-operative angiography.

Conclusions

High-frequency duplex focusing on the vacular-morphology is a worthwhile diagnostic tool to evaluate-potential pedal target vessels and extremely helpful when contrast-related methods (selective DSA, CE-MRA) do not sufficiently depict the pedal vasculature.

 

Diabetic macroangiopathy is associated with severe tibial occlusive disease. The pedal arteries, however, remain patent in many patients, and may serve as runoff vessels.1, 2 Bypass grafting to pedal target vessels, including pedal branches such as the anterior lateral malleolar artery, has been established as an effective limb salvage procedure.3, 4, 5, 6, 7, 8 Consequently, appropriate evaluation of the pedal arteries is mandatory in every patient with diabetes with critical foot ischemia. Imaging of pedal arteries with contrast material–enhanced methods, such as selective digital subtraction angiography (DSA) or contrast-enhanced magnetic resonance angiography (CE-MRA), may be incomplete in patients with severe inflow disease if the contrast agent within the pedal target vessels falls below the sensitivity threshold.9, 10, 11 The first reports of peripheral arterial duplex ultrasound (US) scanning date from the 1980s.12 Since that time duplex US scanning has been accepted as a valuable tool for assessment of peripheral arterial occlusive disease. Many authors state that duplex US scanning can be used reliably to predict infrainguinal reconstruction strategies.13, 14, 15, 16, 17, 18, 19, 20 In contrast, some series report moderate performance of duplex US scanning in evaluating the tibial vasculature.21, 22, 23 In addition, there are concerns about high interobserver variability in duplex examinations at the pedal level.24 The recent development of high-frequency (10-13 MHz) probes has led to higher in-plane resolution, which should enable adequate examination of the most peripheral vasculature. Because renal insufficiency is common among patients with diabetes, any imaging technique (eg, duplex US scanning) that does not impair renal function is preferred.

Several institutions, which do not focus on peripheral vascular surgery, frequently refer patients to our department with angiographic studies or CE-MRA images that do not sufficiently depict the most peripheral vasculature. Thus we have been searching for an additional, more compatible noninvasive technique to determine operability in these patients. The purpose of this prospective study was to assess the value of highly sensitive duplex US scanning in preoperative evaluation of the pedal target vessels.

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Patients and methods 

Patients with diabetes with limb-threatening forefoot critical limb ischemia (CLI grade III, category 5, according to the recommended standards for lower-extremity ischemia25) were considered potential candidates for pedal bypass surgery and were included in this prospective study if noninvasive testing (physical examination, pulse palpation, segmental oscillometry, ankle-brachial index [ABI]) indicated infrapopliteal occlusive disease and angiographic images demonstrated no potential target vessel at the calf level that would provide pulsatile blood flow to the ischemic area. Exclusion criteria were severe concomitant disease (coronary disease, pulmonary disease, non-ambulatory status) that would exclude the patient from surgery. Informed consent was obtained from all patients.

Duplex US scanning 

Duplex US scanning of the pedal vasculature was performed by an experienced angiologist who was not aware of results of any previous pedal imaging procedure. The pedal vessels were divided into four segments: dorsal pedal artery proximal, dorsal pedal artery distal, retromalleolar artery, and plantar artery. The artery segments were examined with a 13-MHz linear array transducer with a GE LOGIQ 700 scanner (GE Medical Systems, Solingen, Germany). The dorsal pedal artery was scanned with the patient supine, and the retromalleolar and plantar arteries were scanned with the patient in the lateral decubitus position. Because the calf arteries are located in a deeper anatomic layer, they were not examined with the 13-MHz probe, which provides optimal in-plane resolution up to 2.5 mm depth of field.

The color-flow mode was used to identify the vessel and to position the sample volume. In case of low-flow conditions in very small arteries, grading of arterial stenosis based on peak systolic velocity (PSV) ratios may lead to moderate interobserver agreement and therefore inadequate selection of patients.24 Therefore, in addition to assessment of hemodynamic parameters (peak systolic velocity, end-diastolic velocity), our study protocol also focused on the vascular anatomy. The minimal and maximal diameters of the vascular segments were recorded. Vascular calcification was scored on a scale of 1 to 3 (1, vessel without relevant calcification; 2, noncircumferential calcified plaque; 3, circumferential calcification). In severely calcified artery segments that inhibited insonation, flow proximal and distal to the lesion were compared to estimate severity of stenosis. The maximal systolic velocity was recorded for every pedal artery segment, and in addition the resistance index was calculated with the embedded software with the formula Resistance Index = (Vmax syst − Vmin diast)/Vmax syst. A pedal artery was rated suitable for surgery if it demonstrated a diameter of 1 mm or greater at the proposed site of anastomosis, no diameter less than 0.5 mm along its entire course, and a patent lumen (or flow without acceleration following a severely calcified segment) to the mid-tarsal level. On the basis of these findings the angiologist identified the pedal artery segment most suitable for a bypass procedure (ie, the most proximal pedal artery segment demonstrating the largest diameter and the lowest grade of calcification). A vessel was regarded as unsuitable for surgery if the diameter was less than 0.5 mm along its entire course. Examination times of duplex US scanning were recorded.

Contrast–enhanced imaging techniques 

In addition to noninvasive testing, each patient underwent at least one contrast-enhanced imaging technique of the pedal vasculature (selective DSA or CE-MRA). Selective DSA was performed with a DV 1.2 digital vascular imaging unit (Philips Medical Systems, Eindhoven, The Netherlands). Nonionic contrast medium (Iopromid, Ultravist; Schering, Vienna, Austria) was administered by injection into the ipsilateral common femoral artery with a constant flow rate of 10 mL/s. Total volume of contrast material ranged from 25 to 170 mL (median, 80 mL). Biplane projections of the forefoot were obtained at the discretion of the radiologist. Filming was continued until the pedal runoff vessels were opacified, collateral vessels were clearly demonstrable, or a soft tissue blush appeared. Vasodilating drugs or hyperthermia were not used.

CE-MRA angiography was performed with a standard 1.0 T imager (Siemens Harmony; Siemens Medical Systems, Erlangen, Germany) equipped with high-performance gradients (≥20 mT/m, minimum rise time ≤400 μs). Selective imaging of the forefoot was performed with a quadrature head coil. A fast low-angle shot three-dimensional sequence (FLASH 3D; repetition time, 6.2; echo time, 2.24) was performed with sagittal slabs (thickness, 90 mm). Acquisition time was 27 seconds; and 20 mL of gadolinium was administered, with a flow rate of 2.5 mL/s, starting with the first set of images. Data were processed with the MIP algorithm, whereby a three-dimensional image of the pedal arteries was created. Matrix size was 126 × 526, and voxel size was 1.52 × 0.76 × 1.13 mm.

DSA and MRA studies were interpreted by two radiologists unaware of findings at duplex US scanning. The four pedal arterial segments were scored as clearly visualized or as not visualized or faintly visualized.

On the basis of results of DSA and CE-MRA, a vascular surgeon unaware of the duplex US scanning findings predicted the distal site of anastomosis. Patients were excluded from pedal revascularization if none of the three imaging procedures (duplex US scanning, DSA, CE-MRA) demonstrated a suitable pedal target vessel. Exploratory dissection of a pedal vascular segment was performed when at least one diagnostic procedure showed a pedal segment suitable for a distal anastomosis.

All operations were performed under 3.5× loupe magnification. Reversed autologous vein was used as the sole bypass material, except in one patient, in whom a composite graft of lesser saphenous vein and Omniflow prosthesis (Bio Nova, Cambridge, England) was used. Angiography was performed after the procedure in every patient.

Data analysis 

Statistical analysis was performed with SPSS software (version 8.0 for Windows; SPSS, Chicago, Ill).

Agreement between DSA, CE-MRA, and duplex US scanning for the entire examined pedal artery segment was expressed with cross tables. Pedal vascular segments were scored as clearly visualized or as not visualized or faintly visualized (DSA and MRA) and correlated with the diameter as assessed with duplex US scanning (diameter <1 mm vs diameter ≥1 mm). The McNemar test was used to demonstrate the tendency of a method to depict more vascular segments.26, 27 Statistical level of significance was assumed at P < .05. Agreement between duplex US scanning findings (angiologist), site of distal anastomosis as predicted on the basis of contrast-enhanced methods (vascular surgeon), and definitive site of anastomosis were expressed with κ statistics. Data were interpreted according to Landis and Koch28 (<0.0, poor; 0.00-0.20, slight; 0.21-0.40, fair; 0.41-0.60, moderate; 0.61-0.80, substantial; 0.81-1, almost perfect).

Runoff, as assessed at completion angiography, was retrospectively scored on a scale of 1 to 3 by a vascular surgeon unaware of any previous imaging findings (1, runoff to the dorsal pedal or plantar region without depiction of the pedal arch; 2, partial depiction of the pedal arch, but no major pedal artery connecting the dorsal and plantar region; 3, complete depiction of the pedal arch). Resistance index in the anastomosed pedal arterial segment was correlated with these findings.

Patency of a bypass graft to a specific pedal artery (determined by means of pulse palpation and additional duplex US scanning in uncertain cases) after 3-month follow-up validated suitability of the artery for pedal reconstruction. In cases where only exploratory dissection was performed or when early (<30 days) graft failure occurred, the pedal vessel was rated as not suitable for surgery.

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Results 

The study population consisted of 33 patients, 28 men and 5 women, who received treatment between April 2000 and January 2002. This cohort represents 27% of all infrapopliteal bypass reconstruction procedures (n = 122) performed for limb salvage during this period. Median age was 70 years (range, 48-86 years). Three men received bilateral treatment.

Thirty-five patients underwent preoperative DSA, 31 patients underwent preoperative CE-MRA, and 30 patients underwent both DSA and CE-MRA. Comparison of findings at duplex US scanning and DSA in the entire 140 (35 × 4) examined pedal artery segments is presented in Fig 1. Duplex US scanning and DSA findings agreed in 99 segments (70%). Duplex US scans depicted significantly more pedal artery segments than did DSA (P = .004, McNemar test). Thirty segments not visualized on DSA had a diameter greater than 1 mm on duplex US scans. Eleven segments with diameter less than 1 mm were clearly depicted on DSA images. The highest rate of concurrence (80%) was in the plantar artery position.

  • View full-size image.
  • Fig 1. 

    Comparison of findings at digital subtraction angiography (DSA) and duplex ultrasound scanning in 35 patients. DPA prox, Proximal dorsal pedal artery; DPA dist, distal dorsal pedal artery; RMA, retromalleolar artery; Plant A, plantar artery; Duplex +, diameter ≥1 mm; Duplex −, diameter <1 mm; DSA +, clearly depicted; DSA −, not depicted or faintly depicted.

Agreement between duplex US scanning and CE-MRA was found in 80 of 124 (31 × 4) examined pedal artery segments (64%; Fig 2). Agreement was best in the proximal dorsal pedal artery (74%) and worst in the plantar artery (58%). Statistically, the difference in depicting pedal artery segments was not significant (P = .652, McNemar test).

  • View full-size image.
  • Fig 2. 

    Comparison of findings at contrast-enhanced magnetic resonance angiography (CE-MRA) and duplex US scanning in 31 patients. DPA prox, Proximal dorsal pedal artery; DPA dist, distal dorsal pedal artery; RMA, retromalleolar artery; Plant A, plantar artery; Duplex +, diameter ≥1 mm; Duplex −, diameter <1 mm; CE-MRA +, clearly depicted; CE-MRA −, not depicted or faintly depicted.

Two of 36 patients were excluded from pedal revascularization because all three imaging techniques failed to demonstrate a pedal target vessel.

Overall agreement between DSA and CE-MRA findings, site of anastomosis as proposed at duplex US scanning, and surgery was found in 25 of 34 patients operated on. Disagreement was noted in 11 patients (Table I).

Table I. Agreement between the site of distal anastomosis predicted by a vascular surgeon on the basis of contrast-related methods (DSA/CE-MRA), the site of anastomosis predicted by the angiologist (duplex) and the definitive site of distal anastomosis
CaseOperative predictionDefinitive anastomosisAgreementFollow-up months
DSA/CE-MRADuplexDSA/CE-MRADuplex
1DpproxDpproxDpprox++7/patent
2PlantPlantPlant++19/patent
3RmRmRm++2/patent/died
4DpdistDpdistDpdist++11/patent
5RmRmRm++13/patent
6NSDpdistDpdist−+20/patent
7DpproxDpproxDpprox++16/patent
8PlantNSNS−+expl dissection
9RmPlantPlant−+18/patent
10DpproxDpproxDpprox++8/patent
11DpdistDpdistDpdist++16/patent
12DpdistDpdistDpprox−−15/patent
13DpproxDpproxDpprox++6/occluded
14DpproxDpproxDpdist−−15/patent
15DpdistDpdistDpdist++early occlusion
16RmRmRm++12/patent
17RmRmRm++6/patent
18RmRmRm++20/patent
19RmRmPlant−−no vein transplant
20RmDpproxRm+−early occlusion
21DpproxDpproxDpprox++2/patent/lost
22PlantPlantPlant++16/patent
23DpproxDpproxDpprox++7/occluded
24DpdistDpdistDpdist++13/patent
25PlantRmRm−+24/patent
26RmRmRm++13/patent
27DpdistDpproxDpprox−+early occlusion
28DpproxDpproxDpprox++1/patent/died
29DpdistNSNS−+expl dissection
30NSNSNo op++
31DpdistDpdistDpdist++6/patent
32DpproxDpdistDpprox+−14/patent
33NSNSNo op++
34RmRmRm++12/patent
35DpproxDpproxDpprox++15/patent
36DpproxDpproxDpprox++16/patent

Dpprox, Dorsal pedal artery proximal; Dpdist, dorsal pedal artery distal; Rm, retromalleolar artery; Plant, plantar artery; NS, not suitable for surgery.

Duplex US scanning versus DSA or CE-MRA 

Agreement, expressed as κ, was 0.71 (SE 0.09). Consensus between contrast-enhanced imaging and duplex US scanning was noted in 28 of 36 patients (77%). Duplex US scans demonstrated a dorsal pedal artery 1.6 mm in diameter in one patient in whom DSA and CE-MRA had depicted no pedal target vessel. In two patients a pedal vessel was clearly visualized with CE-MRA, whereas duplex US scans demonstrated no pedal target vessel. In one patient there was no consensus; in the remaining five patients both methods predicted the same pedal vessel, but different segments (proximal vs distal).

DSA or CE-MRA versus definitive anastomosis 

Agreement was substantial (κ 0.67, SE 0.09). Consensus was found in 27 of 36 patients (75%). In two patients the artery explored on the basis of CE-MRA findings was determined to be unsuitable for surgery. One dorsal artery pedal artery not depicted with DSA and CE-MRA was found suitable for surgery at exploratory dissection. This patient underwent a successful pedal artery bypass procedure, and the graft was still patent at 20-month follow-up. In six patients a pedal artery segment proximal or distal to the site as predicted was chosen intraoperatively.

Duplex US scanning versus definitive anastomosis 

Agreement was almost perfect (κ 0.82, SE 0.07). Consensus was found in 31 of 36 patients (86%). In two patients the surgeon chose an arterial segment proximal to the site proposed by the angiologist, and in two patients more distal arteriotomy was performed.

In one patient the dorsal pedal artery was identified as the first-choice target artery by the angiologist; however, the surgeon chose the retromalleolar artery on the basis of selective DSA and CE-MRA. This patient had early graft occlusion.

In summary, findings at duplex US scanning disagreed with the surgeon's decision regarding the site of distal anastomosis in five patients, and DSA or CE-MRA findings did not correspond in nine patients.

In only two patients findings at duplex US scanning were incorrect, compared with surgical findings, and DSA or CE-MRA findings were correct. In contrast, findings at DSA or CE-MRA were incorrect in 6 patients and findings at duplex US scanning matched well with the definitive surgical decision.

In one patient the operation was terminated despite a suitable pedal runoff vessel, because of lack of autologous bypass vein; both the greater and lesser saphenous veins demonstrated thrombotic occlusion. Excluding this patient, 33 pedal vascular procedures in 30 patients were left for comparison of duplex US scans with operative results. Median follow-up was 11 months (range, 0-24 months). In 30 patients the anastomosed artery had been rated suitable for surgery according to findings at duplex US scanning. Two patients had early graft occlusion. In two patients the pedal arteries explored on the basis of CE-MRA findings were determined to be unsuitable, as predicted at duplex US scanning. The patient in whom there was no agreement between DSA or CE-MRA and duplex US scans had early graft occlusion.

Maximal systolic velocity in the pedal arterial target segments ranged from 0 to 104 cm/s (median, 34.25 cm/s). Resistance index ranged from 0 to 0.83 (median, 0.56).

In the 31 patients who underwent pedal artery bypass, resistance index could not be correlated with scoring of runoff according to intraoperative angiography (Table II).

Table II. Correlation between pedal run-off (as assessed by completion angiogram) and the calculation of the resistance index in 31 patients who underwent pedal artery bypass surgery
Run-off scoreNo. of patientsResistance index
I90.40-0.80 (median, 0.57)
II160.34-0.83 (median, 0.63)
III60.34-0.78 (median, 0.59)

Duration of duplex US scanning ranged from 5 to 48 minutes (median, 12 minutes).

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Discussion 

The purpose of this study was to establish the accuracy of high-frequency duplex US scanning in preoperative evaluation of pedal anatomy.

Duplex US scans depicted more pedal artery segments than did selective DSA. The reason may be that severe tibial occlusive disease and cardiac dysfunction with low flow conditions lead to low concentrations of contrast agent in the most peripheral vasculature. Thus the ability of DSA to depict pedal arteries can be limited. Some authors have concluded that CE-MRA is superior to DSA for evaluation of pedal arteries in critical foot ischemia.29, 30 Nevertheless, contrast timing of MRA studies can be difficult, and superimposition of venous signals may lead to misinterpretation.11 In this series we encountered no significant difference between duplex US scanning and CE-MRA in depicting pedal artery segments. However, two patients who underwent exploratory surgery on the basis of MRA findings had occluded arteries, as predicted at duplex US scanning.

Detection of blood flow with duplex US scanning does not depend on local concentration of contrast agent. Consequently its application in the most peripheral vascular territory, with the least local amount of contrast agent as detected by concurrent imaging methods, can be beneficial.

Diameter greater than 1 mm is relevant in evaluating a pedal target vessel intraoperatively.31, 32 Current magnetic resonance technology enables in-plane resolution of up to 0.8 mm voxel size.33 In-plane resolution of DSA studies is up to 0.3 mm, depending on the matrix and the image intensifier used; however, accuracy is limited by parallactic error.34 Highly sensitive 10-MHz to 13-MHz duplex US scanning probes provide axial resolution of up to 0.1 mm. As a consequence, duplex US scanning is superior to DSA or CE-MRA for preoperative evaluation of arterial diameter.

Grade of vessel calcification, which cannot be assessed with DSA or MRA, is another relevant piece of information. Severe calcification can be managed with the fracture technique intraoperatively, and does not exclude a patient from distal revascularization.35 Still, the surgeon will select the pedal artery segment with the lowest grade of calcification for anastomosis.

In summary, duplex US scanning is a valuable tool for preoperative assessment of parameters (vessel diameter, grade of calcification) that are the main criteria for choosing the site of anastomosis intraoperatively when performing pedal bypass reconstruction. Pedal artery anatomy can also be assessed at surgical exploration. On the other hand, unnecessary incision of the forefoot likely will impair wound healing and can jeopardize the operative result. Thus examination of the pedal vasculature preoperatively with duplex US scanning and marking the optimal site for the distal anastomosis, as proposed by Mazzariol et al36 helps keep pedal incisions short.

In this small series, duplex US scanning correctly predicted the anastomosed pedal artery segment in 29 of 34 patients who underwent surgery. On the basis of findings at contrast-enhanced imaging a vascular surgeon picked the correct target segment in 27 patients.

The limitations of duplex US scanning in the most distal vascular territory are mainly that evaluation of runoff is difficult. The pedal arch cannot be examined directly along its entire course. In this study hemodynamic parameters (maximal systolic and end-diastolic velocity) could not be correlated with results of completion angiography or operative results. This confirms earlier reports that grading vascular disease at the pedal level on the basis of hemodynamic parameters alone can lead to misinterpretation.24 Because the pedal arteries run superficially, applying too much pressure with the Doppler scanning probe may disturb the flow and mimic stenotic lesions.

Proia et al16 demonstrated that PSV ratio can be used to identify tibial arteries suitable for surgery. A twofold increase in PSV at an isolated pedal stenosis was not found in our patients. The pedal arteries were either patent along their entire course or demonstrated diffuse lumen narrowing. Thus we cannot confirm that PSV measurement is a valuable tool for detection of hemodynamic relevant stenosis at the pedal level.

The main issue in evaluating the pedal vessels is differentiating patent arteries, with an inner diameter that renders them suitable for surgery, from occluded arteries. Thus, in our opinion, morphologic parameters (diameter, calcification) are more important than hemodynamic measurements in this most distal vascular territory.

Nine of our patients demonstrated no pedal arch at completion angiography, and none had early bypass occlusion. As a consequence, we believe a patent pedal arch is not a prerequisite for pedal bypass reconstruction.

Because it may be questionable to regard contrast-enhanced imaging techniques as standard procedure for imaging of potential target vessels at the pedal level, we additionally compared results of high-frequency duplex US scanning with operative results.37, 38 The anatomy of the anastomosed artery is only one factor that determines bypass graft patency. Other factors, such as quality of the vein graft and operative skill, also are significant. However, in this series the agreement between suitability of a pedal vessel assessed with preoperative duplex US scanning and early operative results was substantial and better than the correlation between DSA or CE-MRA findings and operative results (false positive results in three patients, false negative results in one patient; Table I).

Preoperative highly sensitive duplex US scanning focusing on pedal artery anatomy proved to be a valuable diagnostic tool. Duplex US scanning of the pedal vasculature, which can be performed in 15 minutes, is cost-effective and helps the surgeon in planning the bypass reconstruction. Because of limited facilities (only one duplex US scanner), at our institution, DSA and CE-MRA remain the methods of choice to determine the occlusive pattern from the pelvis to the tibial level. However, on the basis of our data and according to the literature, we think it is possible to plan a pedal bypass reconstruction with duplex US scanning as the sole preoperative imaging procedure. Duplex US scanning is extremely useful when DSA or MRA scans do not sufficiently depict the pedal vasculature. In our daily routine, highly sensitive duplex US scanning has replaced CE-MRA of the forefoot as an additional imaging test in evaluation of pedal target vessels. No patient is denied pedal revascularization on the basis of DSA findings alone.

To accurately determine the site of distal anastomosis and keep skin incisions short, high-frequency duplex US scanning is performed in every patient scheduled to undergo a pedal bypass procedure.

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References 

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☆ Competition of interest: none.

PII: S0741-5214(03)01044-9

doi:10.1016/S0741-5214(03)01044-9

Journal of Vascular Surgery
Volume 39, Issue 1 , Pages 169-175, January 2004

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