A prospective study of the natural history of femoropopliteal artery stenosis using duplex ultrasound

doi:10.1016/S0950-821X(05)80264-6

European Journal of Vascular Surgery

Volume 7, Issue 4, July 1993, Pages 444-447

https://doi.org/10.1016/S0950-821X(05)80264-6 Get rights and content

A foreknowledge of impending femoral artery occlusion might allow prevention of a deterioration in ischaemia by percutaneous transluminal angioplasty (PTA) in the preocclusive stage. A window of opportunity exists before a femoral stenosis progresses to occlusion and its treatment by PTA becomes more difficult, riskier and associated with lower patency. The size of this window is unknown. This is the first report of a study of the natural history of femoral stenoses using Duplex ultrasound. The aims of the study were to determine in patients with symptomatic peripheral arterial disease: (1) the incidence of progression from stenosis to occlusion; (2) the change in severity of stenosis over time; and (3) the relationship between severity of stenosis and progression to occlusion. The velocity ratio (VR) of 43 femoral artery stenoses in 38 patients was measured by Duplex ultrasound. The examination was repeated after a median of 28 (range 5–76) weeks. Nine/43 (21 %) stenoses progressed to occlusion within a median of 13 weeks. Little overall change in VR was demonstrable if occlusion did not occur. Only stenoses with a VR >3 progressed to occlusion in the study period. The data suggest that severe stenoses progress more rapidly than moderate, with a relatively brief window of opportunity. If PTA is to be undertaken, stenoses with a VR greater than 3 should be treated with minimum delay.

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Cited by (19)

Validating fatty acid binding protein 3 as a diagnostic and prognostic biomarker for peripheral arterial disease: A three-year prospective follow-up study
2023, eClinicalMedicine
Citation Excerpt :
Inadequate management of PAD can lead to catastrophic consequences, including nonfatal coronary or cerebral vascular events, lower-limb amputations, and death. Patients managed early on in their PAD disease see improvements in their ambulatory and exercise tolerance; however, a substantial number of patients with PAD are either undiagnosed, misdiagnosed, or receive their diagnosis late in the disease process, putting them at an increased risk of morbidity and mortality.4–6 One reason for the delayed diagnosis (and subsequent poor prognosis) of patients with PAD is the lack of a simple, readily available, reliable test.
Patients with peripheral arterial disease (PAD) often remain undiagnosed and therefore suboptimally managed. Here, we investigated the diagnostic and prognostic potential of fatty acid binding protein 3 (FABP3) in patients with PAD.
In the discovery phase, 374 PAD and 184 non-PAD patients were recruited from vascular surgery ambulatory clinics at St. Michael's Hospital (Toronto, Ontario, Canada) between October 4, 2017 to October 29, 2018. The diagnostic ability of baseline FABP3 level was investigated through receiver operator characteristic (ROC) curves to determine two cutoff points: 1) an exclusionary “rule out” cutoff point, and 2) a confirmatory “rule in” cutoff point. Next, these cutoff points were confirmed in the external validation phase using a separate cohort of 312 patients (180 PAD and 132 non-PAD) recruited from ambulatory vascular surgery clinics at St. Michael's Hospital (Canada) between November 6, 2018–July 30, 2019. Cox regression analyses were used to explore the independent association between FABP3 and major adverse limb events (MALE – defined as need for arterial revascularization or major amputation) and decrease in ankle-brachial index (ABI -defined as drop ≥0.15) during 3 years of follow-up.
In the discovery phase, FABP3 levels were significantly elevated in patients with PAD compared to non-PAD patients. ROC analysis demonstrated that FABP3 had an AUC of 0.83 (95% CI: 0.81–0.86, p-value < 0.001). FABP3 exclusionary cutoff was <1.55 ng/ml (sensitivity = 96%; specificity = 40%), whereas FABP3 confirmatory cutoff was >3.55 ng/ml (sensitivity = 43%; specificity = 95%) – values that were confirmed in the external validation phase. Cox regression analysis demonstrated FABP3 to be an independent predictor of increase in MALE [HR = 1.14 (1.03–1.29); p-value = 0.010] and worsening PAD status (drop in ABI >0.15 [HR = 1.11 (1.02–1.19); p-value = 0.009]).
Our findings suggested that FABP3 levels can be used as both a diagnostic and prognostic biomarker for PAD, and may facilitate risk stratification in select individuals for purposes of vascular evaluation or intensive medical management.
Funding for this study was provided by the Bill and Vicky Blair Foundation.
Peripheral Arteries
2011, Clinical Ultrasound
Superficial femoral artery stenoses: Characteristics of progressing lesions
1997, Journal of Vascular Surgery
Purpose: The purpose of this study was to assess the effect of superficial femoral artery (SFA) stenosis morphologic characteristics and lesion location on the rate of atherosclerotic disease progression.
Methods: We identified 19 patients who required arteriography for treatment of critical leg ischemia and who had previously undergone arteriography of that leg when minimal or no symptoms were present. These initial incidental arteriographic evaluations were performed during evaluation of arterial disease in another vascular bed from 4 to 81 months (mean, 32 months) previously. Distinct SFA stenoses or occlusion on the final arteriogram (n = 98) were characterized by their location, length, stenosis severity, and morphologic appearance on the initial arteriogram. The contribution of patient-specific risk factors to disease progression was also assessed.
Results: Stenosis progression occurred independently among multiple lesions within the same patient (negligible intraclass correlation coefficient, r = 0.06). Lesions in the adductor canal region were more likely to occlude than lesions elsewhere in the SFA (adjusted odds ratio = 10.7; p = 0.03). Severity of initial lesion stenosis also was predictive of occlusion (adjusted odds ratio = 1.8; p = 0.04). However, most progressing lesions (93%) actually arose in areas of initially mild disease (stenoses <50%) despite more severe initial lesions elsewhere. Increasing age ( p = 0.023) and previous contralateral leg bypass ( p = 0.036) were also associated with increasing rates of lesion progression. Smooth-asymmetric lesions progressed 11% more slowly than other lesion types ( p = 0.003).
Conclusions: Our analysis of atherosclerotic SFA lesion progression in patients with critical ischemia shows that initial stenosis severity was associated with higher occlusion rates and that smooth-asymmetric lesions progressed more slowly than lesions with other morphologic characteristics. Severe stenoses usually arose from minimally diseased regions and progressed more rapidly than preexisting, more highly stenotic lesions. Most SFA occlusions resulted from disease progression in the adductor canal region whether or not antecedent lesions were seen on arteriography and whether or not more severe stenoses were initially present elsewhere. Increased age and history of previous contralateral bypass were patient-specific predictors of lesion progression. (J Vasc Surg 1997;25:512-21.)
Evaluation of femoropopliteal arteries with duplex ultrasound after angioplasty. Can we predict results at one year?
1996, European Journal of Vascular and Endovascular Surgery
To determine if Duplex ultrasound (DUS) 1 day after percutaneous transluminal angioplasty (PTA) is prognostic for haemodynamic and clinical results at 1 year.
Prospective study.
Thirty-four femoropopliteal artery segments were treated with PTA. The peak systolic velocity ratio (PSV ratio = PSV in stenosis: PSV in normal segment) was determined with DUS before PTA, 1 day after PTA and 1 year after PTA. Clinical results were assessed with the SVS/ISCVS (Society for Vascular Surgery/International Society for CardioVascular Surgery) results classification.
A 1 year, clinical benefit from PTA was seen in 16 of 25 patients (64%) and haemodynamic improvement in 20 of 34 treated segments (59%). With DUS three residual stenoses were found 1 day after PTA; all occluded within 1 year. Segments with good DUS results after PTA showed haemodynamic deterioration in 30%. Clinical improvement was seen in most patients with DUS improvement, whereas no change or deterioration was found in patients with both good and poor DUS results at 1 year.
Residual stenosis on DUS 1 day after PTA is prognostic for failure within 1 year. However, good DUS results after PTA cannot predict haemodynamic success. Haemodynamic success at 1 year does not imply clinical success.
Natural history of severe atheromatous disease of the thoracic aorta: A transesophageal echocardiographic study
1996, Journal of the American College of Cardiology
This study sought to prospectively observe the morphologic and clinical natural history of severe atherosclerotic disease of the thoracic aorta as defined by transesophageal echocardiography.
Atherosclerosis of the thoracic aorta has been shown to be highly associated with risk for embolic events in transesophageal studies, but the natural history of the disease under clinical conditions has not been reported.
During a 20-month period, 191 of 264 patients undergoing transesophageal echocardiography had adequate visualization of the aorta to allow atherosclerotic severity to be graded as follows: grade I= normal (44 patients); grade II= intimal thickening (52 patients); grade III= atheroma <5 mm (62 patients); grade IV= atheroma ≥5 mm (19 patients); grade V= mobile lesion (14 patients). All available patients with grades IV (8 patients) and V (10 patients) disease as well as a subgroup of 12 patients with grade III disease had follow-up transesophageal echocardiographic studies (mean [±SD] 11.7 ± 0.9 months, range 6 to 22).
Of 30 patients undergoing follow-up transesophageal echocardiographic studies, 20 (66%) had no change in atherosclerotic severity grade. Of the remaining 10 patients, atherosclerotic severity progressed one grade in 7 and decreased in 3 with resolved mobile lesions. Of 18 patients with grade IV or V disease of the aorta who underwent a follow-up study, 11 (61%) demonstrated formation of new mobile lesions. Of 10 patients with grade V disease on initial study who underwent follow-up study, 7 (70%) demonstrated resolution of a specific previously documented mobile lesion. However, seven patients (70%) with grade V disease also demonstrated development of a new mobile lesion. Of 33 patients with grade IV or V disease, 8 (24%) died during the study period, and 1 (3%) had a clinical embolic event.
The presence of severe atherosclerotic disease of the thoracic aorta as defined by transesophageal echocardiography is associated with a high mortality rate. Although the morphologic natural history of the disease process itself is marked by stability over a 1-year period, individual lesion morphology is dynamic, with formation and resolution of mobile components occurring frequently over the same period. The dynamic nature of individual lesion morphology potentially enhances the possibility of developing a successful therapeutic strategy.
The value of Duplex surveillance after endovascular intervention for femoropopliteal obstructive disease
1996, European Journal of Vascular and Endovascular Surgery
The objective of the present study was to assess prospectively whether serial Duplex examination was useful in identifying impending failure after endovascular interventions of the femoropopliteal arteries.
Non-university hospital. Prospective clinical study.
124 Patients were successfully treated by endovascular procedures during a 5 year period. The follow-up was by colour-flow Duplex examination at fixed intervals. At similar intervals clinical examination, including ankle blood pressure measurement was performed to assess the clinical/haemodynamic status of the patients according to the SVS/NA-ISCVS guidelines. For the diagnosis of impending failure the Duplex criterion was a peak systolic velocity ratio > 2.5 and the clinical/haemodynamic criterion was a level < +2. Actual failure of the vascular procedure was defined as the occurrence of an occlusion in the treated arterial segment or a recurrent stenosis causing symptoms severe enough to require a reintervention. No prophylactic reinterventions were performed on the basis of abnormal Duplex findings alone.
Abnormal Duplex findings indicating restenosis were observed in 52 patients. Duplex abnormalities predicted treatment failure with a sensitivity of 86% and a specificity of 75%, while clinical/haemodynamic assessment had a sensitivity of 93% and a specificity of 90%. The hypothetical management outcome if Duplex surveillance had been used as a basis for reintervention was assessed. It appeared that only one patient with failure would have received a redo endovascular procedure at the time he had a restenosis.
Clinical/haemodynamic assessment was more useful for the follow-up of endovascular interventions than Duplex surveillance.

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View full text

A prospective study of the natural history of femoropopliteal artery stenosis using duplex ultrasound

Clin Rad

Lancet

Distribution and symmetry of arteriosclerotic lesions of the lower extremities: an arteriographic study of 200 limbs

Cardiovasc Intervent Radiol

Poststress Doppler ankle pressures

Arch Surg

5 Year results of a prospective study of percutaneous transluminal angioplasty

Ann Surg

Noncoronary angioplasty

Radiology

Fate of patients undergoing transluminal angioplasty for lower limb ischaemia

Radiology

Percutaneous transluminal angioplasty of the femoropopliteal artery: initial and long term results

Radiology