Endovascular surgery based solely on noninvasive preprocedural imaging

Abstract

Purpose: Conventional pre-endovascular procedural evaluation uses both noninvasive testing and diagnostic arteriography. Diagnostic and therapeutic procedures often must be performed separately because of concerns about excessive contrast administration or inappropriate location of vascular access for the interventional procedure. We wanted to determine if patients could successfully undergo endovascular procedures based on noninvasive modalities alone.

Methods: One hundred nineteen consecutive patients requiring intervention for lower-extremity ischemia were evaluated by means of physical examinations and segmental pressure measurements. Patients then underwent magnetic resonance angiography (MRA) to image native vessels or duplex scanning for failing bypass grafts. Suitable patients underwent endovascular procedures with "road map" arteriography, which was compared with preoperative duplex scanning or MRA findings. Costs of the conventional and noninvasive approaches were compared, on the basis of estimated hospital cost schedule.

Results: Sixty consecutive endovascular procedures were performed in 56 patients (105 lesions angioplastied), either alone (30, 50%) or in combination (30, 50%) with another vascular reconstruction. Completely noninvasive evaluation was accomplished in 43 procedures (72%), either by means of duplex scanning (11, 18%) or MRA (32, 53%). Conventional arteriography (CA) was required in 2 patients (3%) because of MRA contraindications and in 1 patient because of complex previous arterial reconstruction. Fourteen patients had earlier CAs. The findings of the noninvasive modalities were confirmed in every case by means of intraoperative arteriography, and no additional lesions were revealed (no false positive or negative studies). After endovascular interventions, the mean patient ankle-brachial index (ABI) improved from 0.64 +/- 0.03 to 0.81 +/- 0.03 (P <.001) and the mean limb-status category improved from 3.4 +/- 0.2 to 0.8 +/- 0.2 (P <.001). There were 4 initial technical failures (7%), 1 morbidity (1%), and no mortalities. The noninvasive approach was less costly than if preprocedural diagnostic CA had been used, allowing $551 saved for each duplex scanning case and $235 saved for each MRA case. If the cost of a short-stay unit after a diagnostic arteriogram was included, the savings were greater: $695 saved for each duplex scanning case and $379 saved for each MRA case.

Conclusion: Endovascular procedures can be performed based on preprocedural noninvasive modalities alone. For patients requiring endovascular procedures, knowledge of the arterial anatomy before obtaining arterial access avoids the need for additional punctures or sessions (eg, antegrade puncture for femoral angioplasty after retrograde puncture for the diagnostic arteriogram). This approach is less costly than performing preprocedural diagnostic arteriography and avoids the hazards of arterial puncture and nephrotoxic contrast agents.