The natural history of duplex-detected stenosis after femoropopliteal endovascular therapy suggests questionable clinical utility of routine duplex surveillance

Abstract

Duplex ultrasound (DU) surveillance (DUS) criteria for vein graft stenosis and thresholds for reintervention are well established. The natural history of DU-detected stenosis and the threshold criteria for reintervention in patients undergoing endovascular therapy (EVT) of the femoropopliteal system have yet to be determined. We report an analysis of routine DUS after infrainguinal EVT. Consecutive patients undergoing EVT of the superficial femoral artery (SFA) or popliteal artery were prospectively enrolled in a DUS protocol (≤1 week after intervention, then at 3, 6, and 12 months thereafter). Peak systolic velocity (PSV) and velocity ratio (Vr) were used to categorize the treated artery: normal was PSV <200 cm/s and Vr <2, moderate stenosis was PSV = 200-300 cm/s or Vr = 2-3, and severe stenosis was PSV >300 cm/s or Vr >3. Reinterventions were generally performed for persistent or recurrent symptoms, allowing us to analyze the natural history of DU-detected lesions and to perform sensitivity and specificity analysis for DUS criteria predictive of failure. Ninety-four limbs (85 patients) underwent EVT for SFA-popliteal disease and were prospectively enrolled in a DUS protocol. The initial scans were normal in 61 limbs (65%), and serial DU results remained normal in 38 (62%). In 17 limbs (28%), progressive stenoses were detected during surveillance. The rate of thrombosis in this subgroup was 10%. Moderate stenoses were detected in 28 (30%) limbs at initial scans; of these, 39% resolved or stabilized, 47% progressed to severe, and occlusions developed in 14%. Five (5%) limbs harbored severe stenoses on initial scans, and 80% of lesions resolved or stabilized. Progression to occlusion occurred in one limb (20%). The last DUS showed 25 limbs harbored severe stenoses; of these, 13 (52%) were in symptomatic patients and thus required reintervention regardless of DU findings. Eleven limbs (11%) eventually occluded. Sensitivity and specificity of DUS to predict occlusion were 88% and 60%, respectively. DUS does not reliably predict arterial occlusion after EVT. Stenosis after EVT appears to have a different natural history than restenosis after vein graft bypass. EVT patients are more likely to have severe stenosis when they present with recurrent symptoms, in contrast to vein graft patients, who commonly have occluded grafts when they present with recurrent symptoms. The potential impact of routine DU-directed reintervention in patients after EVT is questionable. The natural history of DU-detected stenosis after femoropopliteal endovascular therapy suggests questionable clinical utility of routine DUS.