Variable Utilization of Cross-Sectional Imaging Prior to Percutaneous Peripheral Vascular Interventions
Nathan K. Itoga, MD, Kenneth Tran, MD, Vivian Ho, MD, Ventia Chandra, MD, Ronald L. Dalman, MD, Endmund J. Harris, MD, Jason T. Lee, MD, Matthew W. Mell, MD, MS.
Stanford University, Stanford, CA, USA.
Objectives: Consensus guidelines regarding pre-procedural cross-sectional imaging (PPCSI) for peripheral artery disease (PAD) do not exist and may be influenced by patient complexity, variation of disease presentation, and physician preference. The objective of this study was to determine the utility of PPCSI prior to endovascular PAD intervention.
Methods: Patients receiving first time endovascular revascularization procedure for PAD from 2013-2015 were evaluated for PPCSI, defined as magnetic resonance angiography (MRA) or computerized tomographic angiography (CTA) done within 180 days prior to revascularization. Data collected included patient and physician demographics, peri-operative characteristics, and disease severity and distribution. The primary outcome was technical success defined as improving inflow and/or revascularization of the target outflow vessels to <50% stenosis.
Results: Of the 348 patients who underwent an attempted revascularization procedure 159 (45.7%) patients underwent PPCSI, including 151 CTA and 8 MRA. Of these, 47.8% were ordered by the referring provider (84% at an outside institution, 16% from within the institution), and 52.2% were ordered by the treating physician. PPCSI was performed a median of 26 days (IQR 9-53) prior to procedure. Analysis of individual vascular surgeon practice identified PPCSI rates ranging from 31-70%. On multivariate analysis chronic kidney disease (CKD) (OR=0.35; CI 0.17-0.73) had the strongest effect against PPCSI, and inpatient/ED evaluation (OR=3.20; CI 1.58-6.50), aorto-iliac (OR=2.78; CI 1.46-5.29) and femoral-popliteal occlusions (OR=2.51; 1.38-4.55) most strongly predicted PPCSI (Table). After excluding 31 diagnostic procedures, technical success did not differ between endovascular procedures with PPCSI (91.3%) or without PPCSI (85.6%), P= 0.11. Technical success rates did not differ in patients with CKD (P=0.37), inpatient/ED evaluation (P=0.71), or aorto-iliac disease (P=0.44). When analyzing 89 femoral-popliteal occlusions, technical success was higher with PPCSI (88%) compared to procedures without PPCSI (69%), P=0.026.
Conclusions: PPCSI use is influenced by inpatient status, CKD, and anatomic consideration. PPCSI does not appear to be associated with overall technical success but may be beneficial for femoral-popliteal occlusions. Routine PPCSI may not be warranted when considering technical success but may be important in treatment planning. Further studies are warranted to determine if radiation, contrast load, and cost justify PPCSI.
| TABLE: Multivariate Analysis of Pre-Procedural Cross Sectional Imaging Variables | |||
| Variable | Odds Ratio | 95% CI | P-value |
| Age | 0.99 | 0.97-1.01 | 0.49 |
| Hypertension | 0.71 | 0.34-1.51 | 0.38 |
| Hyperlipidemia | 0.85 | 0.50-1.43 | 0.54 |
| Diabetes Mellitus | 0.83 | 0.48-1.46 | 0.52 |
| Cerebral Vascular Accident | 0.53 | 0.26-1.07 | 0.08 |
| Chronic Kidney Disease ≥3 | 0.35 | 0.17-0.73 | 0.005 |
| Inpatient/ ED evaluation | 3.20 | 1.58-6.50 | 0.001 |
| Critical Limb Ischemia | 1.25 | 0.46-3.36 | 0.66 |
| Bilateral Disease | 1.03 | 0.50-2.15 | 0.93 |
| Aorto-iliac disease | 2.78 | 1.46-5.29 | 0.002 |
| Common Femoral Disease | 1.16 | 0.79-3.31 | 0.19 |
| Femoral- popliteal Disease | 1.50 | 0.76-2.95 | 0.25 |
| Femoral-popliteal Occlusion | 2.51 | 1.38-4.55 | 0.002 |
| Tibial disease | 0.88 | 0.48-1.62 | 0.69 |
| ***Controlled for by treating surgeon | |||
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