Duplex Ultrasound Criteria For In-stent Stenosis Of The Superior Mesenteric Artery
Jessica Green, MD, PhD, Evan Ryer, MD, Nicholas Borden, BS, Bilal Ali, BS, James Dove, BS, Robert Garvin, MD, Andrew Yang, MD, Ammar Hashmi, MD, Gregory Salzler, MD, James Elmore, MD.
Geisinger Medical Center, Danville, PA, USA.
Objective Duplex ultrasound (DUS) velocity criteria based on the native superior mesenteric artery (SMA) overestimates the degree of stenosis in SMA stents. Previous studies used concurrent (within 4 months) mesenteric angiography and duplex ultrasound to define velocity criteria; however, angiography is limited by single plane projection. This study sought to define mesenteric duplex criteria for >70% stenosis using mesenteric duplex ultrasound and computed tomographic angiography (CTA). Methods A retrospective review of 110 patients undergoing SMA stenting between 2004 and 2018 was conducted from a single institution database. Eighty-one patients had CTA performed within 4 months, and 37 of those within 30 days, of mesenteric duplex ultrasound. Centerline reconstructions of SMA stents were generated using TeraRecon Aquarius iNtuition software and three independent observers measured percent stenosis. Stenotic areas were matched with peak systolic velocity (PSV) and end diastolic velocity (EDV) obtained with DUS. Logistic regression models were generated, and Youden’s index was used to define velocity criteria from receiver operating characteristic (ROC) curves for a >70% in-stent stenosis. Results In the 30-day data set, the highest Youden’s index (79.3%) was obtained at a peak systolic velocity of 301 cm/sec with a sensitivity of 100% and specificity of 79.3% for a 70% in-stent SMA stenosis. PSV of 450 cm/sec was consistent with the highest specificity (100%) and positive predictive value (PPV; 100%) but lower sensitivity (50%) and negative predictive value (NPV; 87.9%). Figure 1 shows the probability of a 70% in-stent stenosis based on peak systolic velocity. Results in the 4-month data set were similar, with a velocity of 301 cm/sec generating the highest Youden’s index (60%) with a sensitivity of 88.9% and specificity of 71.4%. PSV of 450 cm/sec was consistent with a specificity of 93.7%, sensitivity of 38.9%, PPV 63.6%, and NPV 84.3%. EDV was not significant for predicting stenosis. 
Conclusions A PSV of 301 cm/sec maximizes Youden's index; however PSV of 450 cm/sec demonstrates a high specificity, positive predictive value and negative predictive value for predicting a >70% in-stent SMA stenosis. Combining clinical symptoms with duplex criteria can inform decisions for intervention.
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