Arterial Duplex Mapping in a Duplex-First Strategy for Lower Limb Revascularization Planning: Clinical-Planning...

This study aimed to evaluate clinical-planning concordance between preoperative arterial duplex mapping and the intervention ultimately performed in patients with lower limb arterial disease, to assess whether concordance differed according to arterial territory and treatment type, and to estimate the potential budget impact associated with reduced computed tomography angiography (CTA) use.

This was a retrospective, single-center, observational study that included consecutive arterial duplex mapping examinations performed between January 2010 and March 2026 in a tertiary vascular center with a dedicated vascular ultrasound unit. All examinations were performed by 1 of 3 accredited vascular ultrasonographers using a standardized preoperative mapping protocol. The primary outcome was clinical-planning concordance between the duplex-based procedural recommendation and the intervention ultimately performed. The primary unit of analysis was the mapping-procedure episode. As some patients contributed more than 1 episode, sensitivity analyses using generalized estimating equations clustered by patient were performed. A simplified budget impact analysis was performed using Institut Catala de la Salut (ICS) public tariffs.

A total of 3,202 arterial duplex mapping-procedure episodes in 2,432 patients were included. Overall clinical-planning concordance was 3,067/3,202 (95.8%; 95% CI, 95.0-96.4). Concordance remained high across all arterial territories: 393/417 in distal disease (94.2%; 95% CI, 91.6-96.1), 1,801/1,878 in femoropopliteal disease (95.9%; 95% CI, 94.9-96.7), and 873/907 in iliac disease (96.3%; 95% CI, 94.8-97.3). Concordance was also high for open revascularization (95.1%; 95% CI, 93.9-96.1) and endovascular procedures (96.6%; 95% CI, 95.7-97.4). CTA was recorded in 109/3,202 episodes (3.4%; 95% CI, 2.8-4.1), with greater use in iliac disease (9.4%; 95% CI, 7.6-11.4) than in femoropopliteal (1.0%; 95% CI, 0.6-1.6) or distal disease (1.2%; 95% CI, 0.5-2.8). Using ICS tariffs, the estimated cumulative saving was EUR425,854 in the conservative cost difference scenario and EUR789,170 in the avoided CTA scenario.

In an experienced vascular ultrasound unit, a selective duplex-first strategy showed high clinical-planning concordance with the intervention ultimately performed across all arterial territories and treatment types. CTA use remained low overall and was largely concentrated in iliac disease. These findings support the clinical and organizational value of duplex-based planning in centers with dedicated expertise, while emphasizing that complementary imaging remains necessary in selected cases.