Is routine preoperative aortoiliac arteriography necessary in the treatment of lower extremity ischemia?

To determine whether preoperative aortoiliac arteriography can be replaced with noninvasive evaluation in the management of some patients with chronic lower extremity ischemia.

Preoperative evaluation was performed on 184 ischemic limbs (119 patients) over 19 months by means of aortoiliac arteriography with runoff and noninvasive studies, which included common femoral artery duplex scanning, waveform and acceleration time (normal <140 msec), and aortoiliac duplex scanning. An algorithm was proposed for combining indirect (common femoral artery evaluation) and direct (aortoiliac evaluation) noninvasive studies to decrease the need for aortoiliac arteriography when possible.

Aortoiliac occlusive disease (> or =50% stenosis to occlusion) was present at arteriography in 48 limbs (30%), and there was no inflow disease in 114 (70%). Aortoiliac lesions were identified by means of noninvasive studies. The accuracies of femoral waveform, acceleration time, and aortoiliac duplex studies were 85%, 89% and 87%. The negative predictive values were 92%, 94% and 100%. The acceleration time results were not affected by runoff status but were significantly different for various categories of stenosis (p < 0.05). The algorithm was applied to the data obtained. When acceleration time and waveform were normal, 84 of 86 patients (98%) had no stenosis at arteriography. When aortoiliac duplex findings were normal, the arteriographic findings were normal in all examinations.

A combination of indirect and direct noninvasive studies can be used reliably to rule out clinically significant inflow occlusive disease and allows selective use of aortoiliac arteriography in patients with lower extremity ischemia.