In the Journals

New guideline addresses imaging after vascular procedures

The Society for Vascular Surgery released a new guideline outlining which kinds of imaging should be performed after endovascular and open vascular procedures, and how often imaging should be performed.

“It is essential that vascular laboratory testing be performed by qualified personnel using appropriate instrumentation, as demonstrated by individual credentialing and facility accreditation,” the authors wrote.

“The overall aim is to provide the best outcome from the initial procedure,” R. Eugene Zierler, MD, RPVI, medical director of the D. E. Strandness, Jr. Vascular Laboratory at University of Washington Medical Center and the Vascular Laboratory at Harborview Medical Center, and head of the guideline writing group, said in a press release. “All arterial procedures have modes of failure. To make the arterial intervention as durable as possible, we have to understand these modes, how to detect them, and when to re-intervene.”

Diversity of recommendations

The guideline covers imaging after the following types of procedures: carotid artery procedures, thoracic and abdominal aortic repairs, mesenteric and renal artery repairs, and lower extremity arterial revascularization.

The recommendations include:

After carotid artery stenting or carotid endarterectomy, surveillance with duplex ultrasound should be conducted at baseline, then every 6 months for 2 years, then once per year until there is no evidence of restenosis for 2 years.

Contrast-enhanced CT scanning after thoracic endovascular aortic repair should be performed at 1 month, at 1 year and annually thereafter, with a 6-month scan reasonable if the 1-month scan shows an abnormality.

There is little evidence on the optimal strategy for imaging after renal or mesenteric interventions, but duplex ultrasound at 1 month, 6 months, 1 year and annually thereafter may be considered.

Within the first month after aortoiliac endovascular therapy, clinical examination, ankle-brachial index and duplex ultrasound should be performed. Clinical examination and ankle-brachial index, with or without duplex ultrasound, should be performed at 6 months, 1 year and annually thereafter.

Within the first month after femoropopliteal endovascular therapy, clinical examination, ankle-brachial index and duplex ultrasound should be performed. Continued surveillance at 3 months and then every 6 months thereafter is recommended for patients with stents and patients who underwent angioplasty or atherectomy for critical limb ischemia.

Within the first month after tibial endovascular therapy, clinical examination, ankle-brachial index and duplex ultrasound should be performed. Continued surveillance at 3 months and every 6 months thereafter should be considered. Repeat duplex ultrasound should be performed in patients with nonhealing wounds, returned rest pain, new tissue loss or signs of deterioration on clinical exam.

“Evidence is somewhat scarce for many of the endovascular techniques because they change so quickly, unlike the more established open procedures,” Zierler said in the release. “Endovascular procedures are developing rapidly and devices are changing frequently. The life cycle of a certain device or intervention may be quite short.”

Great variability

“The variability of the quality of published data on this topic is so great that no recommendation was supported by high-quality (level A) evidence,” Peter F. Lawrence, MD, chief of vascular surgery and professor of surgery at UCLA’s David Geffen School of Medicine and director of the Gonda Vascular, Wound Treatment and Clinical Tissue Engineering Centers, and Peter Gloviczki, MD, professor of surgery at Mayo Clinic, wrote in a related editorial. – by Erik Swain

Disclosures: The authors, Gloviczki and Lawrence report no relevant financial disclosures.

The Society for Vascular Surgery released a new guideline outlining which kinds of imaging should be performed after endovascular and open vascular procedures, and how often imaging should be performed.

“It is essential that vascular laboratory testing be performed by qualified personnel using appropriate instrumentation, as demonstrated by individual credentialing and facility accreditation,” the authors wrote.

“The overall aim is to provide the best outcome from the initial procedure,” R. Eugene Zierler, MD, RPVI, medical director of the D. E. Strandness, Jr. Vascular Laboratory at University of Washington Medical Center and the Vascular Laboratory at Harborview Medical Center, and head of the guideline writing group, said in a press release. “All arterial procedures have modes of failure. To make the arterial intervention as durable as possible, we have to understand these modes, how to detect them, and when to re-intervene.”

Diversity of recommendations

The guideline covers imaging after the following types of procedures: carotid artery procedures, thoracic and abdominal aortic repairs, mesenteric and renal artery repairs, and lower extremity arterial revascularization.

The recommendations include:

After carotid artery stenting or carotid endarterectomy, surveillance with duplex ultrasound should be conducted at baseline, then every 6 months for 2 years, then once per year until there is no evidence of restenosis for 2 years.

Contrast-enhanced CT scanning after thoracic endovascular aortic repair should be performed at 1 month, at 1 year and annually thereafter, with a 6-month scan reasonable if the 1-month scan shows an abnormality.

There is little evidence on the optimal strategy for imaging after renal or mesenteric interventions, but duplex ultrasound at 1 month, 6 months, 1 year and annually thereafter may be considered.

Within the first month after aortoiliac endovascular therapy, clinical examination, ankle-brachial index and duplex ultrasound should be performed. Clinical examination and ankle-brachial index, with or without duplex ultrasound, should be performed at 6 months, 1 year and annually thereafter.

Within the first month after femoropopliteal endovascular therapy, clinical examination, ankle-brachial index and duplex ultrasound should be performed. Continued surveillance at 3 months and then every 6 months thereafter is recommended for patients with stents and patients who underwent angioplasty or atherectomy for critical limb ischemia.

Within the first month after tibial endovascular therapy, clinical examination, ankle-brachial index and duplex ultrasound should be performed. Continued surveillance at 3 months and every 6 months thereafter should be considered. Repeat duplex ultrasound should be performed in patients with nonhealing wounds, returned rest pain, new tissue loss or signs of deterioration on clinical exam.

“Evidence is somewhat scarce for many of the endovascular techniques because they change so quickly, unlike the more established open procedures,” Zierler said in the release. “Endovascular procedures are developing rapidly and devices are changing frequently. The life cycle of a certain device or intervention may be quite short.”

Great variability

“The variability of the quality of published data on this topic is so great that no recommendation was supported by high-quality (level A) evidence,” Peter F. Lawrence, MD, chief of vascular surgery and professor of surgery at UCLA’s David Geffen School of Medicine and director of the Gonda Vascular, Wound Treatment and Clinical Tissue Engineering Centers, and Peter Gloviczki, MD, professor of surgery at Mayo Clinic, wrote in a related editorial. – by Erik Swain

Disclosures: The authors, Gloviczki and Lawrence report no relevant financial disclosures.