Diagnostic Imaging Pathways - Peripheral Stent Follow-Up
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Population Covered By The Guidance
This pathway provides diagnostic imaging guidance for follow-up of patients with peripheral arterial stents.
Date reviewed: January 2018
Date of next review: January 2021
Published: June 2018
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
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The relative radiation level of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE | |
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None | 0 | |
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Minimal | < 1 millisieverts | |
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Low | 1-5 mSv | |
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Medium | 5-10 mSv | |
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High | >10 mSv |
Teaching Points
Teaching Points
- Doppler ultrasound following clinical assessment is the imaging modality of choice to follow-up patients with endovascular peripheral stents
- Non-invasive angiography such as MRA and CTA has an increasing role in the assessment of lower limb peripheral arterial disease and pre procedural planning
hs1
Follow-up of Peripheral Stent
- The risk of restenosis depends on multiple factors: drug eluting stents may reduce the risk of restenosis, infra-inguinal stents have an increased risk of restenosis; longer segments and complex disease also carry a higher risk 1
- Patient risk factors and co-morbidities should also be considered 2
- Not all restenosis is symptomatic 3
- There is no consensus on the optimal timing for monitoring patients after percutaneous therapy for peripheral vascular disease 2, 4, 5
- Early detection of restenosis is preferred as restenosis is easier to treat than complete occlusion 5
- The risk of restenosis is highest in the first 12 months, but can occur at any time 6
- Close follow-up is suggested in the first year, e.g. at 6 weeks, 3 months, 6 months and 12 months post-procedure, then annually thereafter
- Follow-up assessment should include taking a history to identify recurrent symptoms, physical examination and ABIs 2, 5, 7, 8
- Duplex ultrasound is the preferred imaging modality for follow-up 2, 7, though there have been no randomised trials performed
- Duplex ultrasound is reasonable for routine surveillance after endovascular procedures 2
- Although many clinicians add duplex ultrasound to routine surveillance, 9 the Appropriate Use Criteria panel felt that surveillance more than annually was inappropriate or uncertain for asymptomatic patients 10
- Ongoing imaging is only indicated if further intervention is being considered; other co-morbidities and functional status should be taken into account
hs2
Duplex Colour Doppler Ultrasound
- Lowest cost cross-sectional imaging modality 7
- Recommended imaging modality for routine surveillance and in the setting of recurrent symptoms following surgical or percutaneous intervention 2, 7
- Able to localise lesion site and assess its haemodynamic significance 4, 11
- Sensitive and specific for detecting in-stent stenosis by measuring peak systolic velocity (PSV) or velocity ratio (Vr) 3, 12
- Limitation: Unable to provide information on loss of luminal volume or extent of stenosis (e.g. a focal stenosis compared to diffuse) 9
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Catheter Angiography
- 'Gold standard' for peripheral arterial imaging 7, 13, 14
- Allows for intervention at the time of diagnosis
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Non-invasive Angiography
- Advancing technology has increased the use of CT Angiography (CTA) and magnetic resonance angiography (MRA) for evaluating vascular disease, particularly prior to intervention 7, 13, 15
- When compared to catheter angiography, CTA provides better evaluation of all collateral vessels and surrounding tissues 15
- MRA may also have a role in pre procedural planning and for follow-up assessment after revascularisation 4, 15, 16
- MRA is more sensitive and specific than CTA or ultrasonography for detection of lower-limb PAD 16
References
References
Date of literature search: January 2018
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Katsanos K, Tepe G, Tsetis D, Fanelli F. Standards of practice for superficial femoral and popliteal artery angioplasty and stenting. Cardiovasc Intervent Radiol. 2014;37(3):592-603. (Review article). View the reference
- Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR, Corriere MA, Drachman DE, et al. 2016 AHA/ACC guideline on the management of patients with lower extremity peripheral artery disease: a report of the American college of cardiology/American heart association task force on clinical practice guidelines. Circulation. 2017;135(12):e726-e79. (Guideline). View the reference
- Baril DT, Rhee RY, Kim J, Makaroun MS, Chaer RA, Marone LK. Duplex criteria for determination of in-stent stenosis after angioplasty and stenting of the superficial femoral artery. J Vasc Surg. 2009;49(1):133-9. (Level II evidence). View the reference
- Hirsch AT, Haskal ZJ, Hertzer NR, Bakal CW, Creager MA, Halperin JL, et al. ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric, and abdominal aortic): a collaborative report. Circulation. 2006;113(11):463-654. (Guideline). View the reference
- Sobieszczyk P, Eisenhauer A. Management of patients after endovascular interventions for peripheral artery disease. Circulation. 2013;128(7):749-57. (Review article). View the reference
- Vroegindeweij D, Tielbeek AV, Buth J, Vos LD, van den Bosch HC. Patterns of recurrent disease after recanalization of femoropopliteal artery occlusions. Cardiovasc Intervent Radiol. 1997;20(4):257-62. (Level II evidence). View the reference
- Rybicki FJ, Nallamshetty L, Yucel EK, Holtzman SR, Baum RA, Foley WD, et al. ACR appropriateness criteria on recurrent symptoms following lower-extremity angioplasty. J Am Coll Radiol. 2008;5(12):1176-80. (Level II evidence). View the reference
- Conte MS, Pomposelli FB, Clair DG, Geraghty PJ, McKinsey JF, Mills JL, et al. Society for vascular surgery practice guidelines for atherosclerotic occlusive disease of the lower extremities: management of asymptomatic disease and claudication. J Vasc Surg. 2015;61(3 Suppl):2s-41s. (Guideline). View the reference
- Ho KJ, Owens CD. Diagnosis, classification, and treatment of femoropopliteal artery in-stent restenosis. J Vasc Surg. 2017;65(2):545-57. (Review article). View the reference
- Mohler ER, Gornik HL, Gerhard-Herman M, Misra S, Olin JW, Zierler RE. ACCF/ACR/AIUM/ASE/ASN/ICAVL/SCAI/SCCT/SIR/SVM/SVS 2012 appropriate use criteria for peripheral vascular ultrasound and physiological testing part I: arterial ultrasound and physiological testing. J Vasc Surg. 2012;56(1):e17-51. (Guideline). View the reference
- Leiner T, Kessels AG, Nelemans PJ, Vasbinder GB, de Haan MW, Kitslaar PE, et al. Peripheral arterial disease: comparison of color duplex US and contrast-enhanced MR angiography for diagnosis. Radiology. 2005;235(2):699-708. (Level III evidence). View the reference
- Kawarada O, Higashimori A, Noguchi M, Waratani N, Yoshida M, Fujihara M, et al. Duplex criteria for in-stent restenosis in the superficial femoral artery. Catheter Cardiovasc Interv. 2013;81(4):E199-205. (Level III evidence). View the reference
- Kumamaru KK, Hoppel BE, Mather RT, Rybicki FJ. CT angiography: current technology and clinical use. Radiol Clin North Am. 2010;48(2):213-35. (Review article). View the reference
- Kock MC, Adriaensen ME, Pattynama PM, van Sambeek MR, van Urk H, Stijnen T, et al. DSA versus multi-detector row CT angiography in peripheral arterial disease: randomized controlled trial. Radiology. 2005;237(2):727-37. (Level I evidence). View the reference
- Kasapis C, Gurm HS. Current approach to the diagnosis and treatment of femoral-popliteal arterial disease. A systematic review. Current cardiology reviews. 2009;5(4):296-311. (Level II evidence). View the reference
- Collins R, Burch J, Cranny G, Aguiar-Ibanez R, Craig D, Wright K, et al. Duplex ultrasonography, magnetic resonance angiography, and computed tomography angiography for diagnosis and assessment of symptomatic, lower limb peripheral arterial disease: systematic review. BMJ. 2007;334(7606):1257. (Level I evidence). View the reference
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