Accuracy of duplex ultrasound compared to angiotomography for the diagnosis of extracranial internal carotid stenosis

Introdução: Estenoses de artéria carótida interna (ACI) são causas importantes de acidentes vasculares cerebrais (AVCs). A Ecografia Vascular com Doppler (EVD) costuma ser o primeiro exame a ser realizado durante sua investigação, mas possui acurácia variável na literatura e é comum complementar o estudo com a realização de outro exame quando frente a uma estenose com possibilidade de tratamento cirúrgico. Há carência de estudos de acurácia comparando a EVD com angiotomografia (ATC) na literatura. Métodos: Foi realizado um estudo de acurácia no qual se comparou a EVD com as ATCs de carótida de pacientes da EPM/UNIFESP realizadas em um mesmo período. Incluiu-se pacientes que realizaram ambos exames em um período de até 3 meses. As imagens foram avaliadas independentemente por 2 cirurgiões vasculares e, se houvesse divergência entre eles, um terceiro arbitrou o resultado. Realizou-se análise estatística determinando a acurácia, sensibilidade e especificidade de estenoses nas faixas de 50-99% e 70-99%. Também foi realizada a análise de discordância entre avaliadores de um mesmo exame para se comparar uma técnica à outra. Resultados: Foram incluídos nas análises estatísticas 45 pacientes e 84 artérias. Para estenoses 50-99% obteve-se acurácia de 69%, sensibilidade 89% e especificidade 63%. Para estenoses 70-99% obteve-se acurácia de 84%, sensibilidade de 61% e especificidade de 93%. A área sob a curva ROC é de 0,868. Ocorreu discordância entre avaliadores de ATC com mudança de conduta clínica para cirúrgica em pelo menos 37,5% dos laudos conflitantes. Conclusão: A acurácia da EVD para estenoses entre 50-99% é de 69%. Para estenoses entre 70-99% a acurácia é de 84%. A área sob a curva ROC é de 0,868. A EVD pode ser usada exclusivamente para indicar endarterectomia de carótida desde que seja realizado um segundo exame para confirmação. Análises de ATC podem ser dependentes do avaliador a ponto de mudar a conduta.Introduction: Internal carotid artery (ICA) stenosis are important causes of stroke. Duplex ultrasound scan (DUS) is the first line of investigation, but its accuracy varies on literature and it is usual to complement the study with another exam with higher accuracy when facing a significant stenosis. There is a lack of studies comparing DUS with CT angiography (CTA) in the present literature. Methods: We performed an accuracy study, which compared DUS to Carotid CTAs of EPM/UNIFESP patients in the same period. The patients were selected retrospectively and two independent vascular surgeons evaluated both images. All of them were blinded for the others' analysis. When necessary, a third evaluator was summoned. The statistics included the accuracy of stenosis 50-99% and 70-99%. Discordance between evaluators from each exam was also fulfilled. Results: We included 45 patients and 84 arteries after exclusion criteria applied. For 50-99% stenosis: accuracy 69%, sensibility 89%, and specificity 63%. For stenosis 70-99% accuracy 84%, sensibility 61%, specificity 93%. Area under the ROC curve is 0,868. Discordance between CTA evaluators that represented chance on clinical or surgical approach was 37,5% of the conflicting arteries. Conclusion: The accuracy of DUS for 50-99% range of stenosis is 69%. For 70-99% range of stenosis is 84%. Area under the ROC curve is 0,868. DUS can be used exclusively for indicate carotid endarterectomy since a second exam is performed for confirmation. CTAs analysis could be evaluator-dependent and lead to change of conduct

Accuracy of duplex ultrasonography versus angiotomography for the diagnosis of extracranial internal carotid stenosis

ABSTRACT Introduction: Internal carotid artery (ICA) stenosis causes about 15% of ischemic strokes. Duplex ultrasonography (DUS) is the first line of investigation of ICA stenosis, but its accuracy varies in the literature and it is usual to complement the study with another more accurate exam when faced with significant stenosis. There is a lack of studies that compare DUS with angiotomography (CTA) in the present literature. Methods: we performed an accuracy study, which compared DUS to CTA of patients in a tertiary hospital with a maximum interval of three months between tests. Patients were selected retrospectively, and two independent and certified vascular surgeons evaluated each image in a masked manner. When there was discordance, a third evaluator was summoned. We evaluated the diagnostic accuracy of ICA stenosis of 50-94% and 70-94%. Results: we included 45 patients and 84 arteries after inclusion and exclusion criteria applied. For the 50-94% stenosis range, DUS accuracy was 69%, sensitivity 89%, and specificity 63%. For the 70-94% stenosis range, DUS accuracy was 84%, sensitivity 61%, and specificity 93%. There was discordance between CTA evaluators with a change from clinical to surgical management in at least 37.5% of the conflicting reports. Conclusion: DUS had an accuracy of 69% for stenoses of 50-94% and 84% for stenoses of 70-94% of the ICA. The CTA analysis depended directly on the evaluator with a change in clinical conduct in more than 37% of cases

Angioplasty and stenting for below the knee ulcers in diabetic patients: protocol for a systematic review

Abstract Background The worldwide incidence and prevalence of diabetes mellitus (DM) are increasing. DM has a high social and economic burden due to its complications and associated disorders. Peripheral arterial disease (PAD) is closely related to DM. More than 85% of patients with DM will develop PAD in their lifetime, and between 10 and 25% of patients with DM will have a foot ulcer. In such cases, it is important to determine for each patient whether it is necessary and feasible to revascularise the affected limb as well as the optimal technique. Percutaneous transluminal angioplasty (PTA) is designed to restore blood flow through the vessel lumen by various devices including balloons, drug-coated balloons, bare stents, drug-eluting stents and endovascular atherectomes. This systematic review aims to evaluate the effects of PTA in the treatment of lower limb arterial ulcers in diabetic patients. Methods We will search randomised controlled trials (RCTs) and quasi-RCTs in the following databases (e.g., MEDLINE via PubMed, EMBASE, Lilacs, Cochrane Central Register of Controlled Trials, Ibecs, CINAHL, AMED, World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, and OpenGrey). Our search strategy will use the following free-text terms and controlled vocabulary (e.g., Emtree, MeSH) for ‘foot ulcer’, ‘leg ulcer’, ‘diabetic foot’, ‘Peripheral Arterial Disease’, ‘Diabetes Complications’, ‘Peripheral Vascular Diseases’, ‘critical limb ischemia’, ‘below the knee ulcer’, ‘angioplasty’, ‘stents’, ‘stenting’, and ‘endovascular procedures’. There will be no limits on date or language of publication. Two authors will, independently, select studies and assess the data from them. Risks of bias (RoB) of included studies will be evaluated using the Cochrane’s RoB tool. If possible, we will perform and report structured summaries of the included studies and meta-analyses. Results are not available as this is a protocol for a systematic review, and we are currently in the phase of building a sensitive search strategy. Discussion While there are several available endovascular techniques for revascularisation, it is unclear which technique has better outcomes for ulcers below the knee in diabetic patients. A systematic review is required to validate and demonstrate these techniques and their outcomes to allow an evidence-based clinical decision. Systematic review registration PROSPERO CRD4201706517