Gary J. Becker

Position Statement on the Use of the Ankle Brachial Index in the Evaluation of Patients with Peripheral Vascular Disease A Consensus Statement Developed by the Standards Division of the Society of Interventional Radiology

PERIPHERAL vascular disease (PVD), also known as peripheral arterial disease, affects more than 8–10 million Americans, and its incidence is growing annually (1). PVD is a risk marker for coronary disease, cerebrovascular disease, aneurysmal disease, diabetes, hypertension, and many other conditions. Patients with objectively documented PVD have a fourto six-fold increase in cardiovascular mortality rate over healthy age-matched individuals (2). Fifty percent of people with PVD are symptomatic (3). One of the simplest and most useful parameters to objectively assess lower extremity arterial perfusion is the ankle-brachial index (ABI). The ABI helps to define the severity of the disease and successfully screens for hemodynamically significant disease. The Society of Interventional Radiology (SIR) recommends that all patients being evaluated for peripheral vascular disease should have their ABI measured. The following methodology is recommended: With the patient placed in a supine position, the brachial and ankle systolic pressure measurements are obtained. The higher systolic pressure of the anterior tibial or posterior tibial measurement for each foot is divided by the highest brachial systolic pressure to obtain an ankle brachial pressure ratio. For example, to obtain the left ABI, first measure the systolic brachial pressure in both the left and the right arm. Select the higher of these two values as the brachial artery pressure measurement. There should be a difference of less than 10 mm Hg between each brachial pressure measurement. Next, measure the left anterior tibial and posterior tibial arterial systolic pressures. Select the higher of these two values as the ankle pressure measurement. Then, divide the selected ankle pressure measurement by the previously selected brachial artery systolic pressure measurement. This will give the ABI. ABIs as high as 1.10 are normal; abnormal values are those less than 1.0. The majority of patients with claudication have ABIs ranging from 0.3 to 0.9. Rest pain or severe occlusive disease typically occurs with an ABI lower than 0.50. Indexes lower than 0.20 are associated with ischemic or gangrenous extremities. In patients with diabetes and heavily calcified vessels, the arteries are frequently incompressible. This results in an artifactually elevated ankle pressure, which can underestimate disease severity. In these patients, toe pressure determinations more accurately reflect perfusion.

Concern about safety of carotid angioplasty.

Stroke risk reduction for the large majority of patients with high-grade carotid stenosis is presently best accomplished by carotid endarterectomy. When properly applied according to clearly identified standards and guidelines, this treatment is effective, safe, and durable.1 2 The results of recent large randomized trials demonstrate conclusively not only the effectiveness of surgical therapy for symptomatic and asymptomatic patients in reducing stroke incidence but also the importance of careful studies in providing definitive information.3 4 nnWith this background of hard-won experience, we view with concern the application of catheter-based angioplasty techniques to carotid artery bifurcation and internal carotid artery disease. Reports of such techniques can be found in small published series characterized by lack of complete descriptive information and absent …

Reporting Standards for Inferior Vena Caval Filter Placement and Patient Follow-up: Supplement for Temporary and Retrievable/Optional Filters

THIS Standards document is intended as a Supplement to the Recommended Reporting Standards for Vena Cava Filter Placement and Patient Followup, published in 1999 (1). Since 1999, there has been increased interest in non-permanent vena cava filters, with both increased research and clinical use of these devices. Several such devices are now approved for use in Europe, Canada, and the United States. The previous Standards did address several issues related specifically to non-permanent filters: this document contains additional issues that have arisen in the interval. Although there is a large number of publications regarding vena cava filters, the literature is generally limited, with few good prospective studies, and even fewer randomized controlled trials (2). A randomized trial published in 1998 (3) demonstrated the “initial efficacy of filters for the prevention of pulmonary embolism.” However, prevention of pulmonary embolism (PE) appeared to be shortlived, and was counterbalanced by an increased risk of recurrent deep-vein thrombosis (DVT) in the patients receiving filters (3). The data published in this trial, which was based on 2-year follow-up, resulted in increased interest in non-permanent filters. Of note, further follow-up data from the same trial showed continued filter protection against PE with no increase in post-thrombotic syndrome at 8 years (4).

Training Standards for Physicians Performing Peripheral Angioplasty and Other Percutaneous Peripheral Vascular Interventions

PERCUTANEOUS transluminal angioplasty of peripheral, renal, and visceral arteries has been in widespread clinical use for more than a decade, and it is estimated that approximately 100,000 of these procedures are performed annually in the United States. In recent years controversy has developed among the various medical disciplines about who is qualified to perform percutaneous transluminal angioplasty (and associated peripheral interventions such as intra-arterial thrombolysis, stent placement, atherectomy, and laser angioplasty) and what training standards should be established for physicians entering this field. For this reason, in late 1990 the American Heart Association’s Councils on Cardiovascular Radiology, Cardiovascular Surgery (now CardioThoracic and Vascular Surgery), and Clinical Cardiology formed an ad hoc committee to develop training standards for peripheral percutaneous transluminal angioplasty and related percutaneous peripheral interventions. Members of the committee were interventional radiologists, vascular surgeons, interventional cardiologists, and vascular medicine physicians.

Risk Stratification and Outcomes of Transluminal Endografting for Abdominal Aortic Aneurysm: 7-Year Experience and Long-term Follow-up

PURPOSEnTo determine early and late outcomes of transluminal endografting (TE) in patients with abdominal aortic aneurysm (AAA), stratified by predicted risk of procedure-related mortality with conventional operation.nnnMATERIALS AND METHODSnA retrospective study was conducted in consecutive risk-stratified AAA patients undergoing TE at a not-for-profit cardiovascular referral center from March 1994 through November 2000 with follow-up through February 2001. With use of conventional risk strata (0 = low, 1 = minimal, 2 = moderate, and 3 = high), predicted procedure-related mortalities were 0%-1% in stratum 0 (n = 40), 1%-3% in stratum 1 (n = 118), 3%-8% in stratum 2 (n = 116), and 8%-30% in stratum 3 (n = 31). Main outcome measures were: (i) TE procedural success, (ii) procedure-related mortality, (iii) major nonfatal complications, (iv) composite adverse outcome (ii + iii), (v) length of stay (LOS), (vi) freedom from AAA rupture, (vii) late survival, (viii) late complications, and (ix) endoleaks and their classification and management.nnnRESULTSnWomen were significantly less likely than men to qualify for and undergo endografting: 24 of 91 (26.4%) women underwent TE, compared to 281 of 684 (41.1%) men. Of 305 attempted TE procedures, 291 (95.4%) were successful, four (1.3%) were urgently converted to open repair, and 10 (3.3%) were aborted. Procedure-related mortalities occurred in eight cases (2.6%) overall and one of 40 (2.5%), one of 118 (0.8%), four of 116 (3.4%), and two of 31 (6.5%) cases for risk strata 0-3, respectively. Perioperative survivors were significantly younger than nonsurvivors (74.3 y +/- 9 vs 81.6 y +/- 5.1; P =.0087). Forty-six patients (15.1%) had major complications. Composite adverse outcome was worse for patients in stratum 3 than those in stratum 1 (P =.0296) and those in strata 0, 1, and 2 combined (P =.026). Procedure-related mortality declined with institutional experience, from 4% among the first 100 patients undergoing TE to 1% among the last 105. For strata 0-3, median LOS were 2, 3, 3, and 4 days, respectively. Seventy patients (22.9%) had 75 endoleaks, of which 30 necessitated additional procedures, 17 self-resolved, and 22 were untreated as of March 1, 2001. Five patients with endoleak died of unrelated causes. One late-onset type IA endoleak (26 mo) resulted in the only AAA rupture and death in the follow-up period among the 291 patients who underwent successful transluminal endograft implantation. Actuarial survival rates at 1 year after TE were 90.3% +/- 1.9% for the overall study group and 97.5% +/- 2.5%, 94% +/- 2.5%, 86.9% +/- 3.3%, and 81.3% +/- 7.7% for risk strata 0-3, respectively. At 5 years, overall actuarial survival was 69.6% +/- 6.1%. Thirty-eight late deaths were attributable to post-TE AAA rupture (n = 1), AAA rupture late after failed TE with no further treatment (n = 1), other cardiovascular disorders (n = 7), cancer (n = 15), other causes (n = 10), and unknown causes (n = 4). Late deaths occurred in risk strata 0-3 at the following rates: two of 40 (5%), 10 of 118 (8.5%), 16 of 116 (13.8%), and 10 of 31 (32.3%), respectively (stratum 0 vs stratum 3, P =.0017; stratum 1 vs stratum 3, P =.003).nnnCONCLUSIONSnTE is safe and confers durable protection against AAA rupture in treated populations. Still, protection is not absolute in patients with endoleaks, because late AAA enlargement and even rupture can occur. Given current knowledge, technology, and practice, careful patient selection and close surveillance of patients after implantation of transluminal endografts is essential.

The Influence of Female Gender on the Outcome of Endovascular Abdominal Aortic Aneurysm Repair

PURPOSEnWomen appear to have a greater risk of death than men after open surgery for abdominal aortic aneurysm (AAA). The aim of this study is to compare outcomes after endovascular AAA repair in men and women.nnnMATERIALS AND METHODSnFrom March 1994 to November 2000, 305 patients (281 men and 24 women) underwent AAA repair with use of endovascular techniques. Outcomes measured included perioperative mortality, percentage of procedures aborted or converted to open abdominal AAA repair, deployment success rate, angiographic success rate, major complication rate, and percentage of patients with endoleaks.nnnRESULTSnPatients of both genders were comparable with respect to mean age (74.4 in men vs 75.9 in women; NS). According to the Society for Vascular Surgery/International Society of Cardiovascular Surgery risk stratification method, men and women were also comparable in age risk score (0.60 vs 0.67; NS), pulmonary risk score (0.50 vs 0.83; NS), and renal risk score (0.28 vs 0.17; NS). However, the cardiac risk score was higher in men (1.31 vs 0.80; P <.05) and maximum AAA diameter was greater in men (57.0 mm vs 52.1 mm; P <.01). Eight perioperative deaths (2.6%) occurred (2.8% of men, 0% of women; NS). Proportionately more procedures were aborted in women than men: four (16.7%) versus six (2.1%; P <.01). Conversion to open repair occurred in four men (1.4%) and no women (NS). Deployment success was achieved in 96.4% of men and 83.3% of women (P <.01). Angiographic success was achieved in 84.1% of men and 80% of women (NS). Of 46 major complications, 42 (14.9%) occurred in 281 men and four (16.7%) occurred in 24 women (NS). Sixty-seven patients had endoleaks: 60 were men (22.1%) and seven were women (35%; NS).nnnCONCLUSIONSnThere was no difference between men and women with respect to perioperative mortality and major complication rates. These findings indicate that being a woman does not adversely influence the outcome of endovascular AAA repair. However, women had a higher rate of aborted procedures. Precise preoperative evaluation may help reduce this problem in women.

Quality Improvement Guidelines for the Performance of Cervical Carotid Angioplasty and Stent Placement

Developed by a Collaborative Panel of the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, and the Society of Interventional Radiology

Quality improvement guidelines for the performance of cervical carotid angioplasty and stent placement: Developed by a collaborative panel of the American Society of Interventional and Therapeutic Neuroradiology, the American Society of Neuroradiology, and the Society of Interventional Radiology

John D. Barr, MD, John J. Connors, III, MD, David Sacks, MD, Joan C. Wojak, MD, Gary J. Becker, MD, John F. Cardella, MD, Bohdan Chopko, MD, PhD, Jacques E. Dion, MD, Allan J. Fox, MD, Randall T. Higashida, MD, Robert W. Hurst, MD, Curtis A. Lewis, MD, MBA, Terence A.S. Matalon, MD, Gary M. Nesbit, MD, J. Arliss Pollock, MD, Eric J. Russell, MD, David J. Seidenwurm, MD, and Robert C. Wallace, MD, for the ASITN, ASNR, and SIR Standards of Practice Committees

Optimizing radiation use during fluoroscopic procedures: proceedings from a multidisciplinary consensus panel.

James R. Duncan, MD, PhD, Stephen Balter, PhD, Gary J. Becker, MD, Jeffrey Brady, MD, MPH, James A. Brink, MD, Dorothy Bulas, MD, Mythreyi B. Chatfield, PhD, Simon Choi, PhD, MPH, Bairbre L. Connolly, MB, Robert G. Dixon, MD, Joel E. Gray, PhD, Stephen T. Kee, MD, Donald L. Miller, MD, Donald W. Robinson, LTC, MD, Mark J. Sands, MD, David A. Schauer, DSc, Joseph R. Steele, MD, Mandie Street, RT, Raymond H. Thornton, MD, and Robert A. Wise, MD

Carotid artery angioplasty and stent placement: quality improvement guidelines to ensure stroke risk reduction

CERVICAL carotid atherosclerotic stenosis has been correctly surmised to be a potentially preventable cause of stroke for a half-century. For most of this time, neither the absolute risk of the condition nor the specific contributing factors were known. Not surprisingly, therefore, medical therapy was poorly understood and offered a limited armamentarium. Prior dogma maintained that medical therapy alone neither significantly affected the progression of atherosclerosis nor caused its regression. Today an extensive body of literature confirms that cervical carotid artery atherosclerosis is common, relatively easy to evaluate, a major health threat, and surgically correctable. The appropriateness of carotid endarterectomy (CEA) has been evaluated by at least seven randomized trials, and further study is warranted and ongoing. While great strides have been made in the last decade in understanding cervical carotid atherosclerotic stenosis, there are still many important unknowns concerning the clinicopathologic condition, its various manifestations, precipitating biochemical and pathophysiologic events, specific patient risk characteristics, optimal medical therapy, as well as indications for, and best methods of, surgical and interventional therapies. Perhaps one of the best examples of the evolutionary nature of knowledge in this field is the relatively new concept that the principal culpability for clinical neurologic events is not the “degree-of-stenosis” per se, but rather the pathology of the plaque and the ischemia produced by atherothrombotic emboli. This belief is universally accepted in the cardiovascular community but seems to be under-appreciated in the neuroscience community. The ultimate confirmation of this concept is the 10-fold or greater difference in risk for someone with an 80% “nonembologenic” (ie, “asymptomatic”) carotid stenosis as compared to an 80% “embologenic” (symptomatic) stenosis. For the former there is about 1% to 2% per year stroke risk from the lesion itself as compared to the latter, which has about 10% to 20% risk of stroke in the first year (1,2). Further, recent studies of newer pharmacologic agents including antiplatelet agents (such as clopidogrel) and plaque-stabilizing agents (such as HMGCoA-reductase inhibitors [“statins”] and angiotensin converting enzyme [“ACE”] inhibitors) do indeed demonstrate that the natural history of atherosclerotic plaques can be positively influenced in a way that changes the risk/benefit ratio of all therapies for not only coronary atherosclerosis but also for carotid atherosclerosis (3,4). However, none of these new medical therapies have been systematically compared to CEA or carotid artery stent placement (CAS) in controlled clinical trials aimed at evaluating the best method to reduce stroke and stroke-related morbidity and mortality. In March 2000, the American Society of Interventional and Therapeutic Neuroradiology (ASITN), the specialty organization then composed primarily of neuroradiologists and neurosurgeons most involved with cervico-cerebral angiography and cervical and intracranial endovascular intervention, published a review and analysis of the current literature on carotid atherosclerosis and its treatment (5). Since that time, continued progress has been made in further understanding the nature of carotid atherosclerosis, improving surgical techniques, advancing the pharmaceutical armamentarium, and refining a potential endovascular therapy: carotid artery angioplasty and stent placement. Three medical societies that include training in cervico-cerebral angiography as part of their ACGME defined residency programs, the ASITN, the American Society of Neuroradiology (ASNR), and the Society of Interventional Radiology (SIR), recognize the importance of carotid atherosclerosis and its appropriate management. In this issue of the Journal of Vascular and This article also appears in J Vasc Interv Radiol 2003; 14:1095–1097. From the Miami Cardiac and Vascular Institute, Miami, FL (J.J.C., G.J.B.), Department of Radiology, Reading Hospital and Medical Center, Reading PA (D.S.), and Mid-South Imaging and Therapeutics, Memphis, TN (J.D.B.). Received July 3, 2003; accepted August 6. Address correspondence to J.J.C., MCVI, 8900 Kendall Dr, Miami, FL 33176. E-mail budmancon@aol.com