PERIPHERAL ARTERY DISEASE IMAGING TECHNIQUES

Duplex ultrasound, magnetic resonance angiography, and computed tomography (CT) angiography for the assessment and diagnosis of symptomatic, lower limb peripheral arterial disease: a systematic review

Background

This systematic review looked at duplex ultrasound, magnetic resonance angiography (MRA), and computed tomography (CT) angiography for the assessment and diagnosis of symptomatic, lower limb peripheral arterial disease. Contrast angiography, the standard reference test, has drawbacks such as requiring arterial puncture, ionising radiation and the use of a contrast agent which has associated risks. A number of alternative imaging techniques are available. The aim of this systematic review was to assess the comparative clinical and cost effectiveness of the available techniques and identify a technique that is safer and more acceptable to patients but of comparable efficacy to carotid angiography.

Findings

The results of the review suggest that contrast enhanced MRA has a better overall diagnostic accuracy than CT angiography or duplex ultrasound, and that contrast enhanced MRA is generally preferred by patients over contrast angiography.

The only controlled trial of the effectiveness of imaging procedures suggested that the results of duplex ultrasound were comparable to those of contrast angiography, in terms of surgical planning and outcome. This finding conflicts with the results of diagnostic accuracy studies, which reported poor estimates of accuracy for duplex ultrasound in comparison with contrast angiography.

There was insufficient evidence to evaluate the usefulness of CT angiography for the assessment of peripheral arterial disease, particularly newer techniques.

The results of the economic modelling suggest that for peripheral arterial disease patients for whom the whole leg is evaluated by a preoperative diagnostic test duplex ultrasound dominates the other alternatives by presenting higher effectiveness at a lower cost per QALY. However, when the analysis of stenosis is limited to a section of the leg, either above the knee or below the knee, 2D TOF MRA appears to be the most cost-effective preoperative diagnostic strategy.

Conducted by: R Collins1, G Cranny1, J Burch1, R Aguiar-Ibáñez1, D Craig1, K Wright1, E Berry2, M Gough31, J Kleijnen1, M Westwood1

1. Centre for Reviews and Dissemination; 2. Academic Unit of Medical Physics, University of Leeds; 3. Leeds Teaching Hospitals NHS Trust

Further details

Project page on HTA Programme website

Publications

Centre for Reviews and Dissemination. Assessing peripheral arterial disease. CRD Summary Report. York: University of York. 2007

Collins R, Cranny G, Burch J, Aguiar-Ibáñez R, Craig D, Wright K, Berry E, Gough M, Kleijnen J, Westwood M. A systematic review of duplex ultrasound, magnetic resonance angiography and computed tomography angiography for the diagnosis and assessment of symptomatic, lower limb peripheral arterial disease. Health Technol Assess. 2007;11(20): 1-202

Collins R, Burch J, Cranny G, Aguiar-Ibáñez R, Craig D, Wright K, Berry E, Gough M, Kleijnen J, Westwood M. 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):1257-61 (Appendices to the BMJ article)

Posters

Aguiar-Ibáñez R, Craig D, Collins R, Cranny G, Burch J, Wright K, et al. Cost-effectiveness analysis of diagnostic methods in the management of patients with symptomatic, lower limb peripheral arterial disease. ISPOR 9th Annual European Congress; 2006 October; Copenhagen, Denmark

Funding

Commissioned by the HTA Programme