Duplex ultrasonography, magnetic resonance angiography, and computed tomography angiography for diagnosis and assessment of symptomatic, lower limb peripheral arterial disease: systematic reviewBMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39217.473275.55 (Published 14 June 2007) Cite this as: BMJ 2007;334:1257
- Ros Collins, research fellow1,
- Jane Burch, research fellow1,
- Gillian Cranny, research fellow1,
- Raquel Aguiar-Ibáñez, research fellow in health economics1,
- Dawn Craig, research fellow in health economics1,
- Kath Wright, information officer1,
- Elizabeth Berry, senior lecturer2,
- Michael Gough, consultant vascular surgeon3,
- Jos Kleijnen, director4,
- Marie Westwood, senior research fellow1
- 1Centre for Reviews and Dissemination, University of York, York YO10 5DD
- 2Academic Unit of Medical Physics, University of Leeds, Leeds
- 3Leeds Teaching Hospitals NHS Trust, Leeds
- 4Kleijnen Systematic Reviews Ltd, York
- Correspondence to: Ros Collins
- Accepted 10 April 2007
Objectives To determine the diagnostic accuracy of duplex ultrasonography, magnetic resonance angiography, and computed tomography angiography, alone or in combination, for the assessment of lower limb peripheral arterial disease; to evaluate the impact of these assessment methods on management of patients and outcomes; and to evaluate the evidence regarding attitudes of patients to these technologies and summarise available data on adverse events.
Design Systematic review.
Methods Searches of 11 electronic databases (to April 2005), six journals, and reference lists of included papers for relevant studies. Two reviewers independently selected studies, extracted data, and assessed quality. Diagnostic accuracy studies were assessed for quality with the QUADAS checklist.
Results 107 studies met the inclusion criteria; 58 studies provided data on diagnostic accuracy, one on outcomes in patients, four on attitudes of patients, and 44 on adverse events. Quality assessment highlighted limitations in the methods and quality of reporting. Most of the included studies reported results by arterial segment, rather than by limb or by patient, which does not account for the clustering of segments within patients, so specificities may be overstated. For the detection of stenosis of 50% or more in a lower limb vessel, contrast enhanced magnetic resonance angiography had the highest diagnostic accuracy with a median sensitivity of 95% (range 92-99.5%) and median specificity of 97% (64-99%). The results were 91% (89-99%) and 91% (83-97%) for computed tomography angiography and 88% (80-98%) and 96% (89-99%) for duplex ultrasonography. A controlled trial reported no significant differences in outcomes in patients after treatment plans based on duplex ultrasonography alone or conventional contrast angiography alone, though in 22% of patients supplementary contrast angiography was needed to form a treatment plan. The limited evidence available suggested that patients preferred magnetic resonance angiography (with or without contrast) to contrast angiography, with half expressing no preference between magnetic resonance angiography or duplex ultrasonography (among patients with no contraindications for magnetic resonance angiography, such as claustrophobia). Where data on adverse events were available, magnetic resonance angiography was associated with the highest proportion of adverse events, but these were mild. The most severe adverse events, although rare, were mainly associated with contrast angiography.
Conclusions Contrast enhanced magnetic resonance angiography seems to be more specific than computed tomography angiography (that is, better at ruling out stenosis over 50%) and more sensitive than duplex ultrasonography (that is, better at ruling in stenosis over 50%) and was generally preferred by patients over contrast angiography. Computed tomography angiography was also preferred by patients over contrast angiography; no data on patients' preference between duplex ultrasonography and contrast angiography were available. Where available, contrast enhanced magnetic resonance angiography might be a viable alternative to contrast angiography.
Contributors: RC (guarantor) was responsible for study selection, data extraction, validity assessment, data analysis, and writing the paper. JB was involved in study selection, data extraction, validity assessment, data analysis, and writing the paper. GC, RA-I, and DC were involved in data extraction, validity assessment, data analysis, and writing the paper. KW devised the search strategy, carried out the literature searches, and wrote the search methods sections of the paper. EB provided advice on technical issues and commented on drafts of the paper. MG provided clinical advice and commented on drafts of the paper. JK provided advice and commented on drafts of the paper. MW provided input at all stages, commented on drafts of the paper, and took overall responsibility for the review.
Funding: Health Technology Assessment Programme (project No 03/07/04). The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the Department of Health.
Competing interests: EB is now director of a company that undertakes consulting associated with medical imaging research. Neither she nor JK received payment for their contributions to this review.
Ethical approval: Not required.
- Accepted 10 April 2007