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Duplex Criteria for In-Stent Restenosis of Mesenteric Arteries
Michael C Soult, Joseph C Wuamett, Christopher L Stout, Sebastian Larion, Sadaf S Ahanchi, Jean M Panneton
Eastern Virginia Medical School, Norfolk, VA

BACKGROUND – Duplex ultrasound (DUS) criteria are well defined for evaluating high-grade stenosis (≥70%) of the native superior mesenteric artery (SMA) and celiac artery (CA). Our institution defines native vessel stenosis >70% in the SMA as a PSV of >275 cm/s and in the CA as a PSV of > 200 cm/s. However, it has been shown that native vessel criteria overestimate the degree of in-stent restenosis (ISR) and velocity criteria for SMA and CA ISR are not well established. The objective of this study was to define DUS velocity criteria for high-grade ISR of the SMA and CA.
METHODS – A retrospective review of all patients who underwent SMA and/or CA stenting from a single institution was preformed from 2004-2013. Patients were excluded if they did not have a DUS <4 months prior to angiography to assess stent patency or adequate angiographic visualization of the ISR. Peak systolic velocities (PSV) were collected from DUS and correlated to the degree of ISR calculated from the angiogram. An area under receiver operating characteristic curve (AUROC) was created and allowed determination of the optimal PSV for >70% ISR.
RESULTS – Of the 189 mesenteric stents, 103 paired DUS and angiograms were analyzed: 66 SMA stents and 37 CA stents. The mean age of the cohort was 71 years, with 29% male. The average PSV for SMAs with <70% ISR was 367 cm/s and for >70% was 536 cm/s. The average PSV for CA with <70% ISR was 302 cm/s and for >70% was 434 cm/s. After AUROC (Figure 1), an ISR ≥70% in the SMA, a PSV >445 cm/s produced the highest sensitivity (83%) and specificity (83%), with a positive predictive value (PPV) of 81% and a negative predictive value (NPV) of 86% (Area=0.87). For an ISR ≥70%, in the CA, a PSV >289 cm/s produced the highest sensitivity (100%) and specificity (57%), with a PPV of 79% and NPV of 100% (Area=0.85).
CONCLUSIONS – Increased PSV correlates with increasing degree of ISR for both SMA and CAs. The PSV criteria are higher for ISR than that for native visceral vessel stenosis. The proposed new velocity criteria define ≥70% stenosis as 445 cm/s in the stented SMA and 289 cm/s in the stented CAs.

Figure 1: Receiver Operating Curve with Optimal PSV for >70% ISR

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