Vascular surgery
explains. “This is very common in arteries that are heavily calcified. Therefore, I think completion angiogram needs to be used in the context of the other information that you get from the Duplex or Doppler. “There are a lot of studies that have shown that completion angiogram and completion Duplex ultrasound can predict early graft thrombosis particularly in patients with below-the-knee bypasses. Therefore, in my practice, this data has driven me to use a combination of completion angiogram and completion Duplex ultrasound. If I’m in a hybrid room, I tend to use angiogram, but if I’m not in a hybrid room, I tend to use ultrasound to look at the anastomosis. If you are concerned about the vein conduit, then a completion angiogram and intraoperative intravascular ultrasound (IVUS) are the best way to go, as it’s hard to Duplex the entire vein. But all of this
Professor of Vascular Surgery, University of Leicester, acknowledges that there is a lack of major Randomised Control Trials (RCTs) on outcomes for completion assessment angiography and completion assessment using Doppler, but comments that, “sometimes you just need to employ common sense.” He points out that across the available
observational studies: l Routine completion angiography does not consistently improve outcomes in Peripheral Artery Disease (PAD) surgery.
is complementary to using an intraoperative Doppler. This is my first ‘go to’, as soon as I’m done with the bypass,” she concludes.
Real-world practice Professor Athanasios Saratzis, NIHR Research
Completion assessment: what happens in practice?
During a recent webinar, hosted by Huntleigh, attendees were asked about their current practice. Case: femoro-BK popliteal graft, with three vessel runoff, using ipsilateral LSV, completed without incident. Arterial clamps have just been removed. What would you do? Below are the results of the survey:
Fig. 1
100 90 80 70 60 50 40 30 20 10 0
67%
How often do you use pulse palpation (either of the graft, outflow vessel or distal pulses)?
Fig. 3 12% 10% 7% 5%
100 90 80 70 60 50 40 30 20 10 0
How often do you use Intraoperative Duplex?
46% 21% 10% 10% 13%
l Intraoperative Doppler is reliable, quick, non- invasive and identifies most technical issues.
l Selective imaging guided by abnormal Doppler findings is safe and efficient.
l The philosophy is shifting towards physiologic assessment first, imaging second.
Therefore, he concludes that the clinical implication is to use intraoperative Doppler as the primary completion check, reserving completion imaging for abnormal findings or case uncertainty. However, there appears to be a gap between the guidelines and what happens in real-world practice, as a survey of vascular surgeons reveals. (See figures 1-4) When asked about their practice at completion for a specific case study scenario, nearly one-third had never used completion angiogram, nearly half had never used intraoperative Duplex, only 13% always used intraoperative Doppler probe assessment, while the majority (67%) always used pulse palpation. “The guidelines say, ‘always do a completion
angiogram or Duplex’, yet we do not have the best evidence out there, and surgeons don’t always perform completion angiograms. So, what needs to change?” questions Prof. David Bosanquet. “Do the guidelines need to change to reflect clinical practice, or does clinical practice need to shift more towards the guidelines?” “As physicians, especially when working in
Fig. 2
100 90 80 70 60 50 40 30 20 10 0
How often do you use completion angiogram?
Fig. 4 31% 23% 13% 18% 15%
100 90 80 70 60 50 40 30 20 10 0
How often do you
use Intraoperative Doppler probe assessment?
28% 13% 18%
23%
20%
30
www.clinicalservicesjournal.com I February 2026
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