Duplex Ultrasound Surveillance after Infrainguinal Peripheral Artery Revascularisation: A Systematic Review with Narrative Synthesis

OBJECTIVE: This systematic review aimed to evaluate the clinical effectiveness of duplex ultrasound (DUS) surveillance following infra-inguinal revascularisation, both surgical and endovascular, in patients with intermittent claudication (IC) or chronic limb threatening ischaemia (CLTI). DATA SOURCES: Ovid MEDLINE, Embase, and Cochrane Library. REVIEW METHODS: A systematic search of MEDLINE, Embase, and the Cochrane Library was conducted from inception to 1 June 2024, following PRISMA guidelines. Studies were eligible if they reported DUS surveillance protocols after infra-inguinal revascularisation and included clinical outcomes such as patency, re-intervention, amputation, or death. Randomised controlled trials (RCTs) and observational studies were included. Risk of bias was assessed using RoB 2 and ROBINS-I tools. Following an a priori methodological plan, meta-analysis was not attempted because studies were not sufficiently comparable. RESULTS: Sixty-one studies were included, with 77% evaluating surgical revascularisation and 23% evaluating endovascular. DUS surveillance following surgery was associated with improved primary assisted patency in 70% of studies and lower amputation rates in several comparative studies. One RCT showed no significant benefit, highlighting heterogeneity. Evidence for endovascular surveillance was limited but promising; two prospective comparative studies demonstrated improved patency, reduced amputations (7 - 10% vs. 35 - 50%), and lower mortality with DUS. Economic analyses reported reduced healthcare costs and amputations with DUS following surgical bypass. However, most studies were observational with moderate to high risk of bias, and DUS protocols varied widely in frequency and duration. In endovascular cohorts, benefits were most evident in studies including longer lesions. Where reported, amputation outcomes are presented separately for CLTI and IC. CONCLUSION: DUS surveillance appears to improve patency and limb salvage following surgical revascularisation and may reduce healthcare costs. Emerging evidence suggests potential benefits in endovascular cases, particularly for long lesions. High quality multicentre RCTs and economic evaluations are needed to determine the optimal surveillance strategy and to inform standardised clinical guidelines.