Evaluation of the role of combining inter-arm systolic pressure difference and derivatives of pulse volume recording in detecting subclavian artery stenosis

Abstract

Background: Subclavian artery stenosis (SAS) is a peripheral arterial disease of asymptomatic appearance and disastrous consequences. The traditional screening method remains unsatisfactory.

Objective: The study aimed to assess the diagnostic performances of inter-arm systolic pressure difference (IASBPD), derivatives of pulse volume recording (PVR), and their combination in detecting subclavian artery stenosis.

Materials and methods: The present study was a retrospective analysis of clinical data from inpatients suspected of supra-arch artery stenosis in Fuwai hospital during 1 year, who underwent selective arterial angiographies. We obtained simultaneous blood pressure measurements on four limbs and pulse waves for calculating IASBPD and PVR derivatives prior to the angiographies. We utilized the receiver operating characteristic curve (ROC) to calculate the optimal cut-off value of IASBPD, upstroke time (UT), and upstroke time per cardiac cycle (UTCC) for detecting SAS. Moreover, we compared the sensitivity and specificity of IASBPD, UT, UTCC, and their combinations for diagnosing SAS (Clinical trial number: NCT03521739).

Results: We consecutively enrolled 320 eligible patients. Based on SAS's definition of stenosis above 50%, the area under the curve of IASBPD, UT, and UTCC were 0.84, 0.76, and 0.80 (P < 0.001). And their corresponding cut-off points were 9 mmHg, 202 milliseconds, and 23.2%. The sensitivity and specificity of IASBPD ≥ 9 mmHg were 57.0 and 94.1%. UT ≥ 202 ms and UTCC ≥ 23.2% yielded similar sensitivity (72.6 vs. 72.6%, P > 0.05), but UTCC had higher specificity (81.1 vs. 72.4%, P < 0.05). The sensitivity of the combination of IASBPD and UT (85.2%) or UTCC (78.5%) was significantly higher than IASBPD alone (57%, P < 0.05). The specificity of either combination decreased to 67.6 and 76.8% (P < 0.05).

Conclusions: This present study showed that the combinations of IASBPD and PVR-derived parameters promoted diagnostic sensitivity and preserved adequate specificity than those alone for detecting SAS.

Keywords: atherosclerosis; inter-arm systolic pressure difference; pulse upstroke time; pulse upstroke time per cardiac cycle; subclavian artery stenosis.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 An, Dong, Deng, Chen, Zou, Zhang and Jiang.

Figures

FIGURE 1

An illustration of pulse volume recording (PVR) and its derivative parameters. PVR, pulse volume recording or pulse volume chart; UT, pulse wave upstroke time or pulse wave ascending time, which is the time required from the beginning to the peak of an arterial pulse wave in milliseconds (ms); UTCC, upstroke time per cardiac cycle time in percentage.

FIGURE 2

Angiographies of SAS and recordings of simultaneous extremity blood pressure and PVR. The upper panels are from a representative unilateral SAS case. (A) Arteriography showed the stenotic severity of the proximal lumen of the right subclavian artery. The degree of stenosis was 71.4% (the diameter of the narrowest lumen in the red arrow/the reference diameter of the distal lumen in the blue arrow; (B) the lumen of the left subclavian artery was normal; (C) The simultaneous extremity blood pressure measurement showed inter-arm systolic blood pressure difference = 16 mmHg (right arm systolic pressure 114 mmHg, left arm systolic pressure 130 mmHg). And PVR showed that the peak of the right arm was delayed significantly more than that of the left arm. The UT and UTCC were 260 ms and 28.2%, respectively. While the left arm UT and UTCC were 184 ms and 19.9%, respectively. The lower panels are from a bilateral SAS case. (D) Arteriography shows right SAS of 76.4%; (E) left SAS of 69.1%; (F) the UT of the left and right arms are 309 and 322 ms, and the UTCC is 29.9 and 31.1%, respectively. SAS, subclavian artery stenosis; IASBPD, inter-arm systolic blood pressure difference; please see previous figures or tables for other abbreviations.

FIGURE 3

Area under the curves (AUCs) of UT, UTCC, and IASBPD when SAS ≥ 50%. Panel (A) the UT and UTCC curves when SAS is equal to or greater than 50%, and their corresponding AUC is 0.76 (95% CI: 0.72–0.80) and 0.80 (95% CI: 0.76–0.85) for UT and UTCC, respectively. Panel (B) the IASBPD curve, when SAS is equal to or greater than 50%, corresponds to 0.84 (95% CI: 0.80–0.89). AUC, the area under the curve; CI, confidence interval; please see previous figures or tables for other abbreviations.