1
|
Ahn L, Christensen JM, Fruge S, Meulendijks MZ, Hoftiezer YAJ, Wong FK, Tuano KR, Valerio IL, Eberlin KR. Preoperative Vascular Imaging in Lower Extremity Free Flap Reconstruction: Comparison Between Imaging Modalities. Microsurgery 2024; 44:e31241. [PMID: 39301713 DOI: 10.1002/micr.31241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 08/03/2024] [Accepted: 09/05/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Adequate vascular anatomy and perfusion status are essential for successful lower extremity free tissue transfer. Computed tomography angiography (CTA) is widely available, minimally invasive, and enables visualization of soft tissues and bones. Angiography permits temporal evaluation of flow, identifies potential needs for concurrent endovascular interventions, and enhances visibility in the setting of hardware. Despite widespread availability of these imaging modalities, no standardized algorithm for preoperative imaging prior to lower extremity free flap reconstruction exists. METHODS Current Procedural Terminology (CPT) codes identified patients undergoing free flap reconstruction of the lower extremity over an 18-year period (2002-2020). Electronic medical records were reviewed for patient, treatment, and imaging characteristics, and pre- and post-imaging laboratory values. Outcomes included imaging findings and related complications and surgical outcomes. RESULTS In total, 405 patients were identified, with 59% (n = 238) undergoing preoperative imaging with angiography, 10% (n = 42) with CTA, 7.2% (n = 29) with both imaging modalities, and 24% (n = 96) with neither performed. Forty percent (122 of 309) of patients who underwent preoperative imaging had less than 3-vessel runoff. Four patients developed contrast-induced nephropathy (CIN) after angiography only and one after having both CTA and angiography. Vessel runoff on CTA and angiography demonstrated moderate correlation. CONCLUSION Most patients undergoing lower extremity free tissue transfer underwent preoperative imaging with angiography and/or CTA, 40% of which had less than 3-vessel runoff. Both angiography and CTA had low complication rates, with no statistically significant risk factors identified. Specifically, the incidence of CIN was not found to be significant using either modality. We discuss our institutional algorithm to aid in decision-making for preoperative imaging prior to lower extremity free flap reconstruction. Specifically, we recommend angiography for patients with peripheral vascular disease, internal hardware, or distal defects secondary to trauma.
Collapse
Affiliation(s)
- Leah Ahn
- Beth Israel Deaconess Medical Center Radiology Residency Training Program, Harvard Medical School, Boston, Massachusetts, USA
| | - Joani M Christensen
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Seth Fruge
- Harvard Plastic Surgery Residency Training Program, Harvard Medical School, Boston, Massachusetts, USA
| | - Mara Z Meulendijks
- Hand and Arm Center, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Yannick Albert J Hoftiezer
- Department of Plastic, Reconstructive, and Hand Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Frankie K Wong
- Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering, New York, New York, USA
| | - Krystle R Tuano
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ian L Valerio
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kyle R Eberlin
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Tian Q, Zhu S, Cheng Y, Li J, Qu T, Jia X, Cao L, Chen L, Guo J. Improving image quality consistency and diagnostic accuracy in lower extremity CT angiography using a split-bolus contrast injection protocol. Br J Radiol 2024; 97:838-843. [PMID: 38379411 PMCID: PMC11027256 DOI: 10.1093/bjr/tqae036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 09/04/2023] [Accepted: 02/07/2024] [Indexed: 02/22/2024] Open
Abstract
OBJECTIVES To evaluate the clinical value of using a split-bolus contrast injection protocol in improving image quality consistency and diagnostic accuracy in lower extremity CT angiography (CTA). METHODS Fifty (mean age, 66 ± 12 years) and 39 (mean age, 66 ± 11 years) patients underwent CTA in the lower extremity arteries using split-bolus and fixed-bolus injection schemes, respectively. The objective and subjective image quality of the 2 groups were compared and the diagnostic efficacy for the degree of vessel stenosis was compared using digital subtraction angiography as the gold standard. A P < .05 was considered statistically significant. RESULTS In comparison with the fixed-bolus scheme, the split-bolus scheme greatly improved the consistency of image quality of the low extremities by significantly increasing the arterial enhancement (337.87 ± 64.67HU vs. 254.74 ± 71.58HU, P < .001), signal-to-noise ratio (22.58 ± 11.64 vs. 7.14 ± 1.98, P < .001), and contrast-to-noise ratio (37.21 ± 10.46 vs. 31.10 ± 15.40, P = .041) in the infrapopliteal segment. The subjective image quality was better (P < .001) and the diagnostic accuracy was higher in the split-bolus group than in the fixed-bolus group (96.00% vs. 91.67%, P < .05, for diagnosing >50% stenosis, and 97.00% vs. 89.10%, P < .05, for diagnosing occlusion) for the infrapopliteal segment arteries. CONCLUSIONS Compared with the fixed-bolus injection scheme, the split-bolus injection scheme improves the image quality consistency and diagnostic accuracy especially for the infrapopliteal segment arteries in lower extremity CTA. ADVANCES IN KNOWLEDGE (1) The split-bolus injection scheme of CTA of the lower extremity arteries improves the overall image quality, uniformity of contrast enhancement. (2) Compared with the fixed-bolus injection scheme, the split-bolus injection scheme especially improves the infrapopliteal segment arteries image quality and diagnostic efficacy.
Collapse
Affiliation(s)
- Qian Tian
- Department of Radiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, China
| | - Shumeng Zhu
- Department of Radiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, China
| | - Yannan Cheng
- Department of Radiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, China
| | - Jianying Li
- GE Healthcare, Computed Tomography Research Center, Beijing 100176, China
| | - Tingting Qu
- Department of Radiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, China
| | - Xiaoqian Jia
- Department of Radiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, China
| | - Le Cao
- Department of Radiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, China
| | - Lihong Chen
- Department of Radiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, China
| | - Jianxin Guo
- Department of Radiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an 710061, China
| |
Collapse
|
3
|
Zhang D, Zhou X, Zhang H, Fan X, Lin Z, Xue H, Wang Y, Jin Z, Chen Y. Quick evaluation of lower leg ischemia in patients with peripheral arterial disease by time maximum intensity projection CT angiography: a pilot study. BMC Med Imaging 2021; 21:7. [PMID: 33407186 PMCID: PMC7789570 DOI: 10.1186/s12880-020-00537-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 12/13/2020] [Indexed: 01/05/2023] Open
Abstract
Background The purpose of this study is to evaluate a new method involving time maximum intensity projection (t-MIP) postprocessed from dynamic computed tomographic angiography (dyn-CTA) in diagnosing peripheral arterial disease (PAD). Methods A population of 34 patients with known PAD was examined with a combined CTA protocol consisting of a standard CTA (s-CTA) scan of the lower extremities and a dyn-CTA scan of the calves. For each lower leg, t-MIP images consisting of the MIP0 (sagittal MIP), MIP+θ (45° lateral MIP), and MIP−θ (− 45° lateral MIP) were automatically generated from dyn-CTA. An objective evaluation of the vascular CT attenuation of the best enhancement phase of dyn-CTA and t-MIP was measured; a subjective evaluation of vessel stenosis and occlusion was performed, assigning a score for t-MIP and s-CTA. The CT attenuation of t-MIP and dyn-CTA was compared, as were the runoff scores of t-MIP and s-CTA. Results The CT attenuation of t-MIP CTA of three vascular segments from 68 lower extremities was higher than that of the best enhancement phase of dyn-CTA and s-CTA, with statistically significant differences at the posterior tibial artery and fibular artery (all p < 0.05). There were strong correlations (r ≥ 0.75, p < 0.05) of the runoff scores between t-MIP and s-CTA. Conclusions There is potential clinical applicability of t-MIP in assisting with the diagnosis of lower leg vascular stenosis in dyn-CTA with reliable diagnostic accuracy and convenient immediacy.
Collapse
Affiliation(s)
- Daming Zhang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xueyan Zhou
- School of Technology, Harbin University, Harbin, China
| | - Haiping Zhang
- Department of Radiology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Xiaobing Fan
- Department of Radiology, The University of Chicago, Chicago, IL, 60637, USA
| | - Zehong Lin
- School of Technology, Harbin University, Harbin, China
| | - Huadan Xue
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yining Wang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhengyu Jin
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Yuexin Chen
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| |
Collapse
|
4
|
Rotzinger DC, Lu TL, Kawkabani A, Marques-Vidal PM, Fetz G, Qanadli SD. Computed Tomography Angiography in Peripheral Arterial Disease: Comparison of Three Image Acquisition Techniques to Optimize Vascular Enhancement-Randomized Controlled Trial. Front Cardiovasc Med 2020; 7:68. [PMID: 32411728 PMCID: PMC7198850 DOI: 10.3389/fcvm.2020.00068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 04/07/2020] [Indexed: 12/27/2022] Open
Abstract
Objectives: To prospectively compare three image acquisition techniques in lower extremity CT angiography: the “standard” anterograde technique (SA), the adaptive anterograde technique (AA), and the retrograde acquisition technique (RA). Materials and Methods: Sixty consecutive patients were prospectively enrolled and randomized into three acquisition groups: 20 patients were evaluated with SA, 20 with AA as described by Qanadli et al., and 20 with caudocranial acquisition from the feet to the abdominal aorta (RA). Quantitative image quality was assessed by measuring the intraluminal attenuation at different levels of interest, with a total of 536 levels. Qualitative image quality was assessed by two radiologists in consensus using a Likert scale to rate the arterial enhancement and venous return. For each patient and limb, the presence of occlusive or aneurysmal disease was documented. Results: In quantitative analysis, RA showed lower attenuation values than SA and AA (p < 0.01). AA showed the highest and most homogeneous attenuation along the arterial tree. In qualitative analysis, AA had the lowest rate of non-diagnostic vascular segments (3.9%) compared to SA and RA (4.7 and 13.1%, respectively, p < 0.01). The influence of venous return was significantly different among the different techniques; venous contamination was particularly prevalent at the aortic level with RA (9.4% of patients, 0% with SA and AA, p < 0.01). The presence of stenosis or occlusion had no significant influence on the attenuation values across all levels and acquisition techniques. Conversely, the presence of aneurysmal disease had a significant effect on the luminal attenuation in AA (higher attenuation) and RA (lower attenuation) at the iliac (p = 0.03 and 0.04, respectively) and femoral levels (p = 0.02 and <0.01, respectively). Conclusion: Considering both quantitative and qualitative analysis, AA performed better than SA and RA, providing the highest percentage of optimal vascular enhancement. AA should be recommended as the technique of choice, specifically in the presence of aneurysmal disease. Alternatively, SA can be useful in case of renal failure, as the test bolus is unnecessary. Finally, the increasing availability of fast CT systems will likely overcome the limitations of RA.
Collapse
Affiliation(s)
- David C Rotzinger
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Tri-Linh Lu
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Aida Kawkabani
- Groupement Hospitalier de L'Ouest Lémanique, Nyon, Switzerland
| | - Pedro-Manuel Marques-Vidal
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland.,Department of Internal Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Salah D Qanadli
- Cardiothoracic and Vascular Division, Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Lausanne, Switzerland.,Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| |
Collapse
|
5
|
Park JW, Lee JH. Prevalence and Risk Factors of Peripheral Arterial Disease in Patients with Lumbar Spinal Stenosis and Intermittent Claudication: CT Angiography Study. J Korean Med Sci 2020; 35:e87. [PMID: 32242344 PMCID: PMC7131903 DOI: 10.3346/jkms.2020.35.e87] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 02/05/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND It can be difficult to differentiate between vascular and neurogenic intermittent claudication. The exact diagnosis often cannot be made on clinical evidence and ultimately requires imaging. Perioperative screening for peripheral arterial disease (PAD) in lumbar spinal stenosis (LSS) patients is important because untreated PAD increases the risk of severe vascular events. The aims of this study were to study the prevalence of PAD in LSS patients with symptoms of intermittent claudication, and to study the independent risk factors for PAD. We specified the cases where it was necessary to perform computed tomography angiography (CTA) as a preoperative screening tool in surgery for spinal stenosis. METHODS This study involved a retrospective analysis of 186 consecutive subjects with radiographic evidence of LSS and symptoms of intermittent claudication, who underwent 3D CTA of the lower extremities at our institution during a three-year period. More than 50% luminal narrowing on CT angiograms was determined to be clinically significant and placed in the PAD group. RESULTS Thirty-two subjects were diagnosed with PAD and referred to the general vascular team in our hospital, where they received treatment for PAD. In the non-PAD group (154 subjects), 117 underwent definitive surgery for spinal stenosis such as posterior lumbar interbody fusion and a further 37 underwent conservative treatment. Only hypertension, diabetes, and men gender were found to be statistically significant predictors of PAD. CONCLUSION The current study showed that man gender, diabetes and hypertension were the greatest risk factors for PAD. We conclude that man patients with diabetes and/or hypertension should be put under serious consideration for routine CTA examination when under evaluation for LSS and intermittent claudication.
Collapse
Affiliation(s)
- Jin Woo Park
- Department of Orthopedic Surgery, Kangwon National University Hospital, Chuncheon, Korea
| | - Ji Ho Lee
- Department of Orthopedic Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea.
| |
Collapse
|
6
|
Quantitative Analysis of Lower Leg Muscle Enhancement Measured From Dynamic Computed Tomographic Angiography for Diagnosis of Peripheral Arterial Occlusive Disease. J Comput Assist Tomogr 2020; 44:20-25. [PMID: 31939877 DOI: 10.1097/rct.0000000000000971] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate whether quantitative analysis of lower leg muscle enhancement measured from dynamic computed tomographic angiography (dyn-CTA) could be used for diagnosis of peripheral arterial occlusive disease. METHODS Patients (N = 35) with known peripheral arterial occlusive disease underwent the dyn-CTA of calves first. Five minutes later, standard CTA of the peripheral runoff from the diaphragm to the toes was performed. A runoff score was assigned by radiologists as a reference standard for each of 4 lower leg artery segments. The lower leg muscle enhancement measured from the dyn-CTA was analyzed by using quantitative kinetic parameters, including initial enhancement (E1), peak enhancement (Epeak), and enhancement ratio (ER) calculated from average time attenuation curves. In addition, histogram of lower leg muscle enhancement was evaluated by using the first enhanced phase images. RESULTS Lower extremities were diagnosed as a normal group (n = 22) with each vessel segment score equals to 1 or lower and runoff score, 7 or lower, and otherwise as an ischemia group (n = 48). Average ± SD E1 is 91.4% ± 8.5% and 82.3% ± 10.7%, Epeak is 122.7% ± 10.4% and 115.6% ± 11.1%, and ER is 0.75 ± 0.05 and 0.72 ± 0.09 for normal and ischemia group, respectively. Statistical analysis showed that average E1 and Epeak for the ischemia group were significantly lower (P < 0.05) than the normal group. The histogram analysis demonstrated that mean and median of muscle enhancement in the ischemia group were significantly smaller (P < 0.05), and coefficient of variation (CV) was significantly larger (P < 0.05) than the normal group. There were weak negative correlations (r = -0.42, P < 0.05) between runoff scores and E1 and Epeak, and weak positive correlation (r = 0.40, P < 0.05) between runoff scores and CV. The receiver operating characteristics analysis between the 2 groups had area under the curve of 0.77 and 0.76 for E1 and CV, respectively. CONCLUSIONS Lower leg muscle enhancement measured from the dyn-CTA could be assessed quantitatively to assist diagnosis of ischemia in clinical practice.
Collapse
|
7
|
Donohue CM, Adler JV, Bolton LL. Peripheral arterial disease screening and diagnostic practice: A scoping review. Int Wound J 2019; 17:32-44. [PMID: 31680419 DOI: 10.1111/iwj.13223] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 08/18/2019] [Indexed: 11/28/2022] Open
Abstract
Early reliable, valid screening, diagnosis, and treatment improve peripheral arterial disease outcomes, yet screening and diagnostic practices vary across settings and specialties. A scoping literature review described reliability and validity of peripheral ischaemia diagnosis or screening tools. Clinical studies in the PUBMED database January 1, 1970, to August 13, 2018, were reviewed summarising ranges of reliability and validity of peripheral ischaemia diagnostic and screening tools for patients with non-neuropathic lower leg ischaemia. Peripheral ischaemia screening and diagnostic practices varied in parameters measured such as timing, frequency, setting, ordering clinicians, degree of invasiveness, costs, definitions, and cut-off points informing clinical and referral decisions. Traditional ankle/brachial systolic blood pressure index <0.9 was a reliable, valid lower leg ischaemia screening test to trigger specialist referral for detailed diagnosis. For patients with advanced peripheral ischaemia or calcified arteries, toe-brachial index, claudication, or invasive angiographic imaging techniques that can have complications were reliable, valid screening, and diagnostic tools to inform management decisions. Ankle/brachial index testing is sufficiently reliable and valid for use during routine examinations to improve timing and consistency of peripheral ischaemia screening, triggering prompt specialist referral for more reliable, accurate Doppler, or other diagnosis to inform treatment decisions.
Collapse
Affiliation(s)
- Cornelius M Donohue
- Wound Healing and Limb Preservation Center of Philadelphia LLC, Ardmore, Pennsylvania
| | - Joseph V Adler
- Department of Occupational and Physical Therapy, Good Shepherd Penn Partners at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura L Bolton
- Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| |
Collapse
|
8
|
Buls N, de Brucker Y, Aerden D, Devos H, Van Gompel G, Boonen PT, Nieboer K, Leiner T, de Mey J. Improving the diagnosis of peripheral arterial disease in below-the-knee arteries by adding time-resolved CT scan series to conventional run-off CT angiography. First experience with a 256-slice CT scanner. Eur J Radiol 2019; 110:136-141. [PMID: 30599850 DOI: 10.1016/j.ejrad.2018.11.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 11/24/2018] [Indexed: 01/20/2023]
Abstract
PURPOSE Run-off Computed Tomography Angiography (run-off CTA) of the lower extremities has become the method of choice for the diagnostic imaging of patients suffering from peripheral arterial disease (PAD). However, it remains a challenging radiological examination with a considerable risk of non-diagnostic image quality for the assessment of below-the-knee arteries. In this study, we investigate the diagnostic benefit of adding time-resolved CT scan series to the standard run-off CTA by performing repeated axial acquisitions over the calves of the patient during a second bolus of iodinated contrast injection. MATERIALS AND METHODS This prospective study included 20 patients (9 male, 11 female; mean age 66.1 ± 14.9 years) who received a standard run-off CTA and an additional time-resolved CT scan series after a 10 min delay. The time-resolved series consisted of 18 repeated axial acquisitions over the calves directly below the knee with a 2 s interphase delay. For both series, two observers independently assessed the anterior tibial, posterior tibial and peroneal arteries of both legs for following criteria: arterial enhancement, presence and degree of stenosis, the confidence of grading, degree of stenosis and venous overlay. Quantitative assessment of arterial enhancement was performed by measuring the mean CT values (HU) in all arteries. Radiation exposure was quantified by the effective dose. RESULTS A total of 118 arteries were assessed. The observer study showed that the additional time-resolved series improved both arterial enhancement (64% considered optimal enhanced versus 44%) and diagnostic confidence (59% considered as certain versus 33%) for the assessment of arterial stenosis (all p < 0.05). Venous overlay reduced from 15% to 6%. In all three arteries, the measured contrast enhancement by CT values (HU) was considerably higher (average 48%, p < 0.05) with the time-resolved series. The time-resolved series had an effect on stenosis classification (p = 0.03): a higher number of arteries were graded as having a non-significant stenosis (78.8% versus 71.2%). The interobserver variability in stenosis classification improved from κ = 0.39 to κ = 0.61. The mean effective dose was 5.1 ± 1.3 mSv for the run-off CTA and 0.2 ± 0.07 mSv for the time-resolved series. Per patient, a total volume of 140 mL contrast agent was injected. CONCLUSION A dynamic CT scan protocol with repeated axial series can be added to a standard helical run-off CTA sequence for the lower extremities within the same CT examination, and it increases image quality and diagnostic confidence for the assessment of presence and degree of arterial stenosis in below-the-knee arteries.
Collapse
Affiliation(s)
- Nico Buls
- Department of Radiology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - Yannick de Brucker
- Department of Radiology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - Dimitri Aerden
- Department of Vascular Surgery, Centre for Cardiovascular Diseases, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - Hannes Devos
- Department of Radiology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - Gert Van Gompel
- Department of Radiology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - Pieter Thomas Boonen
- Department of Radiology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - Koenraad Nieboer
- Department of Radiology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - Tim Leiner
- Department of Radiology, University Medical Center Utrecht, Utrecht University, P. O. Box 85500, 3508 GA Utrecht, The Netherlands.
| | - Johan de Mey
- Department of Radiology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Laarbeeklaan 101, 1090 Brussels, Belgium.
| |
Collapse
|
9
|
Wallace A, Pershad Y, Saini A, Alzubaidi S, Naidu S, Knuttinen G, Oklu R. Computed tomography angiography evaluation of acute limb ischemia. VASA 2018; 48:57-64. [PMID: 30376423 DOI: 10.1024/0301-1526/a000759] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Acute limb ischemia (ALI), a subclass of critical limb ischemia, is a medical emergency. The cause of ALI is usually thrombotic or embolic in nature, and the specific etiology often dictates the appropriate therapy. While the diagnosis is a clinical with common presenting symptoms, advances in ultrasound, computed tomography, and magnetic resonance technology have impacted the diagnosis and subsequent therapy. In ALI, the time to revascularization is critical and computed tomography angiography (CTA) provides a highly sensitive and specific technique for rapidly identifying occlusions and precisely defining vascular anatomy prior to interventions. In patients with significant renal disease, magnetic resonance angiography with or without contrast provides effective alternatives at the expense of imaging time. Treatment can include a variety of endovascular or surgical interventions, including thromboembolectomy, angioplasty, or bypass. Proper evaluation of the etiology of the ischemia, affected vasculature, and medical history is critical to select appropriate treatment and improve patient outcomes. Here, we examine the presentation, evaluation, and treatment of ALI and the role of CTA in diagnosis and therapy.
Collapse
|
10
|
Roy TL, Forbes TL, Dueck AD, Wright GA. MRI for peripheral artery disease: Introductory physics for vascular physicians. Vasc Med 2018. [DOI: 10.1177/1358863x18759826] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Magnetic resonance imaging (MRI) has advanced significantly in the past decade and provides a safe and non-invasive method of evaluating peripheral artery disease (PAD), with and without using exogenous contrast agents. MRI offers a promising alternative for imaging patients but the complexity of MRI can make it less accessible for physicians to understand or use. This article provides a brief introduction to the technical principles of MRI for physicians who manage PAD patients. We discuss the basic principles of how MRI works and tailor the discussion to how MRI can evaluate anatomic characteristics of peripheral arterial lesions.
Collapse
Affiliation(s)
- Trisha L Roy
- Division of Vascular Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Schulich Heart Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Thomas L Forbes
- Division of Vascular Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Andrew D Dueck
- Division of Vascular Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Schulich Heart Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
| | - Graham A Wright
- Schulich Heart Research Program, Sunnybrook Research Institute, Toronto, ON, Canada
- Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
11
|
Roy TL, Chen HJ, Dueck AD, Wright GA. Magnetic resonance imaging characteristics of lesions relate to the difficulty of peripheral arterial endovascular procedures. J Vasc Surg 2017; 67:1844-1854.e2. [PMID: 29248239 DOI: 10.1016/j.jvs.2017.09.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Accepted: 09/21/2017] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Limitations with current peripheral arterial imaging modalities make selection of patients for percutaneous vascular interventions difficult. The purpose of this study was to determine whether a novel preprocedural magnetic resonance imaging (MRI) method can identify lesions that would be more challenging to cross during percutaneous vascular intervention. METHODS Fourteen patients with peripheral arterial disease underwent MRI before their intervention. A novel steady-state free precession flow-independent magnetic resonance (MR) angiogram was used to locate lesions, and an ultrashort echo time image was used to characterize hard lesion components including calcium and dense collagen. Lesions were characterized as hard if ≥50% of the lumen was occluded with calcium or collagen (as determined by MR image characteristics) in the hardest cross section within the lesion. The primary outcome was the time it took to cross a guidewire through the target lesion. The secondary outcome was the need for stenting. RESULTS Of 14 lesions, 8 (57%) were defined as hard and 6 (43%) were soft on the basis of MR image characteristics. Hard lesions took significantly longer to cross than soft lesions (average, 14 minutes 49 seconds vs 2 minutes 17 seconds; P = .003). Hard lesions also required stenting more often than soft lesions (Fisher exact test, P = .008). Of 14 lesions, 2 (14%) could not be crossed with a guidewire, and both lesions were hard. MR images also detected occult patencies and noncalcified hard lesions that could not be seen on X-ray angiography. CONCLUSIONS MRI can be used to determine which peripheral arterial lesions are more difficult to cross with a guidewire. Future work will determine whether MRI lesion characterization can predict long-term endovascular outcomes to aid in procedure planning.
Collapse
Affiliation(s)
- Trisha L Roy
- Schulich Heart Program and the Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of Vascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
| | - Hou-Jen Chen
- Schulich Heart Program and the Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| | - Andrew D Dueck
- Schulich Heart Program and the Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Division of Vascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Graham A Wright
- Schulich Heart Program and the Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medical Biophysics, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
12
|
Multidetector (64+) Computed Tomography Angiography of the Lower Limb in Symptomatic Peripheral Arterial Disease. J Comput Assist Tomogr 2017; 41:327-333. [DOI: 10.1097/rct.0000000000000494] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
13
|
Optimized Protocol for Fast CT Angiography of Lower Limbs Using 160-Row Detector. J Comput Assist Tomogr 2016; 40:953-957. [PMID: 27560013 DOI: 10.1097/rct.0000000000000459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We proposed and tested a novel acquisition protocol for optimizing a fast computed tomography angiography using a 160-row detector scanner using a longer contrast injection time coupled with multiphasic rate of injection. METHODS A prospective randomized study was performed to compare image quality, contrast enhancement, and radiation dose in 2 groups (a fast acquisition and a widely accepted slow acquisition). RESULTS There was no difference between groups regarding image quality, noise, and diagnostic performance, but we evidenced a trend to higher radiation dose for the fast acquisition protocol. CONCLUSIONS An optimized protocol for performing a fast acquisition computed tomography angiography of lower limbs is feasible, has sufficient diagnostic quality, and can be used in selected patients who would benefit from a short-time scan.
Collapse
|
14
|
Preuß A, Schaafs LA, Werncke T, Steffen IG, Hamm B, Elgeti T. Run-Off Computed Tomography Angiography (CTA) for Discriminating the Underlying Causes of Intermittent Claudication. PLoS One 2016; 11:e0152780. [PMID: 27054846 PMCID: PMC4824428 DOI: 10.1371/journal.pone.0152780] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 03/19/2016] [Indexed: 12/21/2022] Open
Abstract
AIM To evaluate run-off computed tomography angiography (CTA) of abdominal aorta and lower extremities for detecting musculoskeletal pathologies and clinically relevant extravascular incidental findings in patients with intermittent claudication (IC) and suspected peripheral arterial disease (PAD). Does run-off CTA allow image-based therapeutic decision making by discriminating the causes of intermittent claudication in patients with suspected peripheral arterial disease PAD? MATERIAL AND METHODS Retrospective re-evaluation of CTAs performed in patients with acute or chronic intermittent claudication (i.e., Fontaine stages I to IIB) between January 2005 and October 2013. Allocation to one of three categories of underlying causes of IC symptoms: vascular, musculoskeletal (MSK) or both. Clinically relevant extravascular incidental findings were evaluated. Medical records were reviewed to verify specific therapies as well as main and incidental findings. RESULTS While focused on vascular imaging, CTA image quality was sufficient for evaluation of the MSK system in all cases. The underlying cause of IC was diagnosed in run-off CTA as vascular, MSK and a combination in n = 138 (65%), n = 10 (4%), and n = 66 (31%) cases, respectively. Specific vascular or MSK therapy was recorded in n = 123 and n = 9 cases. In n = 82, no follow-up was possible. Clinically relevant extravascular incidental findings were detected in n = 65 patients (30%) with neoplasia, ascites and pleural effusion being the most common findings. DISCUSSION Run-off CTA allows identification of vascular, MSK, and combined causes of IC in patients with suspected PAD and can guide specific therapy. CTA also allowed confident detection of crEVIF although detection did not necessarily trigger workup or treatment.
Collapse
Affiliation(s)
- Alexandra Preuß
- Department of Radiology, Charité-Universitätsmedizin, Berlin, Germany
| | - Lars-Arne Schaafs
- Department of Radiology, Charité-Universitätsmedizin, Berlin, Germany
| | - Thomas Werncke
- Institute for Radiology, Medizinische Hochschule Hannover, Hannover, Germany
| | - Ingo G. Steffen
- Department of Radiology, Charité-Universitätsmedizin, Berlin, Germany
| | - Bernd Hamm
- Department of Radiology, Charité-Universitätsmedizin, Berlin, Germany
| | - Thomas Elgeti
- Department of Radiology, Charité-Universitätsmedizin, Berlin, Germany
| |
Collapse
|