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Arnold J, Koyfman A, Long B. High risk and low prevalence diseases: Acute limb ischemia. Am J Emerg Med 2023; 74:152-158. [PMID: 37844359 DOI: 10.1016/j.ajem.2023.09.052] [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: 06/05/2023] [Revised: 08/26/2023] [Accepted: 09/29/2023] [Indexed: 10/18/2023] Open
Abstract
INTRODUCTION Acute limb ischemia is a rare but serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of acute limb ischemia, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Acute limb ischemia is defined as a sudden decrease in limb perfusion resulting in cessation of blood flow and nutrient and oxygen delivery to the tissues. This leads to cellular injury and necrosis, ultimately resulting in limb loss and potentially systemic symptoms with significant morbidity and mortality. There are several etiologies including native arterial thrombosis, arterial thrombosis after an intervention, arterial embolus, and arterial injury. Patients with acute limb ischemia most commonly present with severe pain and sensory changes in the initial stages, with prolonged ischemia resulting in weakness, sensory loss, and color changes to the affected limb. The emergency clinician should consult the vascular specialist as soon as ischemia is suspected, as the diagnosis should be based on the history and examination. Computed tomography angiography is the first line imaging modality, as it provides valuable information concerning the vasculature and surrounding tissues. Doppler ultrasound of the distal pulses may also be obtained to evaluate for arterial and venous flow. Once identified, management includes intravenous unfractionated heparin and vascular specialist consultation for revascularization. CONCLUSIONS An understanding of acute limb ischemia can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Jacob Arnold
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Won JH. [General Treatment Strategy for Intervention in Lower Extremity Arterial Disease]. TAEHAN YONGSANG UIHAKHOE CHI 2021; 82:500-511. [PMID: 36238791 PMCID: PMC9432442 DOI: 10.3348/jksr.2021.0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/09/2021] [Accepted: 04/17/2021] [Indexed: 11/19/2022]
Abstract
The prevalence of lower extremity disease is increasing with age. With recent technological advancements, endovascular treatment is being performed more frequently. The treatment goal of intermittent claudication is to improve walking and reduce claudication. To achieve these goals, anatomical durability and patency are important. In patients with critical limb ischemia, the lesions are diffuse and particularly severe in below-the-knee arteries. The treatment goal of critical limb ischemia is to promote wound healing and to prevent major amputation, which is evaluated by the limb salvage rate. Primary stenting using covered or bare metal stents is a widely accepted endovascular treatment. While drug-eluting technologies with or without atherectomy are widely used in the treatment of femoropopliteal disease, balloon angioplasty is the mainstay treatment for below-the-knee intervention. CT angiography provides a road map for planning endovascular treatment in patients without absolute contraindications.
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Itoga NK, Ho VT, Tran K, Chandra V, Dalman RL, Harris EJ, Lee JT, Mell MW. Preprocedural Cross-Sectional Imaging Prior to Percutaneous Peripheral Arterial Disease Interventions. Vasc Endovascular Surg 2020; 54:97-101. [PMID: 31746279 PMCID: PMC8241426 DOI: 10.1177/1538574419887585] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Preprocedural cross-sectional imaging (PCSI) for peripheral artery disease (PAD) may vary due to patient complexity, anatomical disease burden, and physician preference. The objective of this study was to determine the utility of PCSI prior to percutaneous vascular interventions (PVIs) for PAD. Patients receiving first time lower extremity angiograms from 2013 to 2015 at a single institution were evaluated for PCSI performed within 180 days, defined as computed tomography angiography (CTA) or magnetic resonance angiography (MRA) evaluating abdominal to pedal vasculature. The primary outcome was technical success defined as improving the target outflow vessels to <30% stenosis. Of the 346 patients who underwent lower extremity angiograms, 158 (45.7%) patients had PCSI, including 150 patients had CTA and 8 patients had MRA. Of these, 48% were ordered by the referring provider (84% at an outside institution). Preprocedural cross-sectional imaging was performed at a median of 26 days (interquartile range: 9-53) prior to the procedure. The analysis of the institution's 5 vascular surgeons identified PCSI rates ranging from 31% to 70%. On multivariate analysis, chronic kidney disease (odds ratio [OR] = 0.35; 95% confidence interval [CI]: 0.17-0.73) was associated with less PSCI usage, and inpatient/emergency department evaluation (OR = 3.20; 95% CI: 1.58-6.50) and aortoiliac disease (OR = 2.78; 95% CI: 1.46-5.29) were associated with higher usage. After excluding 31 diagnostic procedures, technical success was not statistically significant with PSCI (91.3%) compared to without PCSI (85.6%), P = .11. When analyzing 89 femoral-popliteal occlusions, technical success was higher with PCSI (88%) compared to procedures without (69%) P = .026. Our analysis demonstrates that routine ordering of PCSI may not be warranted when considering technical success of PVI; however, PCSI may be helpful in treatment planning. Further studies are needed to confirm these findings in another practice setting, with more prescriptive use of PCSI to improve procedural success, and thereby improve the value of PCSI.
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Affiliation(s)
- Nathan K. Itoga
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Vy T. Ho
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Kenneth Tran
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Venita Chandra
- Department of Surgery, Stanford University, Stanford, CA, USA
| | | | | | - Jason T. Lee
- Department of Surgery, Stanford University, Stanford, CA, USA
| | - Matthew W. Mell
- Department of Surgery, University of California at Davis, Sacramento, CA, USA
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Muela Méndez M, Morata Barrado PC, Blanco Cañibano E, García Fresnillo B, Guerra Requena M. Preoperative mapping of the aortoiliac territory with duplex ultrasound in patients with peripheral arterial occlusive disease. J Vasc Surg 2018; 68:503-509. [DOI: 10.1016/j.jvs.2017.11.082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 11/10/2017] [Indexed: 11/28/2022]
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Multipath Curved Planar Reformations of Peripheral CT Angiography: Diagnostic Accuracy and Time Efficiency. Cardiovasc Intervent Radiol 2017; 41:718-725. [PMID: 29218656 PMCID: PMC5876266 DOI: 10.1007/s00270-017-1846-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Accepted: 11/13/2017] [Indexed: 11/27/2022]
Abstract
Objectives To compare diagnostic performance and time efficiency between 3D multipath curved planar reformations (mpCPRs) and axial images of CT angiography for the pre-interventional assessment of peripheral arterial disease (PAD), with digital subtraction angiography as the standard of reference. Methods Forty patients (10 females, mean age 72 years), referred to CTA prior to endovascular treatment of PAD, were prospectively included and underwent peripheral CT angiography. A semiautomated toolbox was used to render mpCPRs. Twenty-one arterial segments were defined in each leg; for each segment, the presence of stenosis > 70% was assessed on mpCPRs and axial images by two readers, independently, with digital subtraction angiography as gold standard. Results Both readers reached lower sensitivity (Reader 1: 91 vs. 94%, p = 0.08; Reader 2: 89 vs. 93%, p = 0.03) but significantly higher specificity (Reader 1: 94 vs. 89%, p < 0.01; Reader 2: 96 vs. 95%, p = 0.01) with mpCPRs than with axial images. Reader 1 achieved significantly higher accuracy with mpCPRs (93 vs. 91%, p = 0.02), and Reader 2 had similar overall accuracy in both evaluations (94 vs. 94%, p = 0.96). Both readers read mpCPRs significantly faster than axial images (Reader 1: 5′45″ based on mpCPRs vs. 7′40″ based on axial images; Reader 2: 4′41″ based on mpCPRs vs. 6′57″ based on axial images; p < 0.01). Conclusions mpCPRs are a promising 3D reformation technique that facilitates a fast assessment of PAD with high diagnostic accuracy. Electronic supplementary material The online version of this article (10.1007/s00270-017-1846-3) contains supplementary material, which is available to authorized users.
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Schreiner MM, Platzgummer H, Unterhumer S, Weber M, Mistelbauer G, Loewe C, Schernthaner RE. A BMI-adjusted ultra-low-dose CT angiography protocol for the peripheral arteries—Image quality, diagnostic accuracy and radiation exposure. Eur J Radiol 2017; 93:149-156. [DOI: 10.1016/j.ejrad.2017.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 05/13/2017] [Accepted: 06/01/2017] [Indexed: 11/30/2022]
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Itoga NK, Kim T, Sailer AM, Fleischmann D, Mell MW. Lower extremity computed tomography angiography can help predict technical success of endovascular revascularization in the superficial femoral and popliteal artery. J Vasc Surg 2017; 66:835-843.e1. [PMID: 28502550 DOI: 10.1016/j.jvs.2017.02.031] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/01/2017] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Preprocedural computed tomography angiography (CTA) assists in evaluating vascular morphology and disease distribution and in treatment planning for patients with lower extremity peripheral artery disease (PAD). The aim of the study was to determine the predictive value of radiographic findings on CTA and technical success of endovascular revascularization of occlusions in the superficial femoral artery-popliteal (SFA-pop) region. METHODS Medical records and available imaging studies were reviewed for patients undergoing endovascular intervention for PAD between January 2013 and December 2015 at a single academic institution. Radiologists reviewed preoperative CTA scans of patients with occlusions in the SFA-pop region. Radiographic criteria previously used to evaluate chronic occlusions in the coronary arteries were used. Technical success, defined as restoration of inline flow through the SFA-pop region with <30% stenosis at the end of the procedure, and intraoperative details were evaluated. RESULTS From 2013 to 2015, there were 407 patients who underwent 540 endovascular procedures for PAD. Preprocedural CTA scans were performed in 217 patients (53.3%), and 84 occlusions in the SFA-pop region were diagnosed. Ten occlusions were excluded as no endovascular attempt to cross the lesion was made because of extensive disease or concomitant iliac intervention. Of the remaining 74 occlusions in the SFA-pop region, 59 were successfully treated (80%) and 15 were unsuccessfully crossed (20%). The indications for revascularization were claudication in 57% of patients and critical limb ischemia in the remaining patients. TransAtlantic Inter-Society Consensus A, B, and C occlusions were treated with 87% success, whereas D occlusions were treated with 68% success (P = .047). There were nine occlusions with 100% vessel calcification that was associated with technical failure (P = .014). Longer lengths of occlusion were also associated with technical failure (P = .042). Multiple occlusions (P = .55), negative remodeling (P = .69), vessel runoff (P = .56), and percentage of vessel calcification (P = .059) were not associated with failure. On multivariable analysis, 100% calcification remained the only significant predictor of technical failure (odds ratio, 9.0; 95% confidence interval, 1.8-45.8; P = .008). CONCLUSIONS Analysis of preoperative CTA shows 100% calcification as the best predictor of technical failure of endovascular revascularization of occlusions in the SFA-pop region. Further studies are needed to determine the cost-effectiveness of obtaining preoperative CTA for lower extremity PAD.
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Affiliation(s)
- Nathan K Itoga
- Division of Vascular Surgery, Stanford University, Stanford, Calif.
| | - Tanner Kim
- Division of Vascular Surgery, Stanford University, Stanford, Calif
| | - Anna M Sailer
- Cardiovascular Imaging, Stanford University, Stanford, Calif
| | | | - Matthew W Mell
- Division of Vascular Surgery, Stanford University, Stanford, Calif
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ACR Appropriateness Criteria ® Sudden Onset of Cold, Painful Leg. J Am Coll Radiol 2017; 14:S307-S313. [DOI: 10.1016/j.jacr.2017.02.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 01/30/2017] [Accepted: 02/02/2017] [Indexed: 11/18/2022]
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Liasis L, Malietzis G, Galyfos G, Athanasiou T, Papaconstantinou HT, Sigala F, Zografos G, Filis K. The emerging role of microdialysis in diabetic patients undergoing amputation for limb ischemia. Wound Repair Regen 2016; 24:1073-1080. [PMID: 27733016 DOI: 10.1111/wrr.12492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/11/2016] [Indexed: 01/21/2023]
Abstract
Lower limb ischemia in diabetic patients is a result of macro- and microcirculation dysfunction. Diabetic patients undergoing limb amputation carry high mortality and morbidity rates, and decision making concerning the level of amputation is critical. Aim of this study is to evaluate a novel microdialysis technique to monitor tissue microcirculation preoperatively and predict the success of limb amputation in such patients. Overall, 165 patients with type 2 diabetes mellitus undergoing lower limb amputation were enrolled. A microdialysis catheter was placed preoperatively at the level of the intended flap for the stump reconstruction, and the levels of glucose, glycerol, lactate and pyruvate were measured for 24 consecutive hours. Patients were then amputated and monitored for 30 days regarding the outcome of amputation. Failure of amputation was defined as delayed healing or stump ischemia. Patients were divided into two groups based on the success of amputation. There was no difference between the two groups regarding gender, ASA score, body mass index, comorbidities, diagnostic modality used, level of amputation, as well as glucose, glycerol, and pyruvate levels. However, local concentrations of lactate were significantly different between the two groups and lactate/pyruvate (L/P) ratio was independently associated with failed amputation (threshold defined at 25.35). Elevated preoperative tissue L/P ratio is independently associated with worse outcomes in diabetic patients undergoing limb amputation. Therefore, preoperative tissue L/P ratio could be used as a predicting tool for limb amputation's outcome, although more clinical data are needed to provide safer conclusions.
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Affiliation(s)
- Lampros Liasis
- Department of Surgery, Northwick Park Hospital, Watford Road, Harrow, London, United Kingdom.,1st Propaedeutic Department of Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
| | - George Malietzis
- Department of Surgery and Cancer, Imperial College, Paddington, London, United Kingdom
| | - George Galyfos
- 1st Propaedeutic Department of Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College, Paddington, London, United Kingdom
| | | | - Fragiska Sigala
- 1st Propaedeutic Department of Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
| | - Georgios Zografos
- 1st Propaedeutic Department of Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
| | - Konstantinos Filis
- 1st Propaedeutic Department of Surgery, University of Athens Medical School, Hippocration Hospital, Athens, Greece
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Werncke T, Ringe KI, von Falck C, Kruschewski M, Wacker F, Meyer BC. Diagnostic confidence of run-off CT-angiography as the primary diagnostic imaging modality in patients presenting with acute or chronic peripheral arterial disease. PLoS One 2015; 10:e0119900. [PMID: 25835948 PMCID: PMC4383442 DOI: 10.1371/journal.pone.0119900] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Accepted: 01/16/2015] [Indexed: 12/31/2022] Open
Abstract
Objectives To investigate the reliability of CT-angiography of the lower extremities (run-off CTA) to derive a treatment decision in patients with acute and chronic peripheral artery disease (PAD). Materials and Methods 314 patients referred for run-off CTA were includ-ed in this retrospective study. First, diagnostic confidence of run-off CTA to derive a treat-ment decision was assessed in an interdisciplinary vascular conference using a 2 point scale (sufficient or not sufficient diagnostic confidence) and compared with the image quality eval-uated by two readers in consensus in four different levels (abdominopelvic, thigh, calf, foot arteries). Second, reliability of treatment decision was verified in all patients undergoing re-vascularization therapy. Results Diagnostic confidence of run-off CTA to derive a treatment deci-sion was sufficient in all patients with acute and in 97% of patients (215/221) with chronic PAD, whereas the rate of run-off CTA with non-diagnostic image quality was considerably higher in the calf and foot level (acute vs. chronic; calf: 28% vs.17%; foot: 52% vs. 20%). Reliability of treatment decision was superior for patients with chronic (123/133 = 92%) than for patients with acute PAD (64/78 = 82%, P = 0.02). Conclusion Run-off CTA is a reliable imaging modality for primary diag-nostic work-up of patients with acute and chronic PAD.
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Affiliation(s)
- Thomas Werncke
- Klinik für Radiologie, Charité Universitätsmedizin Berlin, Berlin, Germany
- * E-mail:
| | - Kristina Imeen Ringe
- Institute of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Christian von Falck
- Institute of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Martin Kruschewski
- Klinik für Radiologie, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Frank Wacker
- Institute of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
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Schernthaner RE, Wolf F, Mistelbauer G, Weber M, Sramek M, Groeller E, Loewe C. New hybrid reformations of peripheral CT angiography: do we still need axial images? Clin Imaging 2015; 39:603-7. [PMID: 25825345 DOI: 10.1016/j.clinimag.2015.03.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Revised: 02/16/2015] [Accepted: 03/10/2015] [Indexed: 01/05/2023]
Abstract
PURPOSE To quantify the detectability of peripheral artery stenosis on hybrid CT angiography (CTA) reformations. METHODS Hybrid reformations were developed by combining multipath curved planar reformations (mpCPR) and maximum intensity projections (MIP). Fifty peripheral CTAs were evaluated twice: either with MIP, mpCPR and axial images or with hybrid reformations only. Digital subtraction angiography served as gold standard. RESULTS Using hybrid reformations, two independent readers detected 88.0% and 81.3% of significant stenosis, respectively. However, CTA including axial images detected statistically significant more lesions (98%). CONCLUSION Peripheral CTA reading including axial images is still recommended. Further improvement of these hybrid reformations is necessary.
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Affiliation(s)
- Ruediger Egbert Schernthaner
- Section of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Florian Wolf
- Section of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Gabriel Mistelbauer
- Institute of Computer Graphics and Algorithms, Technical University of Vienna, Favoritenstraße 9-11, 1040 Vienna, Austria.
| | - Michael Weber
- Section of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
| | - Milos Sramek
- Commission for Scientific Visualization, Austrian Academy of Sciences, Donau-City Straße 1, 1220 Vienna, Austria.
| | - Eduard Groeller
- Institute of Computer Graphics and Algorithms, Technical University of Vienna, Favoritenstraße 9-11, 1040 Vienna, Austria.
| | - Christian Loewe
- Section of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria.
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May AM, Sharain K, Rooke TW. 79-year-old man with chronic bilateral calf pain. Mayo Clin Proc 2014; 89:1460-4. [PMID: 25282432 DOI: 10.1016/j.mayocp.2014.02.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2013] [Revised: 01/30/2014] [Accepted: 02/17/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Adam M May
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN
| | - Korosh Sharain
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Rochester, MN
| | - Thom W Rooke
- Advisor to residents and Consultant in Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
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Iglesias J, Peña C. Computed tomography angiography and magnetic resonance angiography imaging in critical limb ischemia: an overview. Tech Vasc Interv Radiol 2014; 17:147-54. [PMID: 25241315 DOI: 10.1053/j.tvir.2014.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Critical limb ischemia (CLI) is exhibited in patients with symptoms of severe claudication (rest pain) and ischemic tissue loss and gangrene. Magnetic resonance angiography and computed tomography angiography have risen to the forefront of vascular imaging over the last 2 decades. Both modalities have been shown to compare favorably with digital subtraction angiography in guiding the clinical management of patients with CLI. Understanding the advantages and limitations of both modalities allows for the proper selection of the best examination for a particular patient with CLI. Ultimately, the enhanced understanding of the vascular anatomy by obtaining noninvasive imaging should make subsequent revascularization safer and more effective.
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Affiliation(s)
- Jonathan Iglesias
- Michigan State University College of Human Medicine, East Lansing, MI
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Rubin GD, Leipsic J, Joseph Schoepf U, Fleischmann D, Napel S. CT angiography after 20 years: a transformation in cardiovascular disease characterization continues to advance. Radiology 2014; 271:633-52. [PMID: 24848958 DOI: 10.1148/radiol.14132232] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Through a marriage of spiral computed tomography (CT) and graphical volumetric image processing, CT angiography was born 20 years ago. Fueled by a series of technical innovations in CT and image processing, over the next 5-15 years, CT angiography toppled conventional angiography, the undisputed diagnostic reference standard for vascular disease for the prior 70 years, as the preferred modality for the diagnosis and characterization of most cardiovascular abnormalities. This review recounts the evolution of CT angiography from its development and early challenges to a maturing modality that has provided unique insights into cardiovascular disease characterization and management. Selected clinical challenges, which include acute aortic syndromes, peripheral vascular disease, aortic stent-graft and transcatheter aortic valve assessment, and coronary artery disease, are presented as contrasting examples of how CT angiography is changing our approach to cardiovascular disease diagnosis and management. Finally, the recently introduced capabilities for multispectral imaging, tissue perfusion imaging, and radiation dose reduction through iterative reconstruction are explored with consideration toward the continued refinement and advancement of CT angiography.
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Affiliation(s)
- Geoffrey D Rubin
- From the Duke Clinical Research Institute, 2400 Pratt St, Box 17969, Durham, NC 27715 (G.D.R.); Department of Medical Imaging and Division of Cardiology, University of British Columbia, Vancouver, BC, Canada (J.L.); Department of Radiology and Radiological Science, Medical University of South Carolina, Charleston, SC (U.J.S.); and Department of Radiology, Stanford University School of Medicine, Stanford, Calif (D.F., S.N.)
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Napoli A, Anzidei M, Zaccagna F, Cavallo Marincola B, Zini C, Brachetti G, Cartocci G, Fanelli F, Catalano C, Passariello R. Peripheral Arterial Occlusive Disease: Diagnostic Performance and Effect on Therapeutic Management of 64-Section CT Angiography. Radiology 2011; 261:976-86. [DOI: 10.1148/radiol.11103564] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Fotiadis N, Kyriakides C, Bent C, Vorvolakos T, Matson M. 64-section CT angiography in patients with critical limb ischaemia and severe claudication: comparison with digital subtractive angiography. Clin Radiol 2011; 66:945-52. [PMID: 21658691 DOI: 10.1016/j.crad.2011.04.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Revised: 04/13/2011] [Accepted: 04/26/2011] [Indexed: 10/18/2022]
Abstract
AIM To assess the utility of 64 section multidetector computed tomography (MDCT) lower-limb angiography in the evaluation of patients with critical limb ischaemia (CLI) or severe intermittent claudication (IC) in grading disease before endovascular treatment. MATERIALS AND METHODS Forty-one consecutive patients with CLI or severe IC were assessed using 64 section MDCT angiography. The MDCT examinations were compared with subsequent intra-arterial digital subtraction angiography (IADSA) examinations performed at the time of endovascular intervention. The MDCT and IADSA examinations were independently scrutinized by readers blinded to the results of the other imaging method. RESULTS For arterial segments with haemodynamically significant disease (stenosis ≥50%), the overall sensitivity, specificity, and accuracy of MDCT in patients with severe claudication and CLI was 99% (95% CI: 98-100%), 98% (95% CI: 97-100%) and 98% (95% CI: 97-99%), respectively. The positive predictive value (PPV) was 97% and the negative predictive value (NPV) was 99%. CONCLUSIONS MDCT angiography is a useful tool in the assessment of patients with severe claudication and CLI and can be reliably used to grade disease severity and plan treatment.
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Affiliation(s)
- N Fotiadis
- Department of Diagnostic Imaging, Barts and The London NHS Trust, London, UK.
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Kau T, Eicher W, Reiterer C, Niedermayer M, Rabitsch E, Senft B, Hausegger KA. Dual-energy CT angiography in peripheral arterial occlusive disease—accuracy of maximum intensity projections in clinical routine and subgroup analysis. Eur Radiol 2011; 21:1677-86. [DOI: 10.1007/s00330-011-2099-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2010] [Accepted: 01/29/2011] [Indexed: 11/30/2022]
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Distally based anterolateral-thigh (ALT) flap with the aid of multidetector computed tomography. J Plast Reconstr Aesthet Surg 2010; 63:e465-8. [DOI: 10.1016/j.bjps.2009.08.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2009] [Revised: 08/12/2009] [Accepted: 08/13/2009] [Indexed: 11/22/2022]
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Siriapisith T, Wasinrat J, Mutirangura P, Ruangsetakit C, Wongwanit C. Optimization of the table speed of lower extremity CT angiography protocols in different patient age groups. J Cardiovasc Comput Tomogr 2010; 4:173-83. [DOI: 10.1016/j.jcct.2010.03.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2009] [Revised: 01/19/2010] [Accepted: 03/19/2010] [Indexed: 11/15/2022]
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Iwasaki H, Shibuya T, Ishizaka T, Suehiro S, Satoh H. Unilateral Acute Lower Extremity Ischemia with Popliteal Artery Aneurysm as a Result of Vascular Type III Entrapment in an Elderly Patient. Vascular 2010; 18:116-20. [DOI: 10.2310/6670.2009.00057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Popliteal artery entrapment syndrome (PAES) is a rare cause of acute limb ischemia in adult patients but commonly demonstrates as claudication in young patients. The most significant, although rare, complication associated with PAES is aneurysm formation. We present the case of an elderly patient with a unilateral popliteal artery aneurysm owing to symptomatic anatomic entrapment. This report presents the oldest patient ever reported with this syndrome and highlights the advantage of multimodal treatment. As multidetector computed tomography highly contributed to the rapid diagnostic confirmation and choice of treatment in the popliteal fossa, limb salvage was achieved in this patient.
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Affiliation(s)
- Hiroto Iwasaki
- *Division of Vascular Surgery, Higashi Takarazuka Satoh Hospital, Takarazuka, Japan; †Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan; ‡Division of Cardiovascular Surgery, Higashi Takarazuka Satoh Hospital, Takarazuka, Japan
| | - Takashi Shibuya
- *Division of Vascular Surgery, Higashi Takarazuka Satoh Hospital, Takarazuka, Japan; †Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan; ‡Division of Cardiovascular Surgery, Higashi Takarazuka Satoh Hospital, Takarazuka, Japan
| | - Toru Ishizaka
- *Division of Vascular Surgery, Higashi Takarazuka Satoh Hospital, Takarazuka, Japan; †Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan; ‡Division of Cardiovascular Surgery, Higashi Takarazuka Satoh Hospital, Takarazuka, Japan
| | - Shigefumi Suehiro
- *Division of Vascular Surgery, Higashi Takarazuka Satoh Hospital, Takarazuka, Japan; †Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan; ‡Division of Cardiovascular Surgery, Higashi Takarazuka Satoh Hospital, Takarazuka, Japan
| | - Hisashi Satoh
- *Division of Vascular Surgery, Higashi Takarazuka Satoh Hospital, Takarazuka, Japan; †Department of Cardiovascular Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan; ‡Division of Cardiovascular Surgery, Higashi Takarazuka Satoh Hospital, Takarazuka, Japan
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Chan D, Anderson ME, Dolmatch BL. Imaging Evaluation of Lower Extremity Infrainguinal Disease: Role of the Noninvasive Vascular Laboratory, Computed Tomography Angiography, and Magnetic Resonance Angiography. Tech Vasc Interv Radiol 2010; 13:11-22. [DOI: 10.1053/j.tvir.2009.10.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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