Multimodality Imaging of Lower Extremity Peripheral Arterial Disease

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Multimodality Imaging of Lower Extremity Peripheral Arterial Disease by Amy W. Pollak, Patrick T. Norton, and Christopher M. Kramer Circ Cardiovasc Imaging Volume 5(6):797-807 November 20, 2012 Copyright © American Heart Association, Inc. All rights reserved.

Computed tomography angiography of aortoiliac occlusive disease. Computed tomography angiography of aortoiliac occlusive disease. Bone segmentation was achieved using automated algorithms with manual correction to produce full-volume maximum intensity projection (MIP) image after bone removal (A) and 3-dimensional volume rendered (VR) image with bones included at a partial transparency (B). Aortic occlusion is annotated on the MIP image by the asterisk directly inferior to the renal arteries. Occlusion of the bilateral common iliac arteries and stents, as well as the external iliac arteries, is also shown on both images. Reconstitution of runoff flow occurs at the superficial femoral arteries bilaterally. Collateral pathways are easily visualized on the VR images. The Arc of Riolan (arrow) supplies the inferior mesenteric artery (IMA) territory from the superior mesenteric artery. The superior rectal artery (arrowhead) supplies the internal iliac arteries (black arrows) from the IMA. The internal iliac artery collateralizes with the circumflex femoral arteries supply the runoff vessels. Amy W. Pollak et al. Circ Cardiovasc Imaging. 2012;5:797-807 Copyright © American Heart Association, Inc. All rights reserved.

Multistation contrast-enhanced magnetic resonance angiography of the abdomen, pelvis, and lower extremities was performed using stepping table acquisition and bi-phasic contrast media injection protocol. Multistation contrast-enhanced magnetic resonance angiography of the abdomen, pelvis, and lower extremities was performed using stepping table acquisition and bi-phasic contrast media injection protocol. Imaging reveals a patent aorto-biiliac surgical bypass graft (extent defined by arrowheads), with bilateral runoff disease consisting of tandem stenoses of the left superficial femoral artery (SFA), punctuated with a focal high-grade stenosis and collateral formation (white arrow) and tandem stenoses with long segment occlusion of the right SFA and popliteal artery with collaterals supplied by the profunda femoral artery (black arrows). Amy W. Pollak et al. Circ Cardiovasc Imaging. 2012;5:797-807 Copyright © American Heart Association, Inc. All rights reserved.

Noncontrast magnetic resonance angiography (MRA). Noncontrast magnetic resonance angiography (MRA). A, Two-dimensional (2-D) time-of-flight (TOF) MRA is acquired as multiple 2-D slices ideally oriented perpendicular to the vessel. The imaging slice is initially nulled and non-nulled blood is allowed to enter the slice at which time readout is performed. A selective saturation band is placed inferior to the imaging slice to suppress venous flow. Because of the 2-D, slice-by-slice nature of the technique, movement occurring between slice acquisitions appears as step artifact on coronal maximum intensity projection reconstruction. Two-dimensional TOF is susceptible to motion because of the long imaging times, as seen in this patient. B, Three-dimensional fast spin echo at 3 Tesla was acquired in 3 stations, revealing excellent imaging characteristics in this normal volunteer. Amy W. Pollak et al. Circ Cardiovasc Imaging. 2012;5:797-807 Copyright © American Heart Association, Inc. All rights reserved.

Duplex ultrasonography showing in-stent restenosis of a right superficial femoral artery (SFA) stent (for reference, the proximal SFA velocity is 96 cm/s, giving a peak systolic velocity [PSV] ratio of 278/96 cm/s, or 2.9). Duplex ultrasonography showing in-stent restenosis of a right superficial femoral artery (SFA) stent (for reference, the proximal SFA velocity is 96 cm/s, giving a peak systolic velocity [PSV] ratio of 278/96 cm/s, or 2.9). EDV indicates end-diastolic velocity; and RI, resistance index. Amy W. Pollak et al. Circ Cardiovasc Imaging. 2012;5:797-807 Copyright © American Heart Association, Inc. All rights reserved.

Duplex ultrasonography showing an occluded superficial femoral artery (SFA) stent without any evidence of flow on color or pulsed wave Doppler. Duplex ultrasonography showing an occluded superficial femoral artery (SFA) stent without any evidence of flow on color or pulsed wave Doppler. Amy W. Pollak et al. Circ Cardiovasc Imaging. 2012;5:797-807 Copyright © American Heart Association, Inc. All rights reserved.

Magnetic resonance angiography showing a clearly patent right superficial femoral artery stent (double arrows). Magnetic resonance angiography showing a clearly patent right superficial femoral artery stent (double arrows). This is a nitinol stent which does not have the metal dropout artifact on magnetic resonance imaging. Amy W. Pollak et al. Circ Cardiovasc Imaging. 2012;5:797-807 Copyright © American Heart Association, Inc. All rights reserved.

Vascular calcifications in a patient with diabetes mellitus. Vascular calcifications in a patient with diabetes mellitus. A, Coronal thin section maximum intensity projection (MIP) of a computed tomography angiography of the tibial peroneal runoff vessels demonstrating how dense calcifications in this patient population obscures analysis of the lumen. B, Contrast-enhanced magnetic resonance angiography is insensitive to vascular calcification as well as bone, simplifying image interpretation as demonstrated in this full-volume MIP from the same patient as in A. Amy W. Pollak et al. Circ Cardiovasc Imaging. 2012;5:797-807 Copyright © American Heart Association, Inc. All rights reserved.

An algorithm for choosing the appropriate imaging modality for a given clinical scenario. An algorithm for choosing the appropriate imaging modality for a given clinical scenario. PAD indicates peripheral arterial disease; CTA, computed tomography angiography; US, ultrasonography; CE-MRA, contrast-enhanced magnetic resonance angiography; NCE, non-contrast enhanced; and GFR, glomerular filtration rate. Amy W. Pollak et al. Circ Cardiovasc Imaging. 2012;5:797-807 Copyright © American Heart Association, Inc. All rights reserved.