Radiologic Evaluation of Peripheral Arterial Disease

Grace Tye, HMS IIIGillian Lieberman, MD

Radiologic Evaluation of Peripheral Arterial Disease

Grace Tye, Harvard Medical School Year IIIGillian Lieberman, MD

January 2003

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Grace Tye, HMS IIIGillian Lieberman, MD

Patient D.M.

• CC: 44 y/o male with pain in his buttocks – Occurs after walking 2 blocks. – Pain is relieved by rest.

• PE: absent femoral pulses

DDx for exertional pain in buttocks

• Intermittent claudication

• Hip arthritis• Spinal cord

compression

Clinical Dx Intermittent claudication

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Grace Tye, HMS IIIGillian Lieberman, MD

Claudication

Definition• Pain secondary to

exercise-induced muscle ischemia

• Relieved by rest within minutes

• Consistently reproduced by same degree of exercise

DDx – Causes of claudication

• Peripheral arterial disease/atherosclerosis

• Inflammatory conditions (e.g. Buerger’s, Takayasu’s)

• Atheroembolism• Irradiation injury• Remote trauma

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Grace Tye, HMS IIIGillian Lieberman, MD

Diagnosing Peripheral Arterial Disease (PAD)

Non-invasive, non-imaging tests• Ankle-brachial index• Segmental limb pressures• Segmental pulse volume recordings

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Grace Tye, HMS IIIGillian Lieberman, MD

Diagnosing PAD: Non-Invasive non-imaging tests

Ankle-Brachial Index (ABI) Segmental Limb Pressures

Segmental Pulse Volume Recordings

Hiatt WR. Medical treatment of peripheral arterial disease and claudication. N Engl J Med 2001;344:1608-21; Schmieder FA, Comerota AJ. Intermittent claudication: magnitude of the problem, patient evaluation, and therapeutic strategies. Am J Cardiol 2001;87:3D-13D.

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Grace Tye, HMS IIIGillian Lieberman, MD

Patient D.M.: Findings• ABI <<0.90• Limb pressures: thigh <<

brachial• Pulse volume recordings:

abnormal waveforms starting at thigh level

Dx PAD causing symptoms of intermittent claudication

Limitations• Cannot localize disease• # stenoses unknown• Stenoses vs. occlusions?

BIDMC/PACS

Example: Patient S.P.

Diagnosing PAD: Non-Invasive non-imaging tests

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Grace Tye, HMS IIIGillian Lieberman, MD

Radiologic Evaluation of PADNoninvasive nonimaging tests Established Dx of PAD

Doppler UltrasoundLocation, #, severity of lesions

Revascularization desired?

Medical management

No Yes

Conventional/MR angiography

Lesion appropriate for bypass graft refer to vascular surgery

Lesion appropriate for PTA, stent interventional radiology

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Grace Tye, HMS IIIGillian Lieberman, MD

Non-Invasive Imaging: Doppler Ultrasound

Goal• Non-invasive evaluation

of location, number, and severity of arterial lesions

Technique• Color Doppler localizes

regions of abnormal flowve

loci

ty

time

• Pulsed Doppler evaluates 1) peak systolic velocity and 2) waveform

Peak systolic velocity

Hung RK, et al. Noninvasive evaluation of peripheral arterial disease. RSNA EJ 1999;3. ej.rsna.org/ej3/0079-98.fin/title.htm.

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Grace Tye, HMS IIIGillian Lieberman, MD

Non-Invasive Imaging: Doppler Ultrasound

Normal waveform is triphasic1) Forward systolic flow2) Reverse diastolic flow3) Forward diastolic flow

Pellerito JS. Current approach to peripheral arterial sonography. Radiol Clin North Am 2001;39:553-67.

Findings in severe stenosis

• Increased peak systolic velocity

• Marked spectral broadening

• Monophasic waveform

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Grace Tye, HMS IIIGillian Lieberman, MD

Patient D.M.: Findings• Abnormal monophasic

waveforms at femoral levels bilaterally

Conclusion• Bilateral aortoiliac

occlusion

BIDMC/PACS

Non-Invasive Imaging: Doppler UltrasoundExample: Patient S.P.

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Grace Tye, HMS IIIGillian Lieberman, MD

Patient D.M.Additional information• HPI: has had symptoms for several

years.• PMH: severe atherosclerosis, s/p

bilateral carotid endarterectomy in 2000.

Diagnosis• Bilateral aortoiliac

occlusive disease secondary to peripheral arterial disease caused by atherosclerosis

BIDMC/PACS

Example: Patient S.P.

Vascular calcification

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Grace Tye, HMS IIIGillian Lieberman, MD

Management and Treatment of Claudication/PAD

Medical Management• Risk factor

modification• Platelet inhibition• Exercise therapy• Pharmacotherapy

Revascularization Interventions

• Percutaneous transluminal angioplasty

• Stenting• Surgery: bypass graft

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Grace Tye, HMS IIIGillian Lieberman, MD

Invasive Imaging: Conventional Angiography

• The gold standard for localization and characterization of arterial occlusive disease

• Indication: intent to revascularize• Contraindications: contrast allergy, renal

insufficiency, abnormal hemostasis, CHF, etc.

• Alternative: MR Angiography

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Grace Tye, HMS IIIGillian Lieberman, MD

Angiography: Percutaneous Transluminal Angioplasty and Stenting

in Patient J.C.Before After

Focal stenoses

External iliac a.

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Grace Tye, HMS IIIGillian Lieberman, MD

Branches of Abdominal Aorta

Celiac a.

SMA

IMA

Common iliac a.

Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000. www.bartleby.com/107/.

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Grace Tye, HMS IIIGillian Lieberman, MD

Patient D.M.: Angiography I Vascular Calcification & Abnormal Aorta

Calcified iliac artery

Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS

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Grace Tye, HMS IIIGillian Lieberman, MD

Patient D.M.: Angiography II - Digital Subtraction Image Occlusion of Infrarenal Aorta

Celiac trunk

SMA

IMA

Renal arteries

Occlusion of infrarenal aorta

Splenic artery

Hepatic artery

Left hepatic artery

Right hepatic artery

Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS

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Grace Tye, HMS IIIGillian Lieberman, MD

Patient D.M.: Angiography III - Digital Subtraction Image Extensive collateral circulation

Superior rectal arteries

Inferior gluteal a.

Obturator a.

Lumbar a.

IMA

Superior gluteal a

Internal iliac a.

Deep iliac circumflex a.

Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS

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Grace Tye, HMS IIIGillian Lieberman, MD

Collateral Circulation to Pelvis

IMA

Internal iliac a.

Superior rectal a.

Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000. www.bartleby.com/107/.

Middle rectal a.

Common iliac a.

External iliac a.

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Grace Tye, HMS IIIGillian Lieberman, MD

Collateral Circulation to Lower Extremity

Uflacker, Renan. Atlas of Vascular Anatomy: An Angiographic Approach. Baltimore, Williams & Wilkins, 1997.

Deep iliac circumflex a.

Lumbar a.

Superficial femoral a.

Deep femoral a.

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Grace Tye, HMS IIIGillian Lieberman, MD

Patient D.M.: Angiography IV Collateral circulation to LLE

Left superficial femoral a.

Left deep femoral a

Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS

Digital Subtraction Image

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Grace Tye, HMS IIIGillian Lieberman, MD

Patient D.M.: Angiography V Collateral circulation to LLE

Popliteal a.

Anterior tibial a.

Peroneal a.

Posterior tibial a.

Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS

Digital Subtraction Image

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Grace Tye, HMS IIIGillian Lieberman, MD

Patient D.M.: Angiography Findings

• Complete occlusion of infrarenal aorta• Extensive collateral circulation

– Pelvis: Superior rectal a. internal iliac a. – LLE: Lumbar a. deep iliac circumflex a.

• No evidence of collateral circulation to RLE– Collateral circulation likely filled from above level of

injection of contrastConclusion: • No appropriate target for PTA or stenting• Refer to vascular surgery

Image courtesy of Michael Mastromatteo, M.D., BIDMC/PACS

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Grace Tye, HMS IIIGillian Lieberman, MD

Surgery: Bypass Graft in Patient J.C.

Vascular hood

Femoral-popliteal graft

Native vessel

Valve

Courtesy of Michael Mastromatteo, M.D., BIDMC/PACSCourtesy of Michael Mastromatteo, M.D., BIDMC/PACS

Digital Subtraction Image

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Grace Tye, HMS IIIGillian Lieberman, MD

Radiologic Evaluation of PAD: Summary

Noninvasive nonimaging tests Established Dx of PAD

Doppler UltrasoundLocation, #, severity of lesions

Revascularization desired?

Medical management

No Yes

Conventional/MR angiography

Lesion appropriate for bypass graft refer to vascular surgery

Lesion appropriate for PTA, stent interventional radiology

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Grace Tye, HMS IIIGillian Lieberman, MD

References1. Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger,

1918; Bartleby.com, 2000. www.bartleby.com/107/. 2. Hiatt WR. Medical treatment of peripheral arterial disease and claudication.

N Engl J Med 2001;344:1608-21.3. Hung RK, et al. Noninvasive evaluation of peripheral arterial disease.

RSNA EJ 1999;3. ej.rsna.org/ej3/0079-98.fin/title.htm.4. Katzen BT. Current status of intravascular ultrasonography. Radiol Clin

North Am 1992;30:895-905.5. O’Leary DH. Vascular ultrasonography. Radiol Clin North Am 1985;23:39-

56.6. Pellerito JS. Current approach to peripheral arterial sonography. Radiol Clin

North Am 2001;39:553-67.7. Schmieder FA, Comerota AJ. Intermittent claudication: magnitude of the

problem, patient evaluation, and therapeutic strategies. Am J Cardiol 2001;87:3D-13D.

8. Taylor KJW. Arterial vascular ultrasonography. Radiol Clin North Am 1992;30:865-78.

9. Uflacker, Renan. Atlas of Vascular Anatomy: An Angiographic Approach. Baltimore, Williams & Wilkins, 1997.

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Grace Tye, HMS IIIGillian Lieberman, MD

Acknowledgments

• Michael Mastromatteo, M.D.• Daniel Saurborn, M.D.• Larry Barbaras and Cara Lyn D’amour• Gillian Lieberman, MD• Pamela Lepkowski