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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
26
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.
27
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