January 2003 Radiologic Evaluation of Peripheral Arterial Disease Grace Tye, Harvard Medical School Year III
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 2
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 3
Diagnosing Peripheral Arterial Disease (PAD) Non-invasive, non-imaging tests Ankle-brachial index Segmental limb pressures Segmental pulse volume recordings 4
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. 5
Example: Patient S.P. Diagnosing PAD: Non-Invasive non-imaging tests 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 BIDMC/PACS Limitations Cannot localize disease # stenoses unknown Stenoses vs. occlusions? 6
Radiologic Evaluation of PAD Noninvasive nonimaging tests Established Dx of PAD Doppler Ultrasound Location, #, severity of lesions No Revascularization desired? Yes Medical management Conventional/MR angiography Lesion appropriate for bypass graft refer to vascular surgery Lesion appropriate for PTA, stent interventional radiology 7
Non-Invasive Imaging: Doppler Ultrasound Goal Non-invasive evaluation of location, number, and severity of arterial lesions Technique Color Doppler localizes regions of abnormal flow Pulsed Doppler evaluates 1) peak systolic velocity and 2) waveform velocity time 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. 8
Non-Invasive Imaging: Doppler Ultrasound Findings in severe stenosis Increased peak systolic velocity Pellerito JS. Current approach to peripheral arterial sonography. Radiol Clin North Am 2001;39:553-67. Normal waveform is triphasic 1) Forward systolic flow 2) Reverse diastolic flow 3) Forward diastolic flow Marked spectral broadening Monophasic waveform 9
Non-Invasive Imaging: Doppler Ultrasound Example: Patient S.P. Patient D.M.: Findings Abnormal monophasic waveforms at femoral levels bilaterally Conclusion Bilateral aortoiliac occlusion BIDMC/PACS 10
Patient D.M. Additional information HPI: has had symptoms for several years. PMH: severe atherosclerosis, s/p bilateral carotid endarterectomy in 2000. Example: Patient S.P. Diagnosis Bilateral aortoiliac occlusive disease secondary to peripheral arterial disease caused by atherosclerosis Vascular calcification BIDMC/PACS 11
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 12
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 13
Angiography: Percutaneous Transluminal Angioplasty and Stenting in Patient J.C. Before After External iliac a. Focal stenoses 14
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/. 15
Patient D.M.: Angiography I Vascular Calcification & Abnormal Aorta Calcified iliac artery 16 Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS
Left hepatic artery Grace Tye, HMS III Patient D.M.: Angiography II - Digital Subtraction Image Occlusion of Infrarenal Aorta Right hepatic artery Splenic artery Hepatic artery Renal arteries Celiac trunk SMA Occlusion of infrarenal aorta IMA 17 Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS
Patient D.M.: Angiography III - Digital Subtraction Image Extensive collateral circulation Lumbar a. IMA Deep iliac circumflex a. Internal iliac a. Superior gluteal a Superior rectal arteries Inferior gluteal a. Obturator a. Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS 18
Collateral Circulation to Pelvis IMA Common iliac a. External iliac a. Internal iliac a. Middle rectal a. Superior rectal a. Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000. www.bartleby.com/107/. 19
Collateral Circulation to Lower Extremity Lumbar a. Deep iliac circumflex a. Superficial femoral a. Deep femoral a. Uflacker, Renan. Atlas of Vascular Anatomy: An Angiographic Approach. Baltimore, Williams & Wilkins, 1997. 20
Patient D.M.: Angiography IV Collateral circulation to LLE Digital Subtraction Image Left superficial femoral a. Left deep femoral a Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS 21
Patient D.M.: Angiography V Collateral circulation to LLE Digital Subtraction Image 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 22
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 contrast Conclusion: No appropriate target for PTA or stenting Refer to vascular surgery Image courtesy of Michael Mastromatteo, M.D., BIDMC/PACS 23
Surgery: Bypass Graft in Patient J.C. Digital Subtraction Image Vascular hood Femoral-popliteal graft Valve Native vessel Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS 24
Radiologic Evaluation of PAD: Summary Noninvasive nonimaging tests Established Dx of PAD Doppler Ultrasound Location, #, severity of lesions No Revascularization desired? Yes Medical management Conventional/MR angiography Lesion appropriate for bypass graft refer to vascular surgery Lesion appropriate for PTA, stent interventional radiology 25
References 1. 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. 26
Acknowledgments Michael Mastromatteo, M.D. Daniel Saurborn, M.D. Larry Barbaras and Cara Lyn D amour Pamela Lepkowski 27