Grace Tye, HMS III
Gillian Lieberman, MD
January 2003
Radiologic Evaluation of
Peripheral Arterial Disease
Grace Tye, Harvard Medical School Year III
Gillian Lieberman, MD
Grace Tye, HMS III
Gillian 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 Æ Intermittent claudication
2
Grace Tye, HMS III
Gillian 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
3
Grace Tye, HMS III
Gillian Lieberman, MD
Diagnosing Peripheral Arterial
Disease (PAD)
Non-invasive, non-imaging tests
• Ankle-brachial index
• Segmental limb pressures
• Segmental pulse volume recordings
4
Grace Tye, HMS III
Gillian Lieberman, MD
Diagnosing PAD:
Non-Invasive non-imaging tests
Ankle-Brachial Index (ABI)
Segmental Limb Pressures
Segmental Pulse Volume Recordings
5
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.
Grace Tye, HMS III
Gillian Lieberman, MD
Diagnosing PAD:
Non-Invasive non-imaging tests
Example: Patient S.P.
Patient D.M.: Findings
• ABI <<0.90
• Limb pressures: thigh <<
brachial
• Pulse volume recordings:
abnormal waveforms
starting at thigh level
Dx Æ PAD causing symptoms of
intermittent claudication
Limitations
• Cannot localize disease
• # stenoses unknown
• Stenoses vs. occlusions?
BIDMC/PACS
6
Grace Tye, HMS III
Gillian Lieberman, MD
Radiologic Evaluation of PAD
Noninvasive nonimaging tests
Established Dx of PAD
Doppler Ultrasound
Æ Location, #, severity of lesions
Revascularization desired?
No
Medical management
Yes
Conventional/MR angiography
Lesion appropriate for bypass graft Æ
refer to vascular surgery
Lesion appropriate for PTA, stent Æ
interventional radiology
7
Grace Tye, HMS III
Gillian Lieberman, MD
Non-Invasive Imaging: Doppler
Ultrasound
Goal
• Non-invasive evaluation
of location, number, and
severity of arterial lesions
Peak systolic velocity
velocity
Technique
• Color Doppler localizes
regions of abnormal flow
• Pulsed Doppler evaluates
1) peak systolic velocity
and 2) waveform
8
time
Hung RK, et al. Noninvasive evaluation of peripheral arterial disease.
RSNA EJ 1999;3. ej.rsna.org/ej3/0079-98.fin/title.htm.
Grace Tye, HMS III
Gillian Lieberman, MD
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
• Marked spectral
broadening
• Monophasic waveform
1) Forward systolic flow
2) Reverse diastolic flow
3) Forward diastolic flow
9
Grace Tye, HMS III
Gillian Lieberman, MD
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
Grace Tye, HMS III
Gillian Lieberman, MD
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
Grace Tye, HMS III
Gillian 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
12
Grace Tye, HMS III
Gillian 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
13
Grace Tye, HMS III
Gillian Lieberman, MD
Angiography: Percutaneous Transluminal
Angioplasty and Stenting
in Patient J.C.
Before
After
External iliac a.
Focal stenoses
14
Grace Tye, HMS III
Gillian Lieberman, MD
Branches of Abdominal Aorta
Celiac a.
SMA
IMA
Common iliac a.
15
Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000.
www.bartleby.com/107/.
Grace Tye, HMS III
Gillian Lieberman, MD
Patient D.M.: Angiography I
Vascular Calcification & Abnormal Aorta
Calcified iliac
artery
16
Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS
Grace Tye, HMS III
Gillian Lieberman, MD
Patient D.M.: Angiography II - Digital Subtraction Image
Occlusion of Infrarenal Aorta
Left hepatic artery
Right hepatic artery
Splenic artery
Hepatic artery
Celiac trunk
Renal arteries
SMA
Occlusion of
infrarenal aorta
IMA
17
Courtesy of Michael Mastromatteo, M.D., BIDMC/PACS
Grace Tye, HMS III
Gillian Lieberman, MD
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
Grace Tye, HMS III
Gillian Lieberman, MD
Collateral Circulation to Pelvis
IMA
Common iliac a.
Internal iliac a.
External iliac a.
Middle rectal a.
Superior rectal a.
19
Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, 2000.
www.bartleby.com/107/.
Grace Tye, HMS III
Gillian Lieberman, MD
Collateral Circulation to Lower Extremity
Lumbar a.
Deep iliac circumflex a.
Superficial femoral a.
Deep femoral a.
20
Uflacker, Renan. Atlas of Vascular Anatomy: An Angiographic Approach. Baltimore, Williams & Wilkins, 1997.
Grace Tye, HMS III
Gillian Lieberman, MD
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
Grace Tye, HMS III
Gillian Lieberman, MD
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
Grace Tye, HMS III
Gillian Lieberman, MD
Patient D.M.: Angiography
Findings
• Complete occlusion of infrarenal aorta
• Extensive collateral circulation
– Pelvis: Superior rectal a. Æ internal iliac a.
– LLE: Lumbar a. Æ 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
Grace Tye, HMS III
Gillian Lieberman, MD
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
Grace Tye, HMS III
Gillian Lieberman, MD
Radiologic Evaluation of PAD:
Summary
Noninvasive nonimaging tests
Established Dx of PAD
Doppler Ultrasound
Æ Location, #, severity of lesions
Revascularization desired?
No
Medical management
Yes
Conventional/MR angiography
Lesion appropriate for bypass graft Æ
refer to vascular surgery
Lesion appropriate for PTA, stent Æ
interventional radiology
25
Grace Tye, HMS III
Gillian Lieberman, MD
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger,
1918; Bartleby.com, 2000. www.bartleby.com/107/.
Hiatt WR. Medical treatment of peripheral arterial disease and claudication.
N Engl J Med 2001;344:1608-21.
Hung RK, et al. Noninvasive evaluation of peripheral arterial disease.
RSNA EJ 1999;3. ej.rsna.org/ej3/0079-98.fin/title.htm.
Katzen BT. Current status of intravascular ultrasonography. Radiol Clin
North Am 1992;30:895-905.
O’Leary DH. Vascular ultrasonography. Radiol Clin North Am 1985;23:3956.
Pellerito JS. Current approach to peripheral arterial sonography. Radiol Clin
North Am 2001;39:553-67.
Schmieder FA, Comerota AJ. Intermittent claudication: magnitude of the
problem, patient evaluation, and therapeutic strategies. Am J Cardiol
2001;87:3D-13D.
Taylor KJW. Arterial vascular ultrasonography. Radiol Clin North Am
1992;30:865-78.
Uflacker, Renan. Atlas of Vascular Anatomy: An Angiographic Approach.
Baltimore, Williams & Wilkins, 1997.
26
Grace Tye, HMS III
Gillian Lieberman, MD
Acknowledgments
•
•
•
•
•
Michael Mastromatteo, M.D.
Daniel Saurborn, M.D.
Larry Barbaras and Cara Lyn D’amour
Gillian Lieberman, MD
Pamela Lepkowski
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