Lower Leg Arteries Research Articles

The system of osteoprotegrin (OPG)/ligand of NF-kB receptor activator (RANKL) in patients with diabetes mellitus, mediacalcinosis and obliteratingatherosclerosis of lower leg arteries

Aim. To study the OPG/RANKL system in patients with diabetes mellitus, mediacalcinosis and obliterating atherosclerosis of lower leg arteries. Materials and methods. The study enrolled 70 patients including 20 with manifest diabetic neuropathy (DN) and mediacalcinosis of lower leg arteries(group 1). 29 patients with diabetes mellitus (DM) and clinical manifestations of obliterating atherosclerosis of lower leg arteries comprised group 2. Thecontrol group 3 consisted of 30 subjects without disturbances of carbohydrate metabolism. Immunoassays with Alkphase-B (Metra biosystems, USA),Osteoprotegrin (Biomedica, Austria), and sRANKL(Biomedica, Austria) kits were used to detect serum markers of bone formation (alkaline phosphatase(AP), OPG, and RANKL respectively). The patients underwent examination by digital X-ray of affected joints in frontal and lateral projections using anAxiom Iconos R 200 apparatus (Siemens, Germany). Bone mineral density (BMD) was measured by dual energy X-ray absorptiometry (Expert 1188,Lunar, USA). Ultrasound duplex scanning of lower leg arteries was performed with Sonoc-5500 (Agilent, USA). Results. OPG levels in diabetic patients were significantly higher than in controls (p

Diagnostic Accuracy of Intraarterial and IV MR Angiography for the Detection of Stenoses of the Infrainguinal Arteries

The objective of our study was to prospectively evaluate the diagnostic accuracy of intraarterial (i.a.) and i.v. MR angiography (MRA) of the infrainguinal arteries in comparison with the reference standard selective digital subtraction angiography (DSA). Twenty consecutive patients with symptomatic peripheral arterial occlusive disease (PAOD) underwent i.v. MRA and i.a. MRA of the infrainguinal arteries and DSA, which served as the reference standard. For i.v. MRA, 27 mL of gadodiamide was injected through a peripheral arm vein; for i.a. MRA, 30 mL of diluted contrast agent (5 mL of gadodiamide in 55 mL of 0.9% saline solution) was twice injected in the superficial femoral artery with a flow rate of 2.5 mL/s through a 5-French sheath that was placed on the occasion of DSA before vascular intervention. A 3D gradient-echo sequence was performed using a dedicated coil system on a 1.5-T MR scanner. Three independent blinded observers localized and quantitatively graded stenoses on i.v. MRA and i.a. MRA. The overall impression of image quality of i.v. MRA and i.a. MRA was documented using a 4-point scale (1, excellent; 4, poor). Interobserver agreement was calculated. The mean sensitivity and mean specificity for the detection of stenoses >or= 50% of the upper leg arteries (i.e., superficial femoral artery and popliteal artery) were 85.5% and 83.3% for i.a. MRA and 82.2% and 86.7% for i.v. MRA, respectively. The mean sensitivity and mean specificity for the detection of stenoses >or= 50% of the lower leg arteries (i.e., proximal anterior tibial artery, tibiofibular trunk, proximal posterior tibial artery, and proximal peroneal artery) were 91.7% and 75.0% for i.a. MRA, respectively, and 87.5% each for i.v. MRA. the diagnostic quality of i.a. MRA images and i.v. MRA images was assessed as excellent or good. i.a. MRA provides sensitivity and specificity for the detection of hemodynamically significant stenoses of the infrainguinal arteries comparable to i.v. MRA and therefore is a good diagnostic tool especially for MR-guided vascular interventions.

Measurement of Skin Perfusion Pressure in Hemodialyzed Patients: Association with Toe/Brachial Index

AbstractBACKGROUNDPatients with diabetes mellitus or renal failure may have calcified lower leg arteries, causing a falsely raised ankle/brachial index (ABI). In such cases, other combined noninvasive complementary observations may be useful. The purpose of this study was to investigate vascular complications of lower extremities in chronic hemodialyzed patients by measuring skin perfusion pressure (SPP) and the toe/brachial index (TBI).METHODSSixty‐five patients treated with regular hemodialysis were recruited. ABI, TBI, and SPP of the foot were measured in outpatient settings.RESULTSSPP was positively correlated with toe pressure (r = 0.560, p < 0.001) and with TBI (r = 0.481, p < 0.001). On the basis of the ABI results and diabetes status of the patients, 129 limbs were divided into 4 groups. For those in the normal ABI class (ABI >0.9), SPP and TBI were decreased in the diabetic normal ABI group compared with those in the non‐diabetic normal ABI group.CONCLUSIONSThese findings not only support that diabetes is a risk factor for arteriosclerosis but also suggest that even in a normal ABI class, diabetic patients with end‐stage renal disease are already susceptible to arteriosclerotic assault of peripheral arterial complications. SPP measurement is a noninvasive, beneficial observation for lower extremity peripheral arterial disease in hemodialyzed patients at risk.

Impaired peripheral circulation in lower-leg arteries caused by higher arterial stiffness and greater vascular resistance associates with nephropathy in type 2 diabetic patients with normal ankle–brachial indices

Diabetic nephropathy is a major cause of lower-limb amputation. We enrolled 250 type 2 diabetic patients without apparent occlusive peripheral arterial disease (ankle–brachial indices >0.9) and 40 age-matched nondiabetic subjects consecutively admitted to our hospital. Flow volume and resistive index (RI), an index of vascular resistance, at the popliteal artery were evaluated using gated two-dimensional cine-mode phase-contrast magnetic resonance imaging. Brachial–ankle pulse wave velocity (baPWV) was measured as an index of arterial distensibility. Flow volume was negatively correlated with both baPWV ( p = 0.0009) and RI ( p < 0.0001) among the patients. When the patients were grouped into four subgroups with or without albuminuria and renal insufficiency according to the levels of urinary albumin excretion rate (≥20 or <20 μg/min) and estimated glomerular filtration rate (eGFR) (<60 or ≥60 ml/min/1.73 m 2), albuminuric patients with renal insufficiency ( n = 30) showed the lowest flow volume ( p = 0.0078) and the highest baPWV ( p = 0.0006) and RI ( p = 0.0274) among the groups. Simple linear regression analyses demonstrated that eGFR correlated positively with flow volume ( p = 0.0020) and negatively with baPWV ( p = 0.0258) and RI ( p = 0.0029) in patients with albuminuria ( n = 92), but not with normoalbuminuria ( n = 158). Impaired peripheral circulation in lower-leg arteries associates with nephropathy in diabetic patients even though they have normal ankle–brachial indices.

The value of color Doppler ultrasound in follow-up of percutaneous transluminal angioplasty of the thigh area

The value of colour-coded Doppler sonography to evaluate results of percutaneous transluminal angioplasty of the superficial femoral artery was tested in 26 patients. Because of good accessibility, morphology may be demonstrated similar to intravenous DSA. However, accurate evaluation of dilatation success also requires haemodynamic measurements. Numerous parameters were determined one day before, one day after and one month after angioplasty at various points of the extremity (dilated segment, popliteal artery, lower leg arteries). Results were compared with those of normal individuals. Because of the large range of scatter and overlapping between normal and pathological values, only a few parameters can be used as valuable indicators for successful PTA. Spectral wave form becomes bi- or triphasic pattern and due to this the Pulsatility Index rises distal to the dilated area. An increasing systolic acceleration rate, peak systolic velocity and prestenotic Pulsatility Index have excellent predictive value. Using a Damping Factor, the later walking range may be predicted.

Pelvic and lower leg arteries: Diagnostic Accuracy of Contrast-Enhanced MR-Angiography at 3.0 Tesla in hybrid technique

Pelvic and lower leg arteries: Diagnostic Accuracy of Contrast-Enhanced MR-Angiography at 3.0 Tesla in hybrid technique

Removal of a Left Atrial Thrombus Adherent to a Patent Foramen Ovale Occluder

A 62-year-old man presented with bilateral thromboembolic occlusion of the lower leg arteries 8 months after closure of a patent foramen ovale with an Amplatzer patent-foramen-ovale occluder (AGA Medical Corporation, Plymouth, MN). Then he developed an acute myocardial ischemia. A left heart catheter revealed thromboembolic occlusion of the right coronary artery, and echocardiography demonstrated a thrombus attached to the device within the left atrium. Cerebral computer tomography showed a new ischemic lesion. In an emergency procedure, the device and the left atrial thrombus were removed, the septal defect was closed, and a coronary artery bypass grafting was performed. The patient was discharged from the hospital in stable condition.

Free Proximal Lateral Leg Flap

Soft tissue reconstruction with free perforator flap is popular in recent years. However, it is still a challenge to repair a small and thin defect with a free flap. A suitable flap must be thin, pliable, and easy to harvest and reconstruct. The proximal lateral leg flap from lateral lower leg is one of the ideal flap for reconstructing such defects. The authors applied free proximal lateral leg flaps to 7 patients with soft-tissue defects from March 2005 to November 2005. The recipient site was the heel in one case, the lateral foot in one case, the dorsal foot in one case, the posterior ankle in two cases, and head and neck in two cases. The largest flap was 11 x 5 cm and the smallest flap was 5 x 2.5 cm in size. The average thickness of this flap is 5.9 mm. Vascular pedicle lengths ranged from 5 to 8 cm. The average diameter of flap artery was 1.2 mm. All flaps survived completely. No major complications were encountered. All the donor wounds were closed primarily without difficulties. The proximal lateral leg flap has many advantages: (1) no need to sacrifice any main arteries in the lower leg; (2) minimal morbidity at the donor site; (3) short time to harvest the flap; (4) thin and flexible flap; and (5) primary closure at the donor site in most cases. We conclude that this free perforator flaps is useful for patients with a small to medium soft-tissue defect.

PTA und Stent distal der AFS

Although angioplasty and stent applications in the iliac vessels and the superficial femoral artery have become routine procedures, their usefulness for the treatment of lesions of the popliteal artery and the lower leg arteries is still under discussion. For the popliteal artery, limitations are mainly due to the high mechanical stress in this area, causing high traction forces. Moreover, beyond the occlusive atherosclerotic changes, specific pathological entities such as aneurysms, emboli, entrapment syndromes, and cystic adventitial disease have to be differentiated. There is hope that the development of innovative stent designs with high flexibility might overcome the limitations. For lesions of the lower leg arteries treatment with percutaneous transluminal angioplasty (PTA) has become the method of choice. However, stent designs as used for cardiac interventions have been adapted for their application below the knee, and first encouraging results may help to justify their broad use in the future. Regarding PTA, innovative equipment and techniques for the treatment of arterial lesions below the knee include dedicated, long, and very flexible balloons, cutting balloon cryoplasty, and laser angioplasty. Regarding stents, bare metal stents, stents with passive or active coatings, and bioabsorbable stents have all been successfully used.

Low Blood Flow Estimates in Lower-Leg Arteries Predict Cardiovascular Events in Japanese Patients With Type 2 Diabetes With Normal Ankle-Brachial Indexes

To examine the association of baseline measures in lower-leg arteries and conventional cardiovascular risk factors with the incidence of cardiovascular disease (CVD) events in type 2 diabetic patients with normal ankle-brachial indexes (ABIs) (>0.9). We studied 129 type 2 diabetic patients and 35 age-matched nondiabetic subjects with no apparent CVD consecutively admitted to our hospital. At baseline, total flow volume and resistive index, as an index of vascular resistance, at the popliteal artery was evaluated using gated two-dimensional cine-mode phase-contrast magnetic resonance imaging. Patients were followed 4.8 +/- 1.5 years (range 3.0-8.2) or until their first event of CVD. On follow-up, 16 patients developed primary CVD events. Patients with CVD had lower blood flow (P < 0.01) and higher vascular resistance (P < 0.05) than patients without CVD. When the patients were grouped into tertiles according to their levels of total flow volume (129.6-85.5, 85.3-63.3, and 62.7-23.8 ml/min), Kaplan-Meier analysis showed a higher probability of developing CVD events in patients in the lowest than in patients in the highest (P = 0.0199, log-rank test) tertile. Multivariate Cox proportional hazards analysis revealed that the lowest tertile for flow volume (hazard ratio [HR] 8.60, 95% CI 1.61-45.97, P = 0.012), hypertension (3.99, 1.12-14.25, P = 0.033), and smoking status (12.01, 1.21-119.28, P = 0.034) were significant independent predictors of CVD events. We have demonstrated that low blood flow estimates in lower-leg arteries may be predictive for CVD events among Japanese patients with type 2 diabetes even though they have a normal ABI.

Clinical Applications of Free Soleus and Peroneal Perforator Flaps

Clinical applications of two free lateral leg perforator flaps are described: a free soleus perforator flap that is based on the musculocutaneous perforator vessels from one of the three main arteries in the proximal lateral lower leg, and a free peroneal perforator flap that is based on the septocutaneous or direct skin perforator vessels from the peroneal artery in the distal and middle thirds of the lateral lower leg. The authors applied free soleus perforator flaps to 18 patients and free peroneal perforator flaps to five patients with soft-tissue defects. The recipient site was the great toe in 14 patients, the hand and fingers in five patients, the leg in two patients, and the upper arm and the jaw in one patient each. The largest soleus perforator flap was 15 x 9 cm, and the largest peroneal perforator flap was 9 x 4 cm. Vascular pedicle lengths ranged from 6.5 to 10 cm in soleus perforator flaps and from 4 to 6 cm in peroneal perforator flaps. All flaps, except for the flap in one patient in the peroneal perforator flap series, survived completely. Advantages of these flaps are that there is no need to sacrifice any main artery in the lower leg, and there is minimal morbidity at the donor site. For patients with a small to medium soft-tissue defect, these free perforator flaps are useful.

Practice Variability in the Management of Subrenal Arterial Stenoses in Seven Belgian Hospitals

This multicentre retrospective study describes the variation of therapeutic options, treatment outcomes and costs for treating subrenal arterial stenoses as observed in daily practice in 1991-99 in seven Belgian hospitals. Data were obtained from clinical record review and from the sickness fund claims database, and included preoperative functional state, presence of acute ischaemia, diabetes and polyvascular disease, state of the lower-leg run-off arteries, anatomical site and type of lesion, type of treatment, result at 30 days and up to 4 years. A total of 441 episodes were studied, but most analyses dealt with a subgroup of 140 lesions in the common iliac up to the superficial femoral artery. The proportion of surgical treatments (as compared to an endovascular or mixed approach) varied from 15% to 81% between the hospitals.In univariate patency analysis, relapse or failure rates at 4 years ranged from 5% for the common iliac artery to 35% for the superficial femoral artery. Polyvascular disease, a poor run-off, multiple stenoses and chronic occlusion were significant risk factors; age and diabetes were not. In the multivariate (stratified Cox regression) analysis, only a location in the superficial femoral artery and a poor preoperative clinical stage were significant risk factors, but type of therapeutic approach was not.The total average cost of treatment was 5,300 荤, of which 15% was contributed by the patient. Surgery was associated with longer stays (median at 11 days) than endovascular treatments (median 1 days), and was 1.9 times more expensive. In conclusion, the results of the present study suggest that a multidisciplinary approach, orienting the patient to the most appropriate therapeutic pathway, could increase both the quality and the cost-effectiveness of the care.

Assessment of skeletal muscle perfusion by contrast medium first-pass magnetic resonance imaging: technical feasibility and preliminary experience in healthy volunteers.

To probe the potential and pitfalls of contrast medium first-pass skeletal muscle perfusion imaging under reproducible stress conditions. Magnetic resonance (MR) signal dynamics in calf muscle and lower-leg arteries of 20 healthy volunteers were analyzed under postarterial occlusion reactive hyperemia and concurrent contrast medium first pass, using a saturation recovery spoiled gradient-echo type sequence without heartbeat synchronization. The signal vs. time curves were analyzed descriptively and by two-compartment deconvolution analysis. Highly significant changes in calf muscle signal dynamics in the hyperemic leg vs. those in the contralateral leg at rest were found in phenomenological and deconvolution analysis. Although a distortion of the arterial signal derived input function by inflow effects was found to cause large variations of the deconvolution results, the magnitude of the observed effects suggested a potential for immediate visual detection of areas with reduced tissue perfusion. The first-pass approach appeared promising for visual evaluation. However, a disentanglement of inflow and contrast medium-induced effects on arterial signal intensity was deemed a prerequisite for input function-based numerical assessment.

Color-flow duplex scanning of the leg arteries by use of a new echo-enhancing agent

Objective: This was a dose-finding and effectiveness study of a newly developed contrast-enhancing agent, sulphur hexafluoride (SF6), in patients with peripheral arterial disease in whom the therapeutic policy could not be established on the basis of standard color-flow duplex scanning of the leg arteries. Methods: In this open-label, randomized, dose-ranging, crossover design, 14 patients in whom the assessment of vessel patency was difficult because of poor visibility (low-flow state) or extensive wall calcifications were studied. Contrast-enhanced duplex scanning was performed on the upper leg (n = 4), lower leg (n = 6), or pedal (n = 4) arteries after intravenous injection of four different dosages of SF6. The results were compared with those from selective angiography of the vessel of interest. Contrast duration and agreement about the diagnosis and the confidence in the diagnosis were obtained before and after administration of the contrast agent. Results: No adverse effects of the contrast agent were seen. Overall agreement was reasonable with regard to vessel patency between contrast-enhanced duplex scanning and angiography (71%). Nine of 14 vessels (64%) appeared open when contrast was applied. In four cases this could not be confirmed by angiography; in two of these cases this was due to the presence of collateral vessels. All vessels that appeared occluded with the contrast agent were also occluded on the angiogram. The confidence in the diagnosis increased from 56% to 91% after contrast administration (P <.0001). Conclusion: SF6-enhanced color-flow duplex scanning is a safe method that may improve the assessment of the patency of leg arteries, particularly in low-flow states. The visualization of collateral vessles during (enhanced) duplex scanning may be misleading because they may be regarded as the vessel of interest. (J Vasc Surg 2002;35:392-6.)

Duplex scanning allows selective use of arteriography in the management of patients with severe lower leg arterial disease

Purpose: Until April 1997 we routinely performed intra-arterial digital subtraction angiography (iaDSA) in all patients with severe lower leg ischemia requiring intervention. After a comparative study of duplex scanning (DS), pulsegenerated runoff, and iaDSA of the lower leg arteries, we postulated that management could be based on DS/pulse-generated runoff in 59% of patients. We prospectively evaluated the safety of such a noninvasive workup strategy. Methods: All consecutive patients referred with severe lower leg ischemia between April 1997 and September 1998 were eligible. Management was based on DS with iaDSA being performed only on indication. Complications within 30 days and 12- and 24-month patency, survival, and limb salvage rates were recorded and compared with historical controls. Results: A total of 125 limbs in 114 patients were evaluated (74% rest pain or tissue loss). In 97 (78%) of 125 limbs, management was based on DS. It comprised conservative treatment (n = 33, 0% after iaDSA), percutaneous transluminal angioplasty (n = 25, 16% iaDSA), femoropopliteal bypass graft (n = 29, 17% iaDSA), femorotibial bypass graft (n = 29, 62% iaDSA), and other surgical procedures (n = 8, 4% iaDSA). Overall, the mortality within 30 days was 4% (5/114), and 2-year survival was 83%. Two-year primary and secondary patency and limb salvage rates were 75%, 93%, and 93% after a femoropopliteal bypass operation, respectively. One-year primary and secondary patency and limb salvage rates were 35%, 73%, and 74%, respectively, after a femorocrural bypass operation. There were no differences in patient characteristics, indication for specific treatment, and immediate and intermediate term outcome between the study and reference population. Conclusion: In a vascular unit with wide expertise in DS of the lower leg arteries, management of patients with severe lower leg ischemia can be based on DS in most patients without negative effects on clinical outcome within 30 days and at 2-years' follow-up. (J Vasc Surg 2001;34:661-7.)

Macroangiopathy in diabetes mellitus

In patients with diabetic angiopathy until today, no histological nor histochemical evidence has been found to define a specific type of diabetic arteriopathy. Consequently, diabetic arteriosclerosis is considered as a more serious form of atherosclerosis characterized by its premature onset. Hyperglycemia is assumed to be the crucial pathophysiological cause of the development of macro- and microangiopathy in diabetes mellitus. Apparently, hyperglycemia has a direct toxic influence on the arterial wall by increased accumulation of irreversible glycosylation end products, and secondly, it provokes endothelial dysfunction. The frequently occurring ulcerations of the diabetic foot are primarily caused by neuropathy; however, peripheral vascular disease (PVD) is often associated. The risk of suffering from PVD in diabetic patients is approximately four-fold. Usually, the distal segments of the lower leg arteries are concerned, where reconstructive intervention is complicated or even impossible. Diabetes is considered as an independent risk factor for cardio- and cerebrovascular diseases with almost twice as high rates for recurrent myocardial infarction, and a 3.7 fold higher relative risk for stroke in diabetic, compared to non-diabetic patients. This review looks at the correlations between hyperglycemia and arteriosclerosis, but also the treatment options in diabetic patients. Until now, there is no evidence for an association between an optimal control of blood glucose levels and a decrease in the risk of coronary heart disease, stroke, or PVD. In contrast, an attenuation of microvascular lesions is achieved by stringent control of blood glucose levels. Thus, although the development of macroangiopathy may not be significantly influenced, the conduction of a stringent control regimen of plasmatic glucose levels is advisable.

Interobserver Variation in Interpretation of Arteriography and Management of Severe Lower Leg Arterial Disease

arteriography is the reference standard for the assessment of the lower leg arteries in patients with severe lower limb ischaemia. Interobserver variation in arteriography interpretation may cause disparities with non-invasive imaging modalities. We determined interobserver variation in lower leg artery assessment with intra-arterial digital subtraction angiography (IaDSA) and subsequent patient management. iaDSA studies of patients evaluated for severe claudication (n =5) or critical ischaemia ( n =43). arteriograms were independently judged by four observers. The popliteal and tibial arteries were graded as fully patent, severely diseased, occluded or non-diagnostic. The dorsalis pedis, common and deep plantar artery were graded as directly, indirectly or not filling the pedal arch or non-diagnostic. Agreement on grading arteries was expressed as kappa-values. Treatment plans (conservative, PTA, surgery, amputation, non-diagnostic) proposed by each observer based on clinical information and iaDSA were compared. the rate of non-diagnostic judgements ranged from 1% in the popliteal to 22% in the pedal arteries. Overall agreement was good for grading the popliteal arteries (kappa=0.64), moderate for the tibial (kappa=0.47--0.54) and fair for the pedal arteries (kappa=0.39). Agreement was good to excellent for grading occluded or fully patent popliteal and tibial artery segments, and fair to moderate for grading severe disease. In 57% of cases at least 3 observers proposed identical treatment, which indicates fair overall agreement (kappa=0.33). interobserver agreement on iaDSA is good to determine occluded or fully patent popliteal or tibial arteries, but not for severe disease. This should be taken into account when other diagnostic modalities are compared with iaDSA. Evaluation of diagnostic modalities as concordance in treatment plans is flawed by interindividual variation.

Measurement of leg arterial compliance of normal subjects and diabetics using impedance plethysmography.

In this study, compliance, a mechanical characteristic of the lower leg arteries, was measured noninvasively. Changes in blood volume and pressure were measured using impedance plethysmography and a mercury sphygmomanometer, respectively. Compliance was calculated by dividing the change in blood volume by the change in pulse pressure (systolic-diastolic pressure). Subjects were 24 asymptomatic persons ranging from 30 to 58 years and 14 diabetics ranging from 41 to 59 years. Peak compliance, mean pressure, and systolic pressure were statistically analyzed using a t test between the asymptomatic and diabetic groups. The average peak compliance of the asymptomatic and diabetic groups was measured as 2.79 and 1.82 microL/mmHg/cm, respectively, and these were significantly different (p < 0.01). It was also found that compliance is a better parameter in differentiating vascular disease than the mean or systolic blood pressure.

Routine donor leg angiography before vascularized free fibula transplantation is not necessary: a prospective study in 120 clinical cases.

To evaluate the value of routine preoperative angiographies of donor sites, 120 patients with free fibula osteoseptocutaneous flap transplantations were included in this prospective study, which consisted of preoperative evaluation of dorsalis pedis and tibial posterior artery pulsation and angiographies of the donor legs (120 patients) and contralateral legs (111 patients). Both pedal pulses were palpable in 114 patients, and only one pulse was palpable in six patients. The respective nonpalpable foot pulses were detectable with pencil Doppler in five patients, but they were not detectable in one patient. Intraoperatively, the latter patient had a relatively hypertrophied peroneal artery as compared with both the tibial posterior and tibial anterior arteries. The angiographic result was arteria peronea magna. The other five patients showed intraoperatively and angiographically normal-sized major arteries of the lower leg. In three patients with normal pedal pulses, hypoplasias of either the tibial anterior or tibial posterior arteries were found intraoperatively. These findings corresponded with the angiographical results. In all patients (n = 119), except one with peroneal artery hemangioma, free osteoseptocutaneous fibula flap was harvested from the originally planned leg without subsequent sequelae to the respective donor leg. In 231 leg angiographies, only 7 cases (3 percent) with abnormalsized major lower leg arteries were described. The diagnoses in these cases were hypoplasia of either the tibial posterior or tibial anterior artery (4 cases), arteria peronea magna (2 cases, one of which was a false positive), absence of peroneal artery combined with hypoplastic tibial posterior artery (1 case), and hemangioma of the peroneal artery (1 case). From this prospective study, it was determined that routine preoperative angiography of the donor leg before fibula transplantation is not justified. It does not add relevant new information about donor leg vascularity, provided that the clinical evaluation of the pedal pulses is well conducted. The only two conditions that may require a preoperative donor leg angiography are abnormal pedal pulses or significant previous lower leg trauma.

Assessment and Quantification of Regional Arterial Perfusion Reserve in Patients with Peripheral Occlusive and Small-Vessel Disease by Rubidium 82-Positron Emission Tomography

The aim of the study was to assess the skeletal muscle blood flow and the regional perfusion reserve by rubidium 82-positron emission tomography (PET) in order to evaluate the functional effects of stenoses and occlusions of lower leg arteries. In 12 patients the authors infused 12 mCi rubidium 82 into the femoral artery (following diagnostic cardiac catheterization) and recorded a dynamic PET sequence of the lower leg at rest and during reactive hyperemia following two minutes of complete arterial blockage by a cuff. Regional perfusion was calculated as the rate of uptake related to the 82 Rb input function. Perfusion reserve was calculated as the regional perfusion during hyperemia related to perfusion at rest. Muscle perfusion at rest was homogeneous in all patients. The regional perfusion reserve was markedly reduced in muscle areas distal to infrapopliteal stenoses or occlusions as compared with muscle areas following nonstenotic arteries and overall reduced in a patient with small-vessel disease. The authors conclude that 82 Rb-PET allows exact measurement of the regional perfusion of the lower leg muscles during rest and reactive hyperemia. Calculation of the regional perfusion reserve gives a quantification of the functional effects of peripheral occlusive artery disease.