Evaluation Of Peripheral Arterial Disease Research Articles

Clinical physiology: the crucial role of MRI in evaluation of peripheral artery disease.

Peripheral artery disease (PAD) is a common vascular disease that primarily affects the lower limbs and is defined by the constriction or blockage of peripheral arteries and may involve microvascular dysfunction and tissue injury. Patients with diabetes have more prominent disease of microcirculation and develop peripheral neuropathy, autonomic dysfunction, and medial vascular calcification. Early and accurate diagnosis of PAD and disease characterization are essential for personalized management and therapy planning. Magnetic resonance imaging (MRI) provides excellent soft tissue contrast and multiplanar imaging capabilities and is useful as a noninvasive imaging tool in the comprehensive physiological assessment of PAD. This review provides an overview of the current state of the art of MRI in the evaluation and characterization of PAD, including an analysis of the many applicable MR imaging techniques, describing the advantages and disadvantages of each approach. We also present recent developments, future clinical applications, and future MRI directions in assessing PAD. The development of new MR imaging technologies and applications in preclinical models with translation to clinical research holds considerable potential for improving the understanding of the pathophysiology of PAD and clinical applications for improving diagnostic precision, risk stratification, and treatment outcomes in patients with PAD.

Toe brachial index and not ankle brachial index is appropriate in initial evaluation of peripheral arterial disease in type 2 diabetes.

Non-invasive clinic-based tools for assessing PAD are not without limitations. Therefore, costly tests like Doppler study, CT angiography and MR angiography are often required to make a diagnosis. Ankle brachial index (ABI), commonly used for assessment of PAD,hashigh false positivity rates in sclerosed, calcified arteries which render them non-compressible. Toe brachial index (TBI) can be an alternative, as digital arteries are relatively unaffected by these changes. To compare the reliability of ABI and TBI in diagnosing PADin type 2 diabetes using CT angiography (CTA) as the reference. 175 adults with T2D were selected. ABI &TBI were measured with an automated vascular Doppler XT 6 ports bilaterally for all subjects. For any subject, the limb with lower ABI and TBI was included for analysis. ABI < 0.9 & TBI < 0.6 were taken as evidence of PAD. CTA showing > 50% narrowing was taken as evidence of PAD. 24% of our study subjects had CTA confirmed PAD. ABI has low sensitivity of 35.29% (95% CI 0.21-0.52) compared to TBI being 82.35% (95% CI 0.66-0.92). The specificity however was similar. ABI < 0.9 was able to detect CTA confirmed PAD, but ABI > 0.9, including the so-called normal ABI (0.9-1.3) was unable to detect PAD. ROC showed ABI at 1.005 has sensitivity 64.71% (95% CI 0.48- 0.79) and specificity 61.7% (95% CI 0.53-0.69) and TBI at 0.6 has sensitivity 82.35% (95% CI 0.66-0.92) & specificity 92% (95% CI 0.87-0.96). Utilizing Cohen's Kappa, the reliability of ABI with respect to CTA showed fair agreement (K = 0.225, p = 0.001), whereas the reliability of TBI with respect to CTA showed substantial agreement (K = 0.759, p < 0.0001). ABI < 0.9 detects PAD reliably, but presence of PAD in patients with ABI > 9.0 including the normal of ABI (0.9-1.3) can be confirmed with TBI, which correlated strongly with CTA. TBI is also non-inferior for PAD detection, when ABI < 0.9. TBI and not ABI can be utilized for initialassessment of PAD in subjects with T2D.

Evaluation of Peripheral Arterial Disease in Patients Presenting with Diabetic Foot Ulcer to Endocrine Clinic

Background and Aim: Diabetes mellitus is an increase in blood glucose levels results in altered fat, protein metabolism, and carbohydrate which leads to cardiac, eye, nervous system dysfunction, and kidney. The major cause of hospitalizations in patients with diabetes mellitus (DM) is diabetic foot ulcers (DFU). The purpose of the present study was to evaluate the peripheral arterial disease in diabetic foot ulcer patients presented to endocrine clinic. Patients and Methods: This descriptive cross-sectional study was carried out on 206 diabetic foot ulcers patients presented to the endocrine clinic in Peshawar from January 2021 to December 2022. Patients were enrolled after taking written informed consent from each individual. Patient’s details such as gender, age, peripheral artery disease (PAD), diabetes types, heart failure, wound size, diabetes duration, end-stage renal disease, DFU history, prior history of amputation, and peripheral neuropathy were recorded. Angiography and revascularization may be required if arterial Doppler ultrasound confirmed PAD. Additionally, wound debridement and topical dressings were applied. In the treatment of wound ischemia, pentoxifylline, and calcium blockers were recommended along with diabetes control procedures and appropriate antibiotics. SPSS version 27 was used for data analysis. Results: Of the total 206 DFU patients, there were 142 (68.9%) male and 64 (31.1%) females. The prevalence of peripheral artery disease (PAD) was 58.3% (n=120). Age-wise distribution of patients were as follows: 31 (15%) in 25-45 years, 107 (52%) in 46-65 years, 60 (29.1%) in 66-85 years, and 8 (3.9%) &gt;85 years. Out of 206 DFU patients, the prevalence of type-I diabetes mellitus and type-II diabetes mellitus was 8 (3.9%) and 198 (96.1%) respectively. PAD prevalence was significantly associated with Type 2 diabetes. The incidence of PAD in plantar foot, non-plantar foot, and heel was 66 (55%), 42 (35%), and 12 (10%) respectively among 120 cases. Out of 206 DFU cases, the incidence of peripheral neuropathy, DFU history, amputation history, heart failure, and chronic renal failure was 142 (68.9%), 104 (50.5%), 54 (26.2%), 46 (22.3%), and 42 (20.4%) respectively. Conclusion: The present study concluded that the prevalence of peripheral artery disease (PAD) was 58.3% among diabetic foot ulcers. Results indicate that DFU and PAD are significantly related. It has been found that male patients with DFU were more likely to suffer from PAD as compared to women with statistically insignificant association. Keywords: Peripheral artery disease, diabetic foot ulcers, type-II diabetes mellitus

Advanced virtual monoenergetic imaging algorithm for lower extremity computed tomography angiography: effects on image quality, artifacts, and peripheral arterial disease evaluation

To investigate the image quality of lower extremity computed tomography angiography (LE-CTA) using a reconstruction algorithm for monoenergetic images (MEIs) to evaluate peripheral arterial disease (PAD) at different kiloelectron volt (keV) levels. A total of 146 consecutive patients who underwent LE-CTA on a dual-energy scanner to obtain MEIs at 40, 50, 60, 70, and 80 keV were included. The overall image quality, segmental image quality of the arteries and PAD segments, venous contamination, and metal artifacts from prostheses, which may compromise quality, were analyzed. The mean overall image quality of each MEI was 2.9 ± 0.7, 3.6 ± 0.6, 3.9 ± 0.3, 4.0 ± 0.2, and 4.0 ± 0.2 from 40 to 80 keV, respectively. The segmental image quality gradually increased from 40 to 70-80 keV until reaching its highest value. Among 295 PAD segments in 68 patients, 40 (13.6%) were scored at 1-2 at 40 keV and 13 (4.4%) were scored at 2 at 50 keV, indicating unsatisfactory image quality due to the indistinguishability between high-contrast areas and arterial calcifications. The segments exhibiting metal artifacts and venous contamination were reduced at 70-80 keV (2.6 ± 1.2, 2.7 ± 0.5) compared with at 40 keV (2.4 ± 1.1, 2.5 ± 0.7). The LE-CTA method using a reconstruction algorithm for MEIs at 70-80 keV can enhance the image quality for PAD evaluation and improve mitigate venous contamination and metal artifacts.

Evaluation of Peripheral Arterial Disease Using Noncontrast Magnetic Resonance Angiography

Introduction: Peripheral arterial disease is common in older age group. PAD is evaluated using Doppler, contrast CT and MR angiography. Many PAD patients have comorbidities like diabetes, hypertension and renal dysfunction. CT and MR contrast administration is considered risky in patients with impaired renal function. CT contrast agents are nephrotoxic. Gadolinium-based MRI contrast are associated with nephrogenic systemic fibrosis in patients with severe renal dysfunction. Aims: The aim of our study was to evaluate the usefulness of non contrast enhanced MR angiography in imaging of peripheral arteries in patients with impaired renal function. Materials and Method: This prospective study was done using ECG-triggered 2D TOF MR Angiograpgy on 1.5 Tesla MR unit in PAD patients having renal dysfunction. We studied various arterial segments of lower limb for the degree of narrowing on MRA and compared the findings in all patients with duplex scan and in some patients with DSA. We determined accuracy, sensitivity, specificity, PPV and NPV of MRA compared to duplex scan for assessment of arterial luminal narrowing. Results: Our study results have demonstrated that in patients with high grade blockage (&gt;50% diameter reduction or arterial occlusion) NC MRA had almost 100 % accuracy, sensitivity, specificity, PPV and NPV when compared to duplex scan in iliac, femoro-popliteal and tibioperoneal segment. In patients with low grade blockage (&lt;50% diameter reduction) NC MRA had low sensitivity with high specificity and NPV. Conclusion: ECG-triggered non contrast-enhanced MR angiography (NCMRA) is safe and highly accurate in PAD patients having renal dysfunction.

Correlation of Multidetector Computed Tomography Peripheral Angiography with Color Duplex Sonography in Peripheral Arterial Disease.

With aging of the global population peripheral arterial disease is increasingly common. Arteriography, computed tomography angiography and magnetic resonance angiography are common modalities used for evaluation of peripheral arterial disease. However, they have limitations of being invasive, costly, limited availability or contraindicated in patients with renal impairment or contrast allergy. Duplex imaging, a method of evaluation of peripheral arterial disease is cost effective, widely available and safe even in patients with renal impairment and contrast allergy. A prospective cross sectional descriptive study involving 114 patients was conducted from November 2015 to October 2016. The patients were evaluated by Doppler ultrasound following multi-detector computed angiography in Department of Radiology, Tribhuvan University Teaching Hospital. The lower limb arteries were divided into 10 segments and stenosis or occlusion of each segment in Computed Tomography angiography were compared with findings in Doppler, Computed Tomography angiography being considered the gold standard. Data was collected in predesigned proforma in Microsoft Excel spread sheet. Duplex imaging showed sensitivity 94.94%, specificity 98.54%, accuracy 97.54%, positive predictive value 96.15 % and negative predictive value 98.06 %. In assessment of 22 segments, partial stenosis seen in Computed Tomography angiography was overestimated as complete stenosis in Doppler. There was significant positive correlation of velocity ratio with degree of partial occlusion (r=0.918 for right lower limb and r=0.895 for left lower limb, p <0.01). Duplex imaging is safe cost effective and reliable method of evaluation of patients with peripheral arterial diseases.

Artificial intelligence for the evaluation of peripheral artery disease using arterial Doppler waveforms to predict abnormal ankle-brachial index.

Patients with peripheral artery disease (PAD) are at increased risk for major adverse limb and cardiac events including mortality. Developing screening tools capable of accurate PAD identification is a necessary first step for strategies of adverse outcome prevention. This study aimed to determine whether machine analysis of a resting Doppler waveform using deep neural networks can accurately identify patients with PAD. Consecutive patients (4/8/2015 - 12/31/2020) undergoing rest and postexercise ankle-brachial index (ABI) testing were included. Patients were randomly allocated to training, validation, and testing subsets (70%/15%/15%). Deep neural networks were trained on resting posterior tibial arterial Doppler waveforms to predict normal (> 0.9) or PAD (⩽ 0.9) using rest and postexercise ABI. A separate dataset of 151 patients who underwent testing during a period after the model had been created and validated (1/1/2021 - 3/31/2021) was used for secondary validation. Area under the receiver operating characteristic curves (AUC) were constructed to evaluate test performance. Among 11,748 total patients, 3432 patients met study criteria: 1941 with PAD (mean age 69 ± 12 years) and 1491 without PAD (64 ± 14 years). The predictive model with highest performance identified PAD with an AUC 0.94 (CI = 0.92-0.96), sensitivity 0.83, specificity 0.88, accuracy 0.85, and positive predictive value (PPV) 0.90. Results were similar for the validation dataset: AUC 0.94 (CI = 0.91-0.98), sensitivity 0.91, specificity 0.85, accuracy 0.89, and PPV 0.89 (postexercise ABI comparison). An artificial intelligence-enabled analysis of a resting Doppler arterial waveform permits identification of PAD at a clinically relevant performance level.

Evaluation of peripheral arterial disease in type 2 diabetic patients using computed tomography angiography

Background: Peripheral artery disease (PAD) in patients with Type 2 diabetes mellitus (T2DM) has broad characteristics and various complications. Aim: The purpose of this study is to evaluate PAD in T2DM and their association with age, gender, and the duration of T2DM. Materials and Methods: This study is a prospective cross-sectional one conducted at the radiology department in Royal Care International Hospital, Khartoum, Sudan, over 3 years. A total of one hundred and ten patients, 69 males and 41 females, were examined using MDCT. A binary logistic regression test was applied to identify independent predictors of PAD. Results: PAD in T2DM is found to be 50.91% atherosclerosis, 43.64% plaques, 29.09% stenosis, and 14.55% thrombosis (mean age 65.84 ± 9.57 years; mean duration of T2DM 29.37 ± 6.7 years). The prevalence of PAD was common in patients over 60-year-old. Atherosclerosis is significantly higher in males than females (59.4% vs. 36.6%, 95% confidence interval = 1.092–5.600, P = 0.03%). Plaques and stenosis of lower-extremity arteries were higher in males than females 44.9% vs. 41.5% and 29.0% vs. 29.3%) respectively. The incidence of thrombosis was higher in femoral arteries than lower distal arteries, and the prevalence was higher in females than males (22% vs. 10.1%, odds ratio = 2.228), respectively. Conclusion: Atherosclerosis, plaques, stenosis, and thrombosis were the most common PAD findings in patients affected with T2DM. Age, gender, and duration of diabetes, relatively risk factors associated with PAD. Thrombosis is more prevalent in the femoral artery than lower distal arteries.

Feasibility of Photo-Optical Transcutaneous Oxygen Tension Measurement During Revascularization of the Lower Extremity

ObjectivesA novel approach in the evaluation of peripheral arterial disease is the photo-optical oxygen tension measurement (pTCpO2). This modality is suggested to be more practical in use in comparison to standard electro-chemical oxygen tension measurement. Hence, pTCpO2 might be of added value to evaluate revascularization of the lower extremities peri-procedural. We conducted a preliminary feasibility study to analyze the potential of pTCpO2 during revascularization. MethodsTen patients scheduled for revascularization of the lower extremities were enrolled. pTCpO2 values of the affected lower extremity were measured pre-operatively, during revascularization and after revascularization. Results were compared to the pre- and postoperative ankle-brachial index (ABI) and to perioperative angiography. Primary endpoint was the feasibility of perioperative pTCpO2 measurement. Secondary endpoints were concordance between pTCpO2, ABI, angiography and clinical outcome. ResultsTwo out of twelve measurements were unsuccessful. Eight out of ten patients experienced significant clinical improvement and pTCpO2 increase. Two patients that did not experience clinical improvement corresponded with no changes in intraoperative angiography and without increase in ABI or pTCpO2. A significant and strong correlation was found between prior and after revascularization ABI and pTCpO2 measurements (r = 0.82 P = 0.04). ConclusionsPhoto-optical transcutaneous oxygen tension measurement may serve as an intraoperative tool to evaluate the success of revascularization. pTCpO2 could be an alternative for the ABI to determine the success of lower extremity revascularization.

Computational methods to automate the initial interpretation of lower extremity arterial Doppler and duplex carotid ultrasound studies

BackgroundLower extremity arterial Doppler (LEAD) and duplex carotid ultrasound studies are used for the initial evaluation of peripheral arterial disease and carotid stenosis. However, intra- and inter-laboratory variability exists between interpreters, and other interpreter responsibilities can delay the timeliness of the report. To address these deficits, we examined whether machine learning algorithms could be used to classify these Doppler ultrasound studies. MethodsWe developed a hierarchical deep learning model to classify aortoiliac, femoropopliteal, and trifurcation disease in LEAD ultrasound studies and a random forest machine learning algorithm to classify the amount of carotid stenosis from duplex carotid ultrasound studies using experienced physician interpretation in an active, credentialed vascular laboratory as the reference standard. Waveforms, pressures, flow velocities, and the presence of plaque were input into a hierarchal neural network. Artificial intelligence was developed to automate the interpretation of these LEAD and carotid duplex ultrasound studies. Statistical analysis was performed using the confusion matrix. ResultsWe extracted 5761 LEAD ultrasound studies from 2015 to 2017 and 18,650 duplex carotid ultrasound studies from 2016 to 2018 from the Indiana University Health system. The results showed the ability of artificial intelligence algorithms and method, with 97.0% accuracy for predicting normal cases, 88.2% accuracy for aortoiliac disease, 90.1% accuracy for femoropopliteal disease, and 90.5% accuracy for trifurcation disease. For internal carotid artery stenosis, the accuracy was 99.2% for predicting 0% to 49% stenosis, 100% for predicting 50% to 69% stenosis, 100% for predicting >70% stenosis, and 100% for predicting occlusion. For common carotid artery stenosis, the accuracy was 99.9% for predicting 0% to 49% stenosis, 100% for predicting 50% to 99% stenosis, and 100% for predicting occlusion. ConclusionsThe machine learning models using LEAD data, with the collected blood pressure and waveform data, and duplex carotid ultrasound data with the flow velocities and the presence of plaque, showed that novel machine learning models are reliable in differentiating normal from diseased arterial systems and accurate in classifying the extent of vascular disease.

Ankle brachial index as a surrogate to vascular imaging in evaluation of peripheral artery disease in patients with type 2 diabetes

BackgroundPeripheral artery disease (PAD) is common in persons with type 2 diabetes (T2DM) and contributes significantly to cardiovascular morbidity and mortality. Controversy exists regarding the utility of ankle brachial index (ABI) for clinical diagnosis of PAD in persons with diabetes. The aim of this study was to evaluate the reliability of ABI for diagnosis of PAD in patients with T2DM using duplex ultrasonography (DUS) as the gold standard.ResultsA total of 319 legs from 163 patients comprising of 156 subjects with intact legs and 7 patients who had undergone unilateral lower limb amputations were studied. The mean age of the participants was 56.1 ± 17.3 years. One hundred and ninety-five legs (61.1%) had sonographically confirmed PAD which was mild, moderate and severe in 40%, 41.5% and 18.5% respectively. The accuracy of ABI in detecting PAD was 76.7% for mild stenosis, 91.7% for moderate stenosis and 93.1% for severe stenosis. The sensitivity of ABI improved with increasing severity of arterial stenosis, reaching 100% in severe cases. ABI demonstrated good agreement with DUS [kappa = 0.65 (95% CI 0.49–0.88), P < 0.001].ConclusionIn comparison to DUS, the ABI demonstrated good reliability for diagnosis of PAD in high risk T2DM patients. The utility of this simple and non-invasive procedure should therefore be maximized in clinical practice.

Is Toe Brachial Index a Better Tool than Ankle Brachial Index for Predicting Outcomes in Diabetic Foot Patients?

Introduction: Diabetes accounts for more than 50% of lower extremity amputation, of which 85% of lower limb amputation in diabetic patients are preceded by foot ulcers. The increasing prevalence of ischaemic ulcers has made ischaemia probably the most important cause of Diabetic Foot Ulcers (DFUs) today. Modalities for assessment of vasculopathy include clinical examination of pulses, Ankle Brachial Pressure Index (ABI), Toe Brachial Pressure Index (TBI), Transcutaneous partial pressure of Oxygen (TCpO2), Duplex imaging, Magnetic Resonance (MR) and Computed Tomography Angiography (CTA). Aim: This study was aimed at evaluation of ABI and TBI in assessment of vasculopathy in DFUs and their association with the various surgical outcomes. Materials and Methods: This study was done as a cross-sectional study on 100 patients with diabetic foot, from December 2016 to April 2018, with prospective follow-up till the outcome of “ulcer healed”, “minor/major amputation” with healing of the amputation stump, was achieved. The multimodality approach for treatment of DFU was taken. Variables like age, gender, duration of present ulcer, previous history of ulcers and interventions, comorbidities, history of smoking and duration of diabetes were recorded and assessed. The examination included examination of peripheral pulses, presence of neuropathy, measurement of ABI and TBI. Investigations included HbA1c levels, swab or pus cultures from the ulcers, objective evaluation of Peripheral Arterial Disease (PAD) by Duplex Ultrasonography and CT Angiography where an intervention was contemplated. The data was entered in MS Excel spreadsheet and analysis was done using Statistical Package for Social Sciences (SPSS) version 21.0. Results: The mean age was 62.55±9.21 years, with maximum patients belonging to the age group 61-70 years (38%) followed by 51-60 years age group (33%). Smoking as a risk factor was present in 59% of all the patients. A total of 53 patients underwent amputation among which 28 were smokers (52.8%). Neuropathy was present in 47.22% (n=51), with 60.87% of all patients with neuropathy undergoing amputation which was significant (p-value=0.005). When defined by ABI alone (ABI &lt;0.9), 46.3% patients had PAD, however, using TBI &lt;0.7 for defining PAD, incidence of PAD increased to 68.31% patients. Thus identifying 21 more patients with PAD as compared to ABI. Poor glycaemic control was significantly associated with poor outcome in the form of amputation (p&lt;0.001). Patients who underwent major amputation had a mean ABI of 0.54±0.22, for minor amputation the mean ABI was 0.85±0.19 and for those who had healed ulcers, had a mean ABI of 0.61±0.27. The cut-off value for ABI to predict amputation was &gt;0.51 with a sensitivity of 77.14 and a specificity of 56.1, which was not found to be significant (p-value=0.0796). The mean TBI for the diabetic feet was 0.25±0.12 for major amputation, 0.42±0.26 for minor amputation and 0.61±0.19 for ulcer healed. With a cut-off value of ≤0.3, the sensitivity and specificity for predicting amputation were 68.75 and 88.68 respectively which was found to be significant (p&lt;0.001). Conclusion: The ABI has been found to under-report ischemia as compared to TBI in diabetic patients. TBI also correlates better with the outcome of a DFU. Thus, making TBI a part of assessment of vasculopathy in DFU patients who have not undergone toe amputations, would help in correctly identifying ischemia and early institution of possible intervention in such patients.

Computed Tomography Angiography Evaluation of Peripheral Arterial Disease and Correlation with Colour Doppler

Background: Peripheral Arterial Disease Is a Major Problem Among the Population of Those 55 Years and Older. MDCT is a Non-Invasive Method of Visualization of Vascular System. It Affords More Widespread Vascular Screening, Allowing Diagnosis to be Made at an Early Stage. The objective is to Assess the Role of Multidetector Computed Tomography Angiography in Peripheral Arterial Disease of Lower Extremities. Subjects &amp; Methods: A Prospective Study of 35 Patients with Signs and Symptoms of PVD, Were Subjected to Colour Doppler Ultrasonography and MDCT Examination Between a Period of 1st August 2018 to 31st May 2019. Results: Our Study Shows a Very Good Sensitivity, Specificity, PPV, NPV and Accuracy of Doppler in Assessing the Soft Plaque (82%, 100%, 100%, 97%, 97% Respectively) &amp; in Evaluation of Stenosis Like &lt;50% Stenosis (100%, 99%, 85%, 100% &amp; 99% Respectively), 50-99% Stenosis (100%, 99%, 96%. 100% &amp; 99.8% Respectively), &amp; Occlusion (84%, 100%. 100%, 98% &amp; 98% Respectively). The Only Parameter Which Showed Poor Result Was in Evaluation of Calcified Plaque. Conclusion: Our Study Shows that Both Colour Doppler &amp; MDCT Can Be Complimentary in Lower Limb Arterial Disease Evaluation.

Managing Complicated Diabetic Foot Ulcers with Peripheral Arterial Disease

Background: Diabetic foot ulcers are an issue of clinical interest as diabetes has become the leading cause of occlusive vasculopathy. The purpose of this study is to evaluate the clinical outcomes and the effect of revascularization in diabetic foot ulcers with peripheral arterial occlusive disease (PAOD).Methods: A total of 46 patients who had surgical treatment for diabetic foot ulcers were evaluated. We conducted an intergroup comparison of their baseline demographic and clinical characteristics, and also compared surgical outcomes between cases with and without PAOD, and also between cases on which revascularization had and had not been performed.Results: Major amputation was performed on 10 patients (21.7%). Minor amputation and reconstructive surgery were performed on 24 patients (52.2%) and 12 patients (26.1%), respectively. In the 19 patients (41.3%) with severe obstruction, eight patients (42.1%) underwent major amputation. In the patients without severe obstruction, two patients (7.4%) underwent major amputation. The high proportion of major amputation in patients with severe obstruction was statistically significant (P&lt;0.01). Among the 19 patients with severe obstruction, nine (47.4%) underwent revascularization and 10 patients (52.6%) did not. In the patients who had revascularization, one patient (11.1%) had major amputation. In the patients who did not have revascularization, seven (70.0%) underwent major amputation. The low proportion of major amputation in patients undergoing revascularization was statistically significant (P=0.02).Conclusion: Results of this study demonstrate that preoperative evaluation of peripheral arterial disease and revascularization are important for reducing the risk of major amputation.

Correlation of Ankle - Brachial Index (ABI) and Low - Density Lipoprotein (LDL) with Diabetic Foot Severity Degree

Abstract: Diabetic foot is a complication of diabetes mellitus which is characterized by ulceration in the legs. The severity of the diabetic foot can be determined by the Wagner-Meggit system which in this study uses 5 categories namely degrees 1 - 5 degrees. ABI (Ankle-Brachial Index) is an evaluation of peripheral arterial disease in diabetic foot patients. LDL is the main factor of atherosclerosis which causes macrovascular disorders in diabetic foot. The purpose of this study was to determine the correlation between ABI and LDL on the severity of diabetic foot based on the Wagner-Meggit classification. The method used is observational analytic with cross sectional approach. A total of 35 samples were obtained by consecutive sampling. Data analysis was performed using the Spearman test and logistic regression. A significant correlation was obtained between ABI and the severity of diabetic foot (p = 0.06; r = -0.424), there was no correlation between LDL and the severity of diabetic foot (p = 0.09; r = -0.395). The results of logistic regression analysis found no correlation between ABI (p = 0.163; OR = 0.008) and LDL (p = 0.69; OR = 0.984) with the severity of the diabetic foot. Obtained Negelkerke R Square value of 0.095. Keywords: Diabetic foot, ABI, LDL, Wagner-Meggit classification

Imaging in the diagnosis and evaluation of peripheral artery disease.

Peripheral artery disease (PAD) is a disease of the systemic arterial tree and is a growing concern globally. It commonly affects the lower extremities and leads to increased mortality and morbidity due to its known association with coronary artery disease and strokes. Over the past several decades, advanced imaging has become a major part in the diagnosis and management of PAD, but there is still no consensus agreement as to the preferred initial imaging test of choice. Over the years, several different trials, reviews, and analyses have compared the three primary imaging modalities in PAD: ultrasound, magnetic resonance angiography (MRA), and computed tomographic angiography (CTA). Overall, the literature suggests that while MRA may have a slight advantage in accuracy, CTA may be the better initial test of choice due to patient comfort and cost-effectiveness. However, each imaging modality has its own risks and contraindications that should be carefully reviewed prior to utilization. This is a review of the current available literature comparing the use of ultrasound, MRA, and CTA in the diagnosis and management of lower extremity PAD.

Role of color Doppler ultrasound and MDCT angiography in the evaluation of peripheral arterial disease

Background and Objective: The main objective is to study the correlation between color Doppler ultrasound and multidetector computed tomography (MDCT) angiography in evaluating peripheral arterial disease. Settings and Design: Prospective observational study. Materials and Methods: The study was conducted in the Department of Radio Diagnosis, SVIMS, over a period of 18 months from March 2018 to July 2019. All of the 80 consecutive patients who were referred to the Department of Radio Diagnosis with clinical suspicion of peripheral arterial disease (PAD) were studied. Color Doppler ultrasound followed by MDCT angiography were done in all of the patients. Results: Out of the total 1680 vessel segments in 80 patients, color Doppler sonography (CDS) was able to detect 545 (32.4%) positive segments, in comparison to the CTA which was able to detect 732 (43.5%) bilaterally, with 11.1% of cases detected more on MDCT angiography predominantly grade-2, 3, 4, except for grade-1. On overall except for wall thickness, MDCT angiography was better in detecting wall calcification, occlusion, and thrombus on comparison with CDS. Conclusion: CDS and MDCT angiography showed good agreement for grade-0, 1 PAD when compared to grade-2, 3, 4. CDS with an advantage of no risk of radiation, contrast related complications should be considered as a preliminary screening test in all patients with clinical suspicion of PAD. MDCT angiography should be considered for grade-2, 3, 4 stenosis assessments for selecting an appropriate treatment.

Evaluation of peripheral artery disease with the TIVITA® Tissue hyperspectral imaging camera system.

Objective, reliable and easy screening for peripheral artery disease (PAD) is essential to confirm the diagnosis and initiate the respective treatment. Therefore, a new non-invasive hyperspectral camera (TIVITA® Tissue) was tested in patients with and without PAD. It was hypothesized that the oxygenation parameters of the TIVITA® Tissue correlate to established modalities for detection of PAD and allow differentiation between individuals with and without PAD. Evaluation of tissue oxygenation was performed in the angiosome of the medial plantar artery in 25 healthy young people and in 24 patients with and 25 patients without PAD in comparable age. Thereby, superficial oxygenation (StO2) and near-infrared (NIR) perfusion index were measured with the TIVITA® Tissue. Additionally, the ankle-brachial-index (ABI), the complaint free walking distance and the vascular quality of life were assessed and demographic data were obtained from all participants. TIVITA® Tissue analysis revealed significantly reduced StO2 and NIR perfusion index in PAD compared to healthy young participants and patients without PAD. StO2 and NIR perfusion index positively correlated with ABI, the complaint free walking distance and the vascular quality of life score. In summary, this new hyperspectral imaging camera bears great potential for PAD screening as well as for follow up.

Likelihood of Normal ABI Increases With Physiologic Testing Referrals From Rural Primary Care Physicians

Disparities in diagnostic capabilities have been noted between rural and urban health care facilities. We believe the clinical evaluation of peripheral arterial disease (PAD) by rural physicians may be similarly affected. Patients referred for arterial physiologic testing in an urban and rural regional health care network for a consecutive 7-month period were reviewed. Patients were classified into 3 groups based on referring physician specialty: (1) vascular surgeon or vascular medicine specialist (Vasc), (2) urban primary care physician (Urban), and (3) rural primary care physician (Rural). Normal patients were defined by a posterior tibial (PT) or dorsalis pedis (DP) ankle-brachial index (ABI) of ⩾0.90, bilaterally. Abnormal patients had both PT and DP ABI &lt;0.90 in one or both extremities. Group comparisons were made for normal and abnormal patients, age (⩾65 years old), and gender. Patients with history of amputations, angioplasty, bypass graft, stent, calcification (PT or DP ABI ⩾1.30), and previous physiologic testing outside the designated period of analysis were considered a separate subclassification and analyzed separately. Emergency room referrals, inpatients, and patients with incomplete examination data were excluded from the analysis. A total of 430 patient exams were evaluated. Group-Rural had significantly greater numbers of normal ABI patients compared with Group-Urban ( P = .0028) and Group-Vasc ( P = .0000). No significant differences were noted between all groups for age and gender. Substantial disparities were noted in normal and abnormal ABI patients between rural health care physicians and their urban primary care and vascular specialist counterparts. Significantly greater numbers of normal ABI referrals by rural primary care physicians may warrant enhanced PAD diagnosis education or telemedicine alternatives.

Free-Breathing Fast Low-Angle Shot Quiescent-Interval Slice-Selective Magnetic Resonance Angiography for Improved Detection of Vascular Stenoses in the Pelvis and Abdomen: Technical Development.

Balanced steady-state free precession-based quiescent-interval slice-selective (bSSFP QISS) magnetic resonance angiography (MRA) is accurate for the noncontrast evaluation of peripheral arterial disease (PAD); however, drawbacks include the need for breath-holding when imaging the abdomen and pelvis, and sensitivity to off-resonance artifacts. The purpose of this study was to evaluate the image quality and diagnostic accuracy in the pelvis and abdomen of free-breathing fast low-angle shot-based QISS (FLASH QISS) techniques in comparison to bSSFP QISS in patients with PAD, using computed tomographic angiography as the reference. Twenty-seven patients (69 ± 10 years, 17 men) with PAD were enrolled in this institutional review board-approved, Health Insurance Portability and Accountability Act-compliant prospective study between April and December 2018. Patients underwent noncontrast MRA using standard bSSFP QISS and prototype free-breathing radial-FLASH and Cartesian-FLASH QISS at 3 T. A subset of patients (n = 22) also underwent computed tomographic angiography as the reference standard. Nine arterial segments per patient were evaluated spanning the abdomen, pelvis, and upper thigh regions. Objective (signal intensity ratio and relative standard deviation) and subjective image quality (4-point scale) and stenosis (>50%) were evaluated by 2 readers and compared using one-way analysis of variance, Wilcoxon, and McNemar tests, respectively. A total of 179 vascular segments were available for analysis by all QISS techniques. No significant difference was observed among bSSFP, radial-FLASH, and Cartesian-FLASH QISS techniques in signal intensity ratio (P = 0.428) and relative standard deviation (P = 0.220). Radial-FLASH QISS demonstrated the best image quality (P < 0.0001) and the highest interreader agreement (κ = 0.721). The sensitivity values of bSSFP, radial-FLASH, and Cartesian-FLASH QISS for the detection of greater than 50% stenosis were 76.0%, 84.0%, and 80.0%, respectively, whereas specificity values were 97.6%, 94.0%, and 92.8%, respectively. Moreover, FLASH QISS consistently reduced off-resonance artifacts compared with bSSFP QISS. Free-breathing FLASH QISS MRA techniques provide improved image quality and sensitivity, high specificity, and reduced off-resonance artifacts for vascular stenosis detection in the abdomen and pelvis.