Lower Extremity Angiography Research Articles

Intraoperative Pedal Pressure Changes Offers Another Quantitative Assessment for Revascularization

IntroductionLower extremity angiography is one of the most prevalent vascular procedures performed, generally via the contralateral common femoral artery. The use of retrograde pedal artery access to perform angiography has long been reserved as a “bail-out” technique to help cross chronic total occlusions that were not amenable from an antegrade approach. Recently, there has been reports and discussion involving increased utilization of pedal access for primary revascularization. The purpose of this study is to describe the outcomes of pedal access as a primary approach and to propose a novel evaluation of distal perfusion changes associated with interventions using direct pressure measurements. MethodsA retrospective observational study evaluating all patients who underwent lower extremity angiography via retrograde pedal access between December 1st 2020 and June 30th 2021 within a single healthcare system spanning 3 hospitals was performed. Demographics, comorbidities, procedural indications, and details were all recorded. Hemodynamic measurements were obtained and recorded upon initial pedal access and post intervention with a pressure transducer connected directly to the access sheath. Outcomes were analyzed with a paired t-test. ResultsTwenty-eight angiograms using primary pedal access for endovascular intervention were performed during the study period. Most patients were African American (75%) females (57.1%) with hypertension (89.3%), hyperlipidemia (78.6%), diabetes (85.7%), coronary artery disease (64.3%), and current tobacco user (57.1%). The most prevalent indication for angiography was nonhealing wounds (67.9%). Pedal access was mostly achieved via the anterior tibial artery (79%). Sixty-three vessels were treated during the 28 angiograms (averaging 2.3 vessels per angiogram), most commonly the superficial femoral (27%), anterior tibial (25%), and popliteal (22%) arteries. Balloon angioplasty with or without stenting (98.5%) was predominately performed with an overall technical success rate of 94%. The mean pre- and post-intervention pressures were 36.5mmHg (standard deviation 25.7) and 83.4mmHg (standard deviation 19.5), respectively. The mean change in pressure after intervention was 46.9mmHg (standard deviation 23.3) (Table 3). There was a statistically significant difference detected between pre-intervention and post-intervention pressure (p<0.00) (Figure 1). There were no major amputations or adverse cardiovascular events at a mean first follow-up duration of 89 days. Six of the total 28 patients (21.4%) underwent repeat endovascular intervention on the ipsilateral extremity within a median of 45 (IQR 22.5-62.3) days. ConclusionPrimary pedal access is a viable option for performing lower extremity angiographic interventions. A significant increase in pedal artery pressure can be observed after angiographic intervention from retrograde pedal artery access. Further studies are necessary to define the clinical prognostic importance of these findings in relation to wound healing rates.

Establishment of an institutional diagnostic reference level for vascular lower extremity computed tomography angiography

About 70% of all collective doses from medical tests come from computed tomography (CT), the primary public radiation exposure source. Patients received higher doses during contrast-enhanced CT procedures (Angiography) than routine CT procedures. The current research aims to quantify the patients' radiation doses, estimate the cancer risk probability, and establish institutional diagnostic reference level (IDRL) during lower extremity angiography. One hundred eleven patients (61.3% male and 38.7% female) underwent contrast-enhanced CT procedures. A 160-Slice CT scanner was used for image acquisition for all patient populations. IDRL values were quantified based on the 3rd quartile value of the CT dose descriptors. All procedures were carried out at Al-Moaallim Medical City, Khartoum, Sudan. A computer software (CT-Expo, ImPACT) was used to extrapolate the effective dosage per extremity CTA examination was estimated. The mean patient age (years) was 56.1 ± 18 (18–82). The patient’s radiation doses was quantified using volume CTDI and dose length product (DLP) to 7.3 ± 2 (2.9–16.8) (mGy) and 3712 ± 126 (279–8374) (mGy.cm), respectively. The average effective doses were 22 mSv (range: 1.7–50) per lower CT angiography for the lower extremity. The proposed IDRL for the VCTA procedure was 3562 mGy cm and 17 mGy for DLP and CTDIvol, respectively. The proposed IDRL is higher than the previously published studies; therefore, patient dose optimization is recommended.

Luminal Gain After Atherectomy Measured by Intravascular Ultrasound (IVUS) and Impact on Short-term Results

Atherectomy has been proposed to debulk lesions prior to intervention. Data on the degree of luminal gain after this procedure are not available. We evaluated immediate luminal gain, measured by intravascular ultrasound (IVUS) following various types of percutaneous atherectomy. Short-term patency and residual stenosis was measured by duplex ultrasound (DUS). We prospectively collected data on 79 consecutive lower extremity revascularization procedures where atherectomy was performed. Severity of arterial stenosis was measured using angiography and IVUS. IVUS was used to identify severe (>70%) stenosis and the percent stenosis pre and immediately post atherectomy. The difference represented percent luminal gain by atherectomy alone. Comparisons were analyzed using various atherectomy techniques including excimer laser, excisional rotational, and orbital atherectomy. Peak systolic velocities from pretreatment DUS were compared with post treatment DUS at 1 month follow up to evaluate effectiveness of atherectomy type in relation to degree of stenosis. We performed lower extremity angiography with atherectomy on 79 legs in 75 patients with an average age of 75.4 years (range, 40-91 years). Procedures included excimer laser (n = 35), excisional rotational (n = 33), and orbital atherectomy (n = 11). Sixty-eight above-knee (ATK) atherectomy and 28 below-knee (BTK) atherectomy procedures were performed. Patients presented with Rutherford Class 3 (62%; n = 49), Class 4 (16%; n = 13), Class 5 (19%; n = 15), and Class 6 (1.3%; n = 1). Atherectomy was performed in 68 vessels ATK and 28 vessels BTK with 16% of patients having multivessel intervention. In-stent stenosis was the indication for atherectomy in 22 vessels (28%). Average luminal gain was 23.6% for ATK atherectomy (range, 10%-39%) and 24.2% for BTK vessels (range, 11%-34%; P > .05). There was no difference in luminal gain based on atherectomy type, laser (25%), excisional rotational (23%) and orbital atherectomy (23%; P > .05. There was also no difference in luminal gain based on gender, male 26% and female 24% (P > .05). Using DUS pre and post angiogram with intervention, we noted an average decrease in PSV of 90 cm/s, 122.4 cm/s, 106.9 cm/s, and 31.4 cm/s for the common femoral artery, superficial femoral artery, above-knee popliteal artery, and below-knee popliteal artery, respectively. Atherectomy results in an average luminal gain of 24% regardless of location of atherectomy (ATK vs BTK), type of atherectomy device, or gender. This is associated with high rates of patency in both BTK and ATK vessels at short-term follow-up.

Virtual Monoenergetic Imaging of Lower Extremities Using Dual-Energy CT Angiography in Patients with Diabetes Mellitus.

Type 2 diabetes mellitus (DM) is the most common metabolic disorder in the world and an important risk factor for peripheral arterial disease (PAD). CT angiography represents the method of choice for the diagnosis, pre-operative planning, and follow-up of vascular disease. Low-energy dual-energy CT (DECT) virtual mono-energetic imaging (VMI) has been shown to improve image contrast, iodine signal, and may also lead to a reduction in contrast medium dose. In recent years, VMI has been improved with the use of a new algorithm called VMI+, able to obtain the best image contrast with the least possible image noise in low-keV reconstructions. To evaluate the impact of VMI+ DECT reconstructions on quantitative and qualitative image quality in the evaluation of the lower extremity runoff. We evaluated DECT angiography of lower extremities in patients suffering from diabetes who had undergone clinically indicated DECT examinations between January 2018 and January 2023. Images were reconstructed with standard linear blending (F_0.5) and low VMI+ series were generated from 40 to 100 keV, in an interval of 15 keV. Vascular attenuation, image noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were calculated for objective analysis. Subjective analysis was performed using five-point scales to evaluate image quality, image noise, and diagnostic assessability of vessel contrast. Our final study cohort consisted of 77 patients (41 males). Attenuation values, CNR, and SNR were higher in 40-keV VMI+ reconstructions compared to the remaining VMI+ and standard F_0.5 series (HU: 1180.41 ± 45.09; SNR: 29.91 ± 0.99; CNR: 28.60 ± 1.03 vs. HU 251.32 ± 7.13; SNR: 13.22 ± 0.44; CNR: 10.57 ± 0.39 in standard F_0.5 series) (p < 0.0001). Subjective image rating was significantly higher in 55-keV VMI+ images compared to the other VMI+ and standard F_0.5 series in terms of image quality (mean score: 4.77), image noise (mean score: 4.39), and assessability of vessel contrast (mean value: 4.57) (p < 0.001). DECT 40-keV and 55-keV VMI+ showed the highest objective and subjective parameters of image quality, respectively. These specific energy levels for VMI+ reconstructions could be recommended in clinical practice, providing high-quality images with greater diagnostic suitability for the evaluation of lower extremity runoff, and potentially needing a lower amount of contrast medium, which is particularly advantageous for diabetic patients.

Initial Experience Using Digital Variance Angiography in Context of Prostatic Artery Embolization in Comparison with Digital Subtraction Angiography.

In previous clinical studies digital variance angiography (DVA) provided higher contrast-to-noise ratio (CNR) and better image quality in lower extremity angiography than digital subtraction angiography (DSA). Our aim was to investigate whether DVA has similar quality reserve in prostatic artery embolization (PAE). The secondary aim was to explore the potential advantages of the color-coded DVA (ccDVA) technology in PAE. This retrospective study evaluated 108 angiographic acquisitions from 30 patients (mean ± SD age 68.0 ± 8.9, range 41-87) undergoing PAE between May and October 2020. DSA and DVA images were generated from the same unsubtracted acquisition, and their CNR was calculated. Visual evaluation of DVA and DSA image quality was performed by four experienced interventional radiologists in a randomized, blinded manner. The diagnostic value of DSA and ccDVA images was also evaluated using clinically relevant criteria (visibility of small [< 2.5 mm] and large arteries [> 2.5 mm], feeding arteries and tissue blush) in a paired comparison. Data were analysed by the Wilcoxon signed rank test or the binomial test, the interrater agreement was determined by the Kendall W or Fleiss Kappa analysis. DVA provided 4.11 times higher median CNR than DSA (IQR: 1.72). The visual score of DVA images (4.40 ± 0.05) was significantly higher than that of DSA (3.39 ± 0.07, p < 0.001). The Kendall W analysis showed moderate but significant agreement (WDVA = 0.38, WDSA = 0.53). The preference of ccDVA images was significantly higher in all criteria (63-89%) with an interrater agreement of 58-79%. The Fleiss Kappa range was 0.02-0.18, significant in all criteria except large vessels. Our data show that DVA provides higher CNR and better image quality in PAE. This quality reserve might be used for dose management (reduction of radiation dose and contrast agent volume), and ccDVA technology has also a high potential to assist PAE interventions in the future.

MAY-THURNER SYNDROME: UNCOMMONLY COMMON

SESSION TITLE: Thrombosis Jamboree: Rare and Unique Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: May-Thurner syndrome is a venous compression syndrome characterized by common iliac vein compression between the left lumbar spine and the common iliac artery. The most common pattern is left common iliac vein compression by the right common iliac artery. Clinical presentation can vary from asymptomatic to signs and symptoms of venous stasis. This can include lower extremity swelling, edema, pain, and ulceration. More advanced stenosis results in deep vein thrombosis (DVT). The exact incidence and prevalence of MTS are unknown; however, it is felt to be underdiagnosed. MTS can be attributed to 2-5% of all venous thromboembolism (VTE). We present a case of DVT and pulmonary embolism (PE) in a patient who was found to have MTS. CASE PRESENTATION: The patient was an 83-year-old male with diabetes mellitus and hypertension who presented to the emergency department (ED) for evaluation of dyspnea on exertion. In the ED he was noted to be in respiratory distress, but otherwise hemodynamically stable. He was hypoxic, requiring supplemental oxygen via nasal cannula. Serum studies and chest radiographs were unremarkable. Computed tomography angiography of the chest revealed saddle pulmonary embolism extending into bilateral upper lobar arteries. After a thorough history, it was felt the VTE was unprovoked. The patient was admitted to the ICU and underwent emergent catheter-directed pulmonary artery thrombectomy. Anticoagulation was initiated with unfractionated heparin infusion. An echocardiogram revealed normal left ventricular function and a moderately dilated right ventricle. Lower extremity ultrasound revealed extensive clot burden in the left femoral, popliteal, and tibial veins. Lower extremity angiography revealed compression of the left common iliac vein. He subsequently underwent venous thrombectomy and common iliac vein stenting. He tolerated the procedures and hospitalization well and was ultimately discharged in stable condition DISCUSSION: MTS is characterized by compression of the left common iliac vein by the right common iliac artery, with resultant stenosis and venous stasis. It is estimated to cause 2-5% of all VTE although the prevalence may be higher (1). Diagnosis requires a high clinical suspicion, as MTS does not present specific findings in the setting of VTE. Initial presentation could range from lower extremity swelling to pain, venous stasis, or ulcerations – all of which could be attributed to the DVT (2). Making the diagnosis is important, however, as it presents a chance for therapeutic endovascular intervention. CONCLUSIONS: Our case highlights first that MTS may be very underdiagnosed. Secondly, it is a cause of provoked venous thromboembolism. It may therefore present a therapeutic endovascular option and may alter the duration of anticoagulation. For these reasons, the clinician should consider MTS in the differential for all VTE, and especially for recurrent VTE Reference #1: 1. Sigua-Arce P, Mando R, Spencer L, Halalau A. Treatment of May–Thurner's syndrome and associated complications: A multicenter experience. Int J Gen Med. 2021;14:4705–10. Reference #2: 2. Knuttinen MG, Naidu S, Oklu R, Kriegshauser S, Eversman W, Rotellini L, et al. May-Thurner: Diagnosis and endovascular management. Cardiovasc Diagn Ther. 2017;7(Suppl 3):S159–64. DISCLOSURES: No relevant relationships by Wajahat Khan No relevant relationships by Nelson Okoh

Clinical significance of early venous enhancement on CT angiography of the ischemic lower limbs.

The authors observed good clinical courses in patients with lower limb ulcers and extensive skin inflammation who showed early venous enhancement at contrast-enhanced lower extremity computed tomographic angiography. The author hypothesized that these early venous enhancements tend to occur in conditions of healthier vascular status. A total of 145 patients who met the inclusion criteria were classified based on the degree of arterial occlusion and early venous enhancement according to lower extremity angiography. Early venous enhancement correlated with age over 65 (t-score = 0.001), absence of ulcer history (t-score = 0.003), absence of amputation history (t-score = 0.004), and low ankle-brachial index (P value = .001). We confirmed that the factors related with early venous enhancement differ from the factor inducing arterial occlusion. Prior to this study, early enhancement of veins in the lower limb was thought to be an artifact. However, in this study, veins that show early enhancement are suspected of being healthier and more responsive to inflammation than those that do not show early enhancement. These findings may help to predict the clinical course and to determine therapeutic planning without additional studies. Also, it can be easily reproduced in other facilities.

New Diagnostic Algorithm to Asymptomatic Coronary Artery Disease in Patients with Lower Peripheral Artery Disease

We retrospectively examined 4255 patients who experienced coronary angiography between September 2015 and January 2020. Medicana International Ankara Hospital Ethics Committee accepted the study schedule [Numbered: 2017/1]. Of the patients, 400 patients underwent both coronary angiography and lower extremity angiography because of peripheral artery disease symptoms. The odds ratios of coronary artery disease according to risk factors have been examined. Angiographically, lower extremity arteries were divided into three groups.

Popliteal Artery Entrapment Syndrome: A Diagnostic and Treatment Enigma for Orthopaedic Surgeons.

Popliteal artery entrapment syndrome (PAES) is an uncommon condition that causes recurrent posterior leg pain and foot paresthesia in running athletes. This condition occurs most commonly due to an accessory or abnormal implant of the medial head of the gastrocnemius muscle. It may mimic or coincide with other chronic conditions of the lower extremity including chronic exertional compartment syndrome but is most consistent with vascular claudication. Clinical features that distinguish PAES from other causes of leg pain include a sensation of coolness of the posterior leg during exercise and associated paresthesia of the plantar aspect of the foot. Physical examination often reveals decreased intensity of the posterior tibial or dorsalis pedis pulses with passive dorsiflexion or active plantarflexion of the ankle. Diagnostic tests that confirm the presence of PAES include lower extremity angiography during active resisted plantarflexion or maximal passive dorsiflexion, and magnetic resonance angiography done after exercise provocation. Nonsurgical treatment with physical therapy and stretching of the gastrocnemius complex should be done as the first line of treatment. When conservative treatments are ineffective, referral to a vascular specialist for surgical intervention with a muscular band excision or transection, vascular bypass, or arterial reconstruction is necessary.

Preoperative Angiography for Free Fibula Flap Harvest: A Case Series.

To assess if preoperative angiography of the lower extremity is necessary to detect abnormalities that alter operative planning of a free fibula flap (FFF). The secondary objective is to determine whether abnormalities are identified on physical examination. A retrospective case series of patients receiving preoperative lower extremity angiography for FFF was performed. Between November 2004 and July 2016, patients assessed for FFF reconstruction by a single surgeon were reviewed. Outcomes analyzed were preoperative physical examination, angiography findings, changes in operative plan, and perioperative complications including flap failure and limb ischemia. Level of agreement between physical examination and angiography findings was analyzed. A total of 132 consecutive patients were assessed for FFF, of which 70 met the inclusion criteria. Mean age was 60.9 (range: 22-88) years old. All patients underwent aortic angiogram runoff, except for 2 who received computed tomography angiography. The surgical plan was altered based on angiography findings in 9 (12.9%) patients, and 7 (77.8%) of these cases had a normal physical examination. A further 6 (8.6%) patients had physical examination findings precluding the use of FFF, whereas imaging demonstrated the contrary. Physical examination demonstrated low predictability of aberrant vascular anatomy, with a sensitivity of 22.2%. There were no limb ischemia complications. Routine preoperative angiography of the lower extremity for all patients being evaluated for FFF is important to ensure safety and success of the procedure. Physical examination alone is insufficient to detect vascular abnormalities that may result in limb or flap compromise.

Increased collateral flow by rescue femorofemoral bypass dissolved residual thrombus in implanted iliofemoral artery stents: a case report

BackgroundFailed aortofemoral and femoropopliteal bypass grafts in the lower extremity artery usually result in acute limb ischemia. Endovascular treatment and surgical revascularization have been reported for limb salvage.Case presentationA 72-year-old Japanese man was admitted with acute limb ischemia due to failed aortofemoral and femoropopliteal bypass grafts. Endovascular treatment with balloon angioplasty, thrombectomy, and stent implantation in the long chronic total occlusion from the right common iliac artery to the superficial femoral artery did not result in efficient flow due to thrombus transfer from a failed aortofemoral bypass graft. However, a rescue femorofemoral bypass (the left femoral to the right deep femoral artery) improved his symptoms, and implanted in-stent flow was gradually recovered. Lower extremity angiography performed 5 months later confirmed the patency of the iliofemoral in-stent flow. However, the femorofemoral bypass graft was unfortunately occluded due to the progression of left external iliac artery stenosis. The patency of the iliofemoral in-stent flow was confirmed at 1 year by ultrasonography.ConclusionsImprovement of the deep femoral artery flow plays an important role in the treatment of acute limb ischemia due to failed aortofemoral and femoropopliteal bypass grafts. Thus, increased collateral circulation to the periphery through the deep femoral artery dissolved the remaining in-stent thrombus in the iliofemoral artery.

Comparative Long-term Outcomes of Patients with Aortoiliac Occlusive Disease Limited to Common Iliac Arteries Who Underwent Endarterectomy versus Bypass Grafting

The objective of this study was to compared outcomes of patients with aortoiliac occlusive disease (AIOD), limited to the common iliac artery, who underwent either aortoiliac thromboendarterectomy (AIE) or aortobiiliac bypass grafting (ABIB). A single-center, retrospective analysis of consecutive patients with AIOD who underwent either AIE or ABIB between 2010 and 2019 from a prospective database. Patients with disease extending to the external iliac or common femoral arteries were excluded. Data collected included demographics, cardiovascular risk factors, indication for surgery, preoperative and postoperative ankle brachial indexes (ABIs), estimated blood loss, major adverse events (MAEs), and long-term patency. The study end point was clinical success, defined as improvement in ABIs with resolution of symptoms. MAEs included return to the operating room for any reason, postoperative myocardial infarction, stroke, pneumonia, or venous thromboembolism. Thirty-three patients, who met inclusion criteria, underwent repair for AIOD (AIE: 13; ABIB: 20) at our institution during this time. In both groups, there were more women than men (AIE: 11, ABIB: 10) with a mean age of 55±7 years and 58±6 years in the AIE and ABIB group, respectively. Indication for surgery included disabling claudication in 19 patients, ischemic rest pain in 13 patients, and tissue loss in one patient. No difference in cardiovascular risk factors or AIOD severity was noted between groups. Patients in the AIE group had slightly higher body mass index (30±5 vs. 26±6, P=0.06). Two patients in each group required concomitant renal/mesenteric artery endarterectomy. One patient in the AIE group required bilateral femoral artery exposure and external iliac thrombectomy. MAEs (4 vs. 0) were higher in the ABIB group including, pneumonia in one patient, myocardial infarction in another, return to the operating room for evacuation of hematoma in the third and bypass graft thrombectomy with lower extremity angiography in the fourth patient. There were no differences in the intensive care unit or hospital length of stay between groups. Patients in both groups achieved return of normal ABI and complete resolution of their symptoms. At mean follow-up time of 43.4±25.2 and 52.9±35.4months in the AIE and ABIB group, respectively, there was no symptomatic recurrence or need for reintervention while two patients in the ABIB group died of non-aortic-related issues. Both procedures were safe, effective, and conferred high long-term primary patency with no need for reintervention in patients with AIOD limited to the common iliac arteries.

CT angiography of lower extremities from anatomy to traumatic and nontraumatic lesions: a pictorial review.

After the introduction and the quick improvement of multidetector computed tomography technology, computed tomographic angiography (CTA) has become the imaging examination of choice for the first assessment of patients affected by lower extremities acute disorders. The widespread availability of CT equipment, the high temporal and spatial resolution with post-processing reformation possibilities represent the main advantages of this technique, which can reliably identify different findings related to arterial vessel pathology, such as occlusion, dissection, active bleeding, and pseudoaneurysm. Radiologists should know the anatomy, the acquisition protocols, and the CTA appearances of the different vascular lesions. The right interpretation of CTA findings is essential to establish the best treatment management of each patient.

Correlation Between Red Cell Distribution Width and Peripheral Vascular Disease Severity and Complexity.

A traditional hematological marker, red cell distribution width (RDW), is accepted as a novel marker of atherosclerotic vascular diseases. Clinical importance of the RDW as a prognostic biomarker in peripheral vascular disease (PVD) has been reported in a few studies. Herein, we aimed to show the correlation between RDW and PVD severity and its complexity in terms of angiographic evaluation. A total of 118 patients who underwent peripheral lower extremity angiography were subsequently evaluated retrospectively. Upon admission, RDW level was measured with automated complete blood count. Severity and complexity of the PVD was evaluated according to Trans-Atlantic Inter-Society Consensus (TASC II) classification. A TASC II A-B lesion was defined as simple PVD, and a TASC II C-D lesion was defined as prevalent and complex PVD. Then, both groups were compared statistically according to clinical, laboratory, and demographic features, including RDW levels. In 49.6% of the patients, TASC II C-D lesions were observed. Advanced age, male gender, and body mass index (BMI) were associated with TASC II groups. Red cell distribution width levels were correlated with presence of PVD, as well as TASC II grades (p:0.02). The fourth quartile (75th percentile) of the RDW levels was 14.1, and patients with RDW levels ≥14.1 had a more significant correlation with the presence and severity of PVD (p:0.001). In the multivariate regression analysis, elevated RDW was found to be an independent predictor of the presence of PVD and also TASC II C-D lesions (OR:2.26, with a 95% confidence interval (CI) 0.051–0.774; p:0.02). Elevated RDW levels was associated with TASC II C-D lesions, which indicated more prevalent and complex PVD.

Finger necrosis with eosinophilia and symmetrical occlusion of the peripheral artery

Case presentationA 59-year-old man with hypertension, dyslipidemia and a current smoking history had presented with bilateral painful finger ulcers (figure 1A). The patient was referred to our hospital for the...

Preoperative Angiography for Free Fibula Flap Harvest: A Meta-Analysis.

The necessity for routine preoperative imaging for free fibula harvest is controversial. The primary objective of this meta-analysis is to determine if lower extremity angiography is necessary to detect abnormalities that may alter flap selection. The secondary objective is to determine if physical examination alone is sufficient to predict these abnormalities. A literature search was performed using Cochrane, CENTRAL, MEDLINE, CINAHL, and EMBASE. Studies were selected for inclusion if they included patients undergoing free fibula flap harvest with preoperative imaging, with or without physical examination findings. Data extraction was performed independently and in duplicate, including a change in flap selection and the level of agreement between physical examination and imaging. Pooled proportions were calculated using a random-effects model and 95% confidence intervals (CI). Sixteen studies were included for analysis. Mean sample size was 42 patients (range: 5-123). Included studies were of low methodologic quality. Pooled proportion of patients who had flap selection change secondary to abnormalities identified on preoperative angiography was 20.1% (95% CI: 9.6-33.2%). A pooled proportion of 71.5% (95% CI: 5-88.7%) of cases requiring change in flap selection was missed by physical examination findings alone. There is low-quality evidence suggesting a necessity for routine preoperative angiography for all patients undergoing free fibula flap harvest. Physical examination alone is insufficient in detecting vascular abnormalities that may result in limb compromise or an inability to successfully harvest a free fibula. Further investigation is warranted for cost-effectiveness of preoperative imaging protocols.

Edetate Disodium-Based Treatment in a Patient With Diabetes and Critical Limb Ischemia After Unsuccessful Peripheral Arterial Revascularizations: A Case Report.

Peripheral artery disease (PAD) is a progressive form of atherosclerosis that affects the lower extremities, particularly in patients with diabetes. Critical limb ischemia (CLI), the end-stage manifestation of this disease, is associated with an increased risk of chronic leg ulcerations, infections, amputations, and mortality. At presentation, 30% of CLI patients require amputation, and 25% will die within 1 year (1). Toxic metal exposure, particularly to cadmium, has been associated with an increased risk of vascular disease in epidemiological studies and PAD severity in patients with coronary artery disease (CAD) (2–4). Toxic metals are ubiquitous and can induce increased oxidative stress, endothelial dysfunction, and inflammation (4). Similarly, chronic cadmium exposure has been found to play a role in the acceleration of vascular disease in animal models (5,6). Edetate disodium is a chelating agent with high affinity for lead and cadmium (7). The Trial to Assess Chelation Therapy (TACT) demonstrated that edetate disodium–based chelation reduced cardiovascular events, especially in patients with diabetes after myocardial infarction (8,9). An 81-year-old man with a 35-year history of insulin-dependent diabetes, a 20 pack-year smoking history (quit date October 2001), atrial fibrillation, and CAD requiring coronary artery bypass in 2001 presented to the vascular service. His medications at baseline included sotalol, rivaroxaban, pentoxifylline, clopidogrel, aspirin, insulin, pregabalin, and atorvastatin. His baseline serum creatinine was 0.77 mg/dL, and his BMI was 22 kg/m2. He had progressive CLI with nonhealing ulcers and pain unimproved by medical therapy. Noninvasive tests demonstrated abnormal ankle-brachial indices bilaterally. Lower-extremity angiography revealed total occlusions of the left external iliac artery, left superficial femoral artery, distal right …

Utility Evaluation of Supportive Devices for Interventional Lower Extremity Angiography

Utility Evaluation of Supportive Devices for Interventional Lower Extremity Angiography

Angiographic assessment of atherosclerotic load at the lower extremity in patients with diabetic foot and charcot neuro-arthropathy

BackgroundThe aim of this study was to investigate atherosclerotic load at the lower extremity in patients with diabetic foot and charcot neuro-arthropathy and compare them with patients with diabetic foot without charcot neuro-arthropathy. MethodsThis retrospective study consists of 78 patients with diabetic foot who had lower extremity angiography with antegrade approach. All patients were classified into two groups; neuro ischemic wounds with charcot neuro-arthropathy (30/78) and without charcot neuro-arthropathy (48/78).Atherosclerotic load at the side of diabetic foot was determined by using the Bollinger angiogram scoring method. Comparison of atherosclerotic load between the two groups was performed. ResultsThe mean of total and infrapopliteal level angiogram scoring of all patients was 33.3 (standard deviation, sd:±17.2) and 29.3 (sd:±15.6), respectively. The mean of total and infrapopliteal level angiogram scoring of neuroischemic wounds with charcot neuro-arthropathy group was 18.1 (sd:±11.6) and 15.7 (sd:±10.4), respectively. The mean of total and infrapopliteal level angiogram scoring of neuroischemic wounds without charcot neuro-arthropathy group was 42.8 (sd:±12.7) and 37.7 (sd:±12.0), respectively. There was a statistically significant difference between the two groups of mean total and infrapopliteal angiogram scoring (p < 0.01). ConclusionThis angiographic study confirms that the atherosclerotic load in patients with diabetic foot and chronic charcot neuro-arthropathy is significantly less than in patients with neuroischemic diabetic foot wounds without chronic charcot neuro-arthropathy.

Repeatability of Non-Contrast-Enhanced Lower-Extremity Angiography Using the Flow-Spoiled Fresh Blood Imaging.

PurposeThe aim of this study was to prospectively evaluate the repeatability of non–contrast-enhanced lower-extremity magnetic resonance angiography using the flow-spoiled fresh blood imaging (FS-FBI).MethodsForty-three healthy volunteers and 15 patients with lower-extremity arterial stenosis were recruited in this study and were examined by FS-FBI. Digital subtraction angiography was performed within a week after the FS-FBI in the patient group. Repeatability was assessed by the following parameters: grading of image quality, diameter and area of major arteries, and grading of stenosis of lower-extremity arteries. Two experienced radiologists blinded for patient data independently evaluated the FS-FBI and digital subtraction angiography images. Intraclass correlation coefficients (ICCs), sensitivity, and specificity were used for statistical analysis.ResultsThe grading of image quality of most data was satisfactory. The ICCs for the first and second measures were 0.792 and 0.884 in the femoral segment and 0.803 and 0.796 in the tibiofibular segment for healthy volunteer group, 0.873 and 1.000 in the femoral segment, and 0.737 and 0.737 in the tibiofibular segment for the patient group. Intraobserver and interobserver agreements on diameter and area of arteries were excellent, with ICCs mostly greater than 0.75 in the volunteer group. For stenosis grading analysis, intraobserver ICCs range from 0.784 to 0.862 and from 0.778 to 0.854, respectively. Flow-spoiled fresh blood imaging yielded a mean sensitivity and specificity to detect arterial stenosis or occlusion of 90% and 80% for femoral segment and 86.7% and 93.3% for tibiofibular segment at least.ConclusionsLower-extremity angiography with FS-FBI is a reliable and reproducible screening tool for lower-extremity atherosclerotic disease, especially for patients with impaired renal function.