Document Detail

Arterial imaging in patients with lower extremity ischemia and diabetes mellitus.
MedLine Citation:
PMID:  20804938     Owner:  NLM     Status:  MEDLINE    
Precise, comprehensive imaging of the arterial circulation is the cornerstone of successful revascularization of the ischemic extremity in patients with diabetes mellitus. Arterial imaging is challenging in these patients because the disease is often multisegmental with a predilection for the distal tibial and peroneal arteries. Occlusive lesions and the arterial wall itself are often calcified and patients presenting with ischemic complications frequently have underlying renal insufficiency. Intra-arterial digital subtraction angiography (DSA), contrast enhanced magnetic resonance angiography (MRA), and more recently, computerized tomographic angiography (CTA) have been used as imaging modalities in lower extremity ischemia. Each has specific advantages and shortcomings in this patient population, which will be summarized and contrasted in this review. DSA is an invasive technique most often performed from a femoral arterial puncture and requires the injection of arterial contrast, which can occasionally cause allergic reactions. In patients with pre-existing renal insufficiency, contrast infusion can result in worsening renal failure; although usually self-limited, it may occasionally require hemodialysis, especially in patients with diabetes. However, DSA provides the highest degree of spatial resolution and image quality. It is also the only modality in which the diagnosis and treatment of arterial disease can be performed simultaneously. MRA is noninvasive, and when enhanced with gadolinium contrast injection provides arterial images of comparable quality to DSA and in some circumstances may uncover distal arterial targets not visualized on DSA. However, spatial resolution is inferior to DSA and erroneous interpretations due to acquisition artifacts are common. Specialized equipment and imaging techniques are necessary to minimize their occurrence in the distal lower extremity. In addition, due to the risk of inducing nephrogenic systemic fibrosis, gadolinium-enhanced MRA cannot be used in patients with renal insufficiency. CTA is noninvasive and rapidly performed, with better spatial resolution than MRA, but requires the largest volume of contrast infusion, exposes patients to high-doses of radiation, and is subject to interpretive error due to reconstruction artifacts especially in heavily calcified arteries, limiting its usefulness in many patients with diabetes. For patients in whom the planned intervention is a surgical bypass, DSA and MRA will provide high quality images of the lower extremity arterial anatomy. For patients in whom a catheter-based intervention is the likely treatment, a diagnostic DSA immediately followed by a catheter-based treatment in the same procedure is the preferred approach. In patients with pre-existing renal dysfunction, in which gadolinium-enhanced MRA is contraindicated, DSA or CTA can be performed. However, patients should have an infusion of intravenous normal saline solution or sodium bicarbonate before the procedure to reduce the incidence of contrast-induced nephropathy.
Frank Pomposelli
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Publication Detail:
Type:  Journal Article; Review    
Journal Detail:
Title:  Journal of vascular surgery     Volume:  52     ISSN:  1097-6809     ISO Abbreviation:  J. Vasc. Surg.     Publication Date:  2010 Sep 
Date Detail:
Created Date:  2010-08-31     Completed Date:  2010-09-27     Revised Date:  2012-10-03    
Medline Journal Info:
Nlm Unique ID:  8407742     Medline TA:  J Vasc Surg     Country:  United States    
Other Details:
Languages:  eng     Pagination:  81S-91S     Citation Subset:  IM    
Copyright Information:
Copyright © 2010. Published by Mosby, Inc.
Division of Vascular and Endovascular Surgery, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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MeSH Terms
Angiography, Digital Subtraction
Arteries / pathology
Contrast Media / adverse effects,  diagnostic use
Diabetic Angiopathies / complications,  diagnosis*
Diagnostic Imaging* / adverse effects,  methods
Image Interpretation, Computer-Assisted
Ischemia / complications,  diagnosis*
Lower Extremity / blood supply*
Magnetic Resonance Angiography
Nephrogenic Fibrosing Dermopathy / etiology,  therapy
Patient Selection
Predictive Value of Tests
Renal Dialysis
Renal Insufficiency / complications,  therapy
Risk Assessment
Risk Factors
Tomography, X-Ray Computed
Reg. No./Substance:
0/Contrast Media

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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