Imaging

Peripheral Artery Disease

Preliminary Diagnosis: Peripheral artery disease

I. What imaging technique is first-line for this diagnosis?

  • Ankle-brachial index (ABI) with segmental pressures and waveforms

II. Describe the advantages and disadvantages of this technique for diagnosis of Peripheral artery disease.

Advantages

  • Simple to perform, well-tolerated, and cost-effective screening examination

  • Segmental pressures help localize the level of disease

  • Dampened waveforms help indicate the level of significant stenosis

Disadvantages

  • Screening examination that does not provide anatomic detail for treatment planning

  • May be limited in patients with heavily calcified vessels (often in diabetic patients)

  • Abnormalities may not be present at rest (in these cases a treadmill test may be utilized to elicit symptoms)

III. What are the contraindications for the first-line imaging technique?

  • No significant contraindications exist

IV. What alternative imaging techniques are available?

  • Doppler US

  • CT angiography

  • MR angiography

  • Angiography

V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of peripheral artery disease.

Doppler US

Advantages

  • The level of a low-resistive waveform can help localize the disease

  • The lesion can often be directly visualized

  • Peak systolic velocity can help determine if a lesion is hemodynamically significant

  • Inexpensive and simple examination to perform

Disadvantages

  • May not provide adequate anatomic detail for treatment planning

  • May not be adequate to evaluate proximal inflow disease (especially in the presence of dense calcifications)

  • Dependent on operator expertise

CT angiography

Advantages

  • Accurately defines the level of disease and may help characterize the nature of plaque

  • Can detect stenosis and occlusions as well as adjacent nonvascular pathology

  • Detailed images are useful for treatment planning

Disadvantages

  • Requires intravenous contrast, which may result in contrast-induced nephropathy

  • Poor evaluation in the presence of extensive calcified plaque

  • Bolus timing must be appropriate to avoid artifact

  • Exposure to ionizing radiation

MR angiography

Advantages

  • Can detect stenosis and occlusions as well as adjacent nonvascular pathology

  • Accurately defines the level of disease

  • Avoids radiation exposure

Disadvantages

  • Poor bolus timing may result in venous contamination artifact

  • May overestimate the degree of stenosis

  • Expensive

  • Time consuming

  • Requires significant patient cooperation to minimize motion artifact

Angiography

Advantages

  • Traditional gold-standard exam

  • Pressure measurements can help determine if a lesion is hemodynamically significant

  • Treatment may be performed at the same time as diagnosis

Disadvantages

  • Invasive procedure with potential for access site and catheter-based complications

  • Not as accurate as CT or MRI in defining the degree of luminal cross-sectional narrowing

  • Requires intravenous contrast, which may result in contrast-induced nephropathy

VI. What are the contraindications for the alternative imaging techniques?

Doppler US

  • No significant contraindications exist

CT angiography

  • Renal failure owing to the risk of contrast-induced nephropathy

  • Pregnancy

  • Contrast allergy may be a relative contraindication

MR angiography

  • Non–MR-compatible hardware

  • Renal failure due to the risk of nephrogenic systemic fibrosis

  • First trimester pregnancy may be a relative contraindication

Angiography

  • Renal failure due to the risk of contrast-induced nephropathy

  • Pregnancy

  • Contrast allergy may be a relative contraindication

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