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Optimized Diagnostic Angiography in High-Risk Patients with Severe Peripheral Vascular Disease¹

¹ From the Department of Radiology, Beth Israel Deaconess Medical Center, Boston, Mass. Presented as a scientific exhibit at the 1998 RSNA scientific assembly. Received March 1, 1999; revision requested April 14 and received May 27; accepted May 28. Address reprint requests to G.G.H., CVDL, Blalock 545, Department of Radiology, Johns Hopkins Hospital, 600 N Wolfe St, Baltimore, MD 21287.

View larger version (87K): [in a new window]   Figure 1a.   (a) Composite image acquired with a DSA stepping technique shows bilateral popliteal artery aneurysms (arrows). An aortic injection was used with simultaneous imaging of both lower limbs. Although there is a suggestion of calf vessels in both lower limbs, it is unclear whether these would be suitable for a DBPG. (b) DSA image (nonstepping) acquired with contrast material injection into the lower aorta shows faint opacification of calf arteries but no vessels in either foot. Note the difficulty of obtaining uniform exposure over the whole image even with use of edge filters (*) and the poor anatomic positioning. (c) Selective DSA image (contrast material injection into the right external iliac artery) shows proper true lateral positioning and optimum exposure, as well as a bifid right posterior tibial artery (arrowheads) suitable for a DBPG.

View larger version (105K): [in a new window]   Figure 1b.   (a) Composite image acquired with a DSA stepping technique shows bilateral popliteal artery aneurysms (arrows). An aortic injection was used with simultaneous imaging of both lower limbs. Although there is a suggestion of calf vessels in both lower limbs, it is unclear whether these would be suitable for a DBPG. (b) DSA image (nonstepping) acquired with contrast material injection into the lower aorta shows faint opacification of calf arteries but no vessels in either foot. Note the difficulty of obtaining uniform exposure over the whole image even with use of edge filters (*) and the poor anatomic positioning. (c) Selective DSA image (contrast material injection into the right external iliac artery) shows proper true lateral positioning and optimum exposure, as well as a bifid right posterior tibial artery (arrowheads) suitable for a DBPG.

View larger version (114K): [in a new window]   Figure 1c.   (a) Composite image acquired with a DSA stepping technique shows bilateral popliteal artery aneurysms (arrows). An aortic injection was used with simultaneous imaging of both lower limbs. Although there is a suggestion of calf vessels in both lower limbs, it is unclear whether these would be suitable for a DBPG. (b) DSA image (nonstepping) acquired with contrast material injection into the lower aorta shows faint opacification of calf arteries but no vessels in either foot. Note the difficulty of obtaining uniform exposure over the whole image even with use of edge filters (*) and the poor anatomic positioning. (c) Selective DSA image (contrast material injection into the right external iliac artery) shows proper true lateral positioning and optimum exposure, as well as a bifid right posterior tibial artery (arrowheads) suitable for a DBPG.

View larger version (150K): [in a new window]   Figure 2a.   (a) DSA image obtained after nonselective injection shows both feet with arterial detail obscured by movement artifact (note the bone edges revealed by movement [arrowheads]). This artifact occurred despite use of restraining straps, which may occlude an underlying vessel. Arrow = site of compression by strapping. (b) Selective DSA image obtained with true lateral positioning shows a distal left peroneal artery (solid arrow) and a narrowed anterior tibial artery (open arrow), which were not seen with the nonselective injection (a).

View larger version (115K): [in a new window]   Figure 2b.   (a) DSA image obtained after nonselective injection shows both feet with arterial detail obscured by movement artifact (note the bone edges revealed by movement [arrowheads]). This artifact occurred despite use of restraining straps, which may occlude an underlying vessel. Arrow = site of compression by strapping. (b) Selective DSA image obtained with true lateral positioning shows a distal left peroneal artery (solid arrow) and a narrowed anterior tibial artery (open arrow), which were not seen with the nonselective injection (a).

View larger version (90K): [in a new window]   Figure 3a.   (a) Conventional screen-film arteriogram (lateral view) obtained with the foot in plantar flexion and an overexposed technique shows some proximal vessels but no foot arteries. Correct exposure over all the areas of interest is impossible due to angulation of the ankle, but the exposure could be improved. (b) Unsubtracted digital arteriogram (lateral view) obtained with the foot in dorsiflexion shows how the ability to position edge filters (*) and optimize exposure allows better demonstration of foot vessels. Arrow = dorsal artery of foot. (c) Selective DSA image (from the same acquisition as in b) shows the dorsal artery of the foot and distal vessels, which were previously obscured by bone opacity.

View larger version (165K): [in a new window]   Figure 3b.   (a) Conventional screen-film arteriogram (lateral view) obtained with the foot in plantar flexion and an overexposed technique shows some proximal vessels but no foot arteries. Correct exposure over all the areas of interest is impossible due to angulation of the ankle, but the exposure could be improved. (b) Unsubtracted digital arteriogram (lateral view) obtained with the foot in dorsiflexion shows how the ability to position edge filters (*) and optimize exposure allows better demonstration of foot vessels. Arrow = dorsal artery of foot. (c) Selective DSA image (from the same acquisition as in b) shows the dorsal artery of the foot and distal vessels, which were previously obscured by bone opacity.

View larger version (130K): [in a new window]   Figure 3c.   (a) Conventional screen-film arteriogram (lateral view) obtained with the foot in plantar flexion and an overexposed technique shows some proximal vessels but no foot arteries. Correct exposure over all the areas of interest is impossible due to angulation of the ankle, but the exposure could be improved. (b) Unsubtracted digital arteriogram (lateral view) obtained with the foot in dorsiflexion shows how the ability to position edge filters (*) and optimize exposure allows better demonstration of foot vessels. Arrow = dorsal artery of foot. (c) Selective DSA image (from the same acquisition as in b) shows the dorsal artery of the foot and distal vessels, which were previously obscured by bone opacity.

View larger version (78K): [in a new window]   Figure 4a.   (a) Selective DSA image of the right foot shows the effects of inadequate collimation: compression of the gray scale and reduced image contrast. (b) Equivalent mask image from a shows a range of opacity from air (*) to bone. (c) Selective DSA image obtained with closer collimation but identical contrast material volume, elapsed time, and windowing as in a shows foot vessels more clearly due to better image contrast. (d) Equivalent mask image from c shows a lesser range of opacity from soft tissue to bone, with air opacity now excluded. As a result, the tarsal bone edges are easier to see.

View larger version (82K): [in a new window]   Figure 4b.   (a) Selective DSA image of the right foot shows the effects of inadequate collimation: compression of the gray scale and reduced image contrast. (b) Equivalent mask image from a shows a range of opacity from air (*) to bone. (c) Selective DSA image obtained with closer collimation but identical contrast material volume, elapsed time, and windowing as in a shows foot vessels more clearly due to better image contrast. (d) Equivalent mask image from c shows a lesser range of opacity from soft tissue to bone, with air opacity now excluded. As a result, the tarsal bone edges are easier to see.

View larger version (73K): [in a new window]   Figure 4c.   (a) Selective DSA image of the right foot shows the effects of inadequate collimation: compression of the gray scale and reduced image contrast. (b) Equivalent mask image from a shows a range of opacity from air (*) to bone. (c) Selective DSA image obtained with closer collimation but identical contrast material volume, elapsed time, and windowing as in a shows foot vessels more clearly due to better image contrast. (d) Equivalent mask image from c shows a lesser range of opacity from soft tissue to bone, with air opacity now excluded. As a result, the tarsal bone edges are easier to see.

View larger version (80K): [in a new window]   Figure 4d.   (a) Selective DSA image of the right foot shows the effects of inadequate collimation: compression of the gray scale and reduced image contrast. (b) Equivalent mask image from a shows a range of opacity from air (*) to bone. (c) Selective DSA image obtained with closer collimation but identical contrast material volume, elapsed time, and windowing as in a shows foot vessels more clearly due to better image contrast. (d) Equivalent mask image from c shows a lesser range of opacity from soft tissue to bone, with air opacity now excluded. As a result, the tarsal bone edges are easier to see.

View larger version (56K): [in a new window]   Figure 5.   Composite image produced with stepping DSA (aortic injection) in a patient with multiple superficial femoral and popliteal artery stenoses clearly shows the proximal arteries. However, artifact due to movement between acquisition of the mask and contrast-enhanced images obscures the infrapopliteal arteries. Rotational movement is greatest in the lower part of the limb, and the interval between acquisition of the mask and contrast-enhanced images is also greatest for infrapopliteal imaging. It is impossible to optimally position both feet with this technique.

View larger version (162K): [in a new window]   Figure 6a.   (a) Selective DSA image (lateral view) acquired with older equipment at another institution and with poor collimation shows image noise, which obscures some finer vessels and suggests a focal occlusion of the left dorsal foot artery (arrow). (b) Equivalent unsubtracted image shows the extent to which air is included in the field of view. The inclusion of air causes gray-scale compression and flare, leading to poor image contrast compounded by use of older equipment. The patient positioning and contrast material injection were good. (c) Unsubtracted digital arteriogram (lateral view) obtained with the foot more dorsiflexed shows the ability to position edge filters (*) and achieve optimum exposure with newer equipment, producing a clearer, less noisy image. (d) Selective DSA image (from the same acquisition as in c) shows fine vessel detail previously obscured by noise and bone opacity and reveals that the dorsal artery occlusion is actually a stenosis (arrow).

View larger version (137K): [in a new window]   Figure 6b.   (a) Selective DSA image (lateral view) acquired with older equipment at another institution and with poor collimation shows image noise, which obscures some finer vessels and suggests a focal occlusion of the left dorsal foot artery (arrow). (b) Equivalent unsubtracted image shows the extent to which air is included in the field of view. The inclusion of air causes gray-scale compression and flare, leading to poor image contrast compounded by use of older equipment. The patient positioning and contrast material injection were good. (c) Unsubtracted digital arteriogram (lateral view) obtained with the foot more dorsiflexed shows the ability to position edge filters (*) and achieve optimum exposure with newer equipment, producing a clearer, less noisy image. (d) Selective DSA image (from the same acquisition as in c) shows fine vessel detail previously obscured by noise and bone opacity and reveals that the dorsal artery occlusion is actually a stenosis (arrow).

View larger version (150K): [in a new window]   Figure 6c.   (a) Selective DSA image (lateral view) acquired with older equipment at another institution and with poor collimation shows image noise, which obscures some finer vessels and suggests a focal occlusion of the left dorsal foot artery (arrow). (b) Equivalent unsubtracted image shows the extent to which air is included in the field of view. The inclusion of air causes gray-scale compression and flare, leading to poor image contrast compounded by use of older equipment. The patient positioning and contrast material injection were good. (c) Unsubtracted digital arteriogram (lateral view) obtained with the foot more dorsiflexed shows the ability to position edge filters (*) and achieve optimum exposure with newer equipment, producing a clearer, less noisy image. (d) Selective DSA image (from the same acquisition as in c) shows fine vessel detail previously obscured by noise and bone opacity and reveals that the dorsal artery occlusion is actually a stenosis (arrow).

View larger version (142K): [in a new window]   Figure 6d.   (a) Selective DSA image (lateral view) acquired with older equipment at another institution and with poor collimation shows image noise, which obscures some finer vessels and suggests a focal occlusion of the left dorsal foot artery (arrow). (b) Equivalent unsubtracted image shows the extent to which air is included in the field of view. The inclusion of air causes gray-scale compression and flare, leading to poor image contrast compounded by use of older equipment. The patient positioning and contrast material injection were good. (c) Unsubtracted digital arteriogram (lateral view) obtained with the foot more dorsiflexed shows the ability to position edge filters (*) and achieve optimum exposure with newer equipment, producing a clearer, less noisy image. (d) Selective DSA image (from the same acquisition as in c) shows fine vessel detail previously obscured by noise and bone opacity and reveals that the dorsal artery occlusion is actually a stenosis (arrow).

View larger version (120K): [in a new window]   Figure 7a.   (a) Selective DSA image (lateral view) of the right foot shows the effect of a high-dose technique. Vessels are visible only where overlying bone or a sufficient thickness of soft tissue has reduced the exposure (arrowheads) to within the gray-scale range. Vessels outside this area have become invisible (burnout) (arrows). (b) Equivalent unsubtracted digital image shows the position of the bones; the thicker soft tissues; and the bright, overexposed area causing burnout.

View larger version (99K): [in a new window]   Figure 7b.   (a) Selective DSA image (lateral view) of the right foot shows the effect of a high-dose technique. Vessels are visible only where overlying bone or a sufficient thickness of soft tissue has reduced the exposure (arrowheads) to within the gray-scale range. Vessels outside this area have become invisible (burnout) (arrows). (b) Equivalent unsubtracted digital image shows the position of the bones; the thicker soft tissues; and the bright, overexposed area causing burnout.

View larger version (108K): [in a new window]   Figure 8a.   (a) Unsubtracted digital image (posteroanterior view) of the left leg shows a wide range of opacities. Exclusive of the knee replacement, the range of opacities includes air (*) and dense cortical bone, thus leading to gray-scale compression. A low-dose technique also contributed to the noisy image quality. (b) Selective DSA image (posteroanterior view) shows a noisy image due to gray-scale compression (a result of poor collimation) and a low-dose technique. The noise impairs demonstration of a complex stenosis at the popliteal trifurcation (arrow). (c) Selective DSA image (oblique view to project the popliteal artery behind the knee replacement) obtained with a higher-dose technique and better collimation shows the complex stenosis at the popliteal trifurcation (arrow) more clearly. There is also a mid-popliteal artery stenosis (obscured by the knee replacement in a and b).

View larger version (98K): [in a new window]   Figure 8b.   (a) Unsubtracted digital image (posteroanterior view) of the left leg shows a wide range of opacities. Exclusive of the knee replacement, the range of opacities includes air (*) and dense cortical bone, thus leading to gray-scale compression. A low-dose technique also contributed to the noisy image quality. (b) Selective DSA image (posteroanterior view) shows a noisy image due to gray-scale compression (a result of poor collimation) and a low-dose technique. The noise impairs demonstration of a complex stenosis at the popliteal trifurcation (arrow). (c) Selective DSA image (oblique view to project the popliteal artery behind the knee replacement) obtained with a higher-dose technique and better collimation shows the complex stenosis at the popliteal trifurcation (arrow) more clearly. There is also a mid-popliteal artery stenosis (obscured by the knee replacement in a and b).

View larger version (96K): [in a new window]   Figure 8c.   (a) Unsubtracted digital image (posteroanterior view) of the left leg shows a wide range of opacities. Exclusive of the knee replacement, the range of opacities includes air (*) and dense cortical bone, thus leading to gray-scale compression. A low-dose technique also contributed to the noisy image quality. (b) Selective DSA image (posteroanterior view) shows a noisy image due to gray-scale compression (a result of poor collimation) and a low-dose technique. The noise impairs demonstration of a complex stenosis at the popliteal trifurcation (arrow). (c) Selective DSA image (oblique view to project the popliteal artery behind the knee replacement) obtained with a higher-dose technique and better collimation shows the complex stenosis at the popliteal trifurcation (arrow) more clearly. There is also a mid-popliteal artery stenosis (obscured by the knee replacement in a and b).

View larger version (151K): [in a new window]   Figure 9a.   (a) Selective DSA image (lateral view) of the right foot in plantar flexion does not show the dorsal foot artery. As a result, and because of poor target vessels in the calf, the patient was treated medically, without success. (b) Selective DSA image (lateral view) with the foot in dorsiflexion shows a patent dorsal foot artery. The image was acquired 1 year later with the same contrast material volume and the same angiographic equipment as in a. The patient subsequently underwent successful DBPG placement in the dorsal foot artery.

View larger version (153K): [in a new window]   Figure 9b.   (a) Selective DSA image (lateral view) of the right foot in plantar flexion does not show the dorsal foot artery. As a result, and because of poor target vessels in the calf, the patient was treated medically, without success. (b) Selective DSA image (lateral view) with the foot in dorsiflexion shows a patent dorsal foot artery. The image was acquired 1 year later with the same contrast material volume and the same angiographic equipment as in a. The patient subsequently underwent successful DBPG placement in the dorsal foot artery.

View larger version (125K): [in a new window]   Figure 10a.   (a) Unsubtracted digital arteriogram (lateral view) of the right foot in plantar flexion in a diabetic patient with severe peripheral neuropathy shows compression of the dorsal foot artery (pseudo-occlusion) by the subluxated talus (arrow). (b) Selective DSA image from the same acquisition shows compression of the dorsal foot artery by the subluxated talus (solid arrow), as well as a more distal stenosis (open arrow). (c) Selective DSA image (lateral view) with the foot in dorsiflexion shows a widely patent proximal dorsal foot artery, thus confirming the presence of a proximal pseudo-occlusion, although the distal stenosis remains.

View larger version (128K): [in a new window]   Figure 10b.   (a) Unsubtracted digital arteriogram (lateral view) of the right foot in plantar flexion in a diabetic patient with severe peripheral neuropathy shows compression of the dorsal foot artery (pseudo-occlusion) by the subluxated talus (arrow). (b) Selective DSA image from the same acquisition shows compression of the dorsal foot artery by the subluxated talus (solid arrow), as well as a more distal stenosis (open arrow). (c) Selective DSA image (lateral view) with the foot in dorsiflexion shows a widely patent proximal dorsal foot artery, thus confirming the presence of a proximal pseudo-occlusion, although the distal stenosis remains.

View larger version (125K): [in a new window]   Figure 10c.   (a) Unsubtracted digital arteriogram (lateral view) of the right foot in plantar flexion in a diabetic patient with severe peripheral neuropathy shows compression of the dorsal foot artery (pseudo-occlusion) by the subluxated talus (arrow). (b) Selective DSA image from the same acquisition shows compression of the dorsal foot artery by the subluxated talus (solid arrow), as well as a more distal stenosis (open arrow). (c) Selective DSA image (lateral view) with the foot in dorsiflexion shows a widely patent proximal dorsal foot artery, thus confirming the presence of a proximal pseudo-occlusion, although the distal stenosis remains.

View larger version (135K): [in a new window]   Figure 11a.   (a) DSA image (lateral view) obtained at another institution with appropriate positioning of the left foot and no significant patient movement fails to show the foot arteries. This failure is probably due to three factors: inadequate contrast material volume or proximal injection, poor radiographic technique, and old equipment. On the basis of this image, amputation was recommended. (b) Selective DSA image (lateral view) obtained with a good technique and good equipment shows a patent proximal dorsal foot artery (arrow), which is suitable for a DBPG.

View larger version (136K): [in a new window]   Figure 11b.   (a) DSA image (lateral view) obtained at another institution with appropriate positioning of the left foot and no significant patient movement fails to show the foot arteries. This failure is probably due to three factors: inadequate contrast material volume or proximal injection, poor radiographic technique, and old equipment. On the basis of this image, amputation was recommended. (b) Selective DSA image (lateral view) obtained with a good technique and good equipment shows a patent proximal dorsal foot artery (arrow), which is suitable for a DBPG.

View larger version (79K): [in a new window]   Figure 12a.   (a) Selective DSA image (lateral view) of the right calf shows opacification of the proximal tibial arteries only (arrow). Delayed imaging showed no further opacification. (b) Selective DSA image obtained after intraarterial injection of papaverine (30 mg) shows filling of the anterior tibial artery (arrow) and peroneal artery (which was not seen previously). The same volume of contrast medium, patient position, and radiographic technique were used as in a.

View larger version (76K): [in a new window]   Figure 12b.   (a) Selective DSA image (lateral view) of the right calf shows opacification of the proximal tibial arteries only (arrow). Delayed imaging showed no further opacification. (b) Selective DSA image obtained after intraarterial injection of papaverine (30 mg) shows filling of the anterior tibial artery (arrow) and peroneal artery (which was not seen previously). The same volume of contrast medium, patient position, and radiographic technique were used as in a.

View larger version (86K): [in a new window]   Figure 13a.   (a) Selective DSA image obtained by using 60 mL of carbon dioxide shows a patent right popliteal artery but apparent occlusion or severe stenosis of the proximal tibial arteries. Note the break in the column of carbon dioxide in the upper popliteal artery (arrow). (b) Selective DSA image obtained with 30% contrast material (12 mL administered at 4 mL/sec) in the same position as in a shows improved image quality. The stenoses at the origins of the tibial arteries are shown to be less extensive than in a.

View larger version (78K): [in a new window]   Figure 13b.   (a) Selective DSA image obtained by using 60 mL of carbon dioxide shows a patent right popliteal artery but apparent occlusion or severe stenosis of the proximal tibial arteries. Note the break in the column of carbon dioxide in the upper popliteal artery (arrow). (b) Selective DSA image obtained with 30% contrast material (12 mL administered at 4 mL/sec) in the same position as in a shows improved image quality. The stenoses at the origins of the tibial arteries are shown to be less extensive than in a.