Non-invasive imaging techniques in lower extremity

artery disease
escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-16/Non-invasive-imaging-techniques-in-lower-
extremity-artery-disease

Vol. 16, N° 5 - 21 Mar 2018

Dr. Mariana Corneli

Dr. Gabriel O. Perea

Non-invasive imaging techniques can detect lower extremity artery disease (LEAD) and
help to characterise the severity of the disease fully by providing anatomical and
haemodynamic information depending on the chosen method. The imaging test of choice
depends on many factors. Discussed here are the advantages, costs, diagnostic

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accuracy and appropriateness of each available modality in a given patient as
recommended by the 2017 European Society of Cardiology guidelines on peripheral
artery disease.

Peripheral Artery Disease

Background
A variety of imaging tests are available for lower extremity artery disease (LEAD). Duplex
ultrasound (DUS), computed tomography angiography (CTA) and magnetic resonance
angiography (MRA) can all provide useful information non-invasively. But what is the
place of imaging tests in this scenario?

The ankle-brachial index (ABI) is the first diagnostic step after clinical examination. An
ABI <0.90 has 75% sensitivity and 86% specificity to diagnose LEAD [1,2]. Sometimes
when clinically suspected, a normal ABI does not definitely rule out a diagnosis of LEAD;
further post-exercise ABI and/or imaging tests are necessary. In addition, imaging tests
can be useful in patients with a high ABI (>1.40) associated with medial calcification [2,3].

The objectives of imaging techniques in LEAD are as follows:

1) identifying sites of stenosis,

2) defining the degree of arterial obstruction,

3) characterising the morphology, exact location and extent of the disease,

4) evaluating distal run-off and collateral circulation.

Fundamentally, this information is useful for patients with symptomatic LEAD. Imaging
helps to localise the lesions targeted for revascularisation (which may require invasive
haemodynamic confirmation), the selection of appropriate equipment or adjunctive
devices, and the choice of arterial access site (i.e., antegrade versus retrograde common
femoral access, retrograde pedal access, etc.). These considerations will determine the
patient position on the table as well as room preparation, and can help to minimise
procedure duration, contrast use, and radiation exposure [4,5].

After revascularisation, either endovascular or surgical, imaging techniques provide

information on the permeability of the ducts and the presence of complications.

The choice of the examination should be determined using an individualised approach to

the anatomic assessment for each patient, including risk-benefit assessment of each
study type.

Imaging tests for lead diagnosis

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LEAD imaging tests can provide anatomical information on the arterial stenosis together
with their haemodynamic repercussions, depending on the modality chosen. In general,
techniques must be combined in order to achieve a proper evaluation of each patient.

Duplex ultrasound

Duplex ultrasound (DUS) is usually the first-line imaging modality for screening. It
assesses peripheral artery stenosis. DUS provides extensive information on arterial
anatomy and haemodynamics, and includes B-mode echography and Doppler modalities.
The lesions are located by two-dimensional (2D) ultrasonography and colour Doppler
mapping, while the degree of stenosis is estimated mostly by Doppler waveform, peak
systolic velocities and velocity ratio analysis [2].

The most commonly used criteria for identifying arterial stenosis >50% are peak systolic
velocity (PSV) >200 cm/s, PSV ratio >2.0, and aliasing and spectral broadening seen with
colour Doppler [6]. High-grade stenosis (PSV >300 cm/s, PSV ratio across the stenosis
>3.5 and/or monophasic post-stenosis flow) is common in the case of >70% proximal
arterial obstruction [2,7].

Advantages: DUS provides anatomic and haemodynamic information non-invasively, it

has great availability, renal function does not affect the safety of the test, it is the least
costly imaging technique and it can be performed by the patient’s bed. No side effects or
adverse events have been reported. Excellent tolerance and lack of radiation exposure
make DUS the method of choice for routine follow-up [8].

Pitfalls: Due to severe artery calcification, it is sometimes challenging to differentiate

high-grade stenosis from complete occlusion. In addition, extensive calcification may
result in incomplete examinations.

DUS presents limited accuracy for iliac disease due to body habitus and bowel gas. A
normal DUS at rest should be completed by another imaging test when iliac stenosis is
suspected [7,8].

The major limitation of DUS compared with other imaging techniques is that it does not
provide full arterial imaging as a clear roadmap, as do the other techniques [2].

Finally, the technique is operator-dependent and proper training is mandatory. Therefore,

complete DUS scanning of the entire arterial network can be time-consuming.

Accuracy: DUS is an accurate technique for LEAD; it presents a sensitivity of 85-90%

and a specificity of >95% to detect stenosis >50%. No significant differences were found
between the above-the-knee and below-the-knee lesions [9].

More recent techniques, such as flow imaging or live three-dimensional (3D) echography,
as well as intravascular ultrasound for plaque characterisation, require further
investigation; their use is still limited in LEAD [2].

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When surgical revascularisation is planned, DUS is also important to address vein quality
for bypass substitutes. It is also the method of choice for routine follow-up after
revascularisation, especially to assess the surveillance of venous grafts [2,7].

In all cases, the information provided by DUS should be combined with ABI
measurement, and multiple criteria should be used for reliable estimation of stenosis.

Computed tomography angiography

Computed tomography angiography (CTA) is an anatomic imaging test. Similar to digital

subtraction angiography (DSA), CTA displays a “roadmap” of the vascularisation (lesion
localisation and severity, together with upstream/downstream status), which is essential
for determining interventional strategies [2,10].

This technique provides information regarding the characterisation of stenosis, such as

localisation, number and length of occlusive lesions, degree of calcification and
arrangement of the calcium component, quality of distal run-off, and also about
extravascular findings.

Adequate peripheral CTA can be performed with a 16-detector row CT scanner. However,
currently most of the equipment uses 64, 128 or 256 detector rows. The coverage of
peripheral CTA includes the abdominal aorta from the celiac trunk to the foot. These types
of study always require the use of intravenous iodine contrast for adequate assessment
of the arterial lumen.

One of the important technical points of the study is to inject an appropriate iodine
concentration inside the vessel lumen to depict small vessels (1-2 mm) and differentiate
vessel lumen from wall calcification. The bolus arrival is automatically detected at the
level of the proximal abdominal aorta and the image acquisition is triggered with a delay
varying between 6 and 10 seconds to ensure that the distal arteries will be properly
opacified. A delayed acquisition covering knee, leg and foot is a good alternative when
distal opacification is likely to be suboptimal on the first pass [10].

The interpretation of CTA is based on the axial images and the use of advanced post-
processing techniques. While volume-rendered 3D reconstruction of the arterial tree
provides a global overview for rapid identification of pathology, maximum intensity
projection (MIP) images provide similar views to traditional angiography and are useful for
qualitative assessment of the degree of stenosis. The usefulness of both volume-
rendered and MIP images is limited by obscuration of the vessels by bones. Thus,
automated software techniques for bone removal have been implemented, although they
still require some degree of manual correction. Either automated or interpreter-generated
centrelines in the vessel of interest can be placed to obtain curved planar reformations,
providing both longitudinal and cross-sectional views of the vessel, which are useful for
quantitative measurements [7,11].

Advantages: Rapid non-invasive acquisition (<5 minutes), higher spatial resolution that
allows good evaluation of calcifications, stents, bypasses and concomitant aneurysms; it
enables scanning of the entire vascular tree in a limited period and 3D reformatting. The

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capacity of CTA to visualise the arterial wall, as well as the lumen, gives the interpreter a
greater degree of certainty when arriving at less common diagnoses [12].

Pitfalls: This method does not provide haemodynamic data for each lesion, has a high
radiation dose and uses iodinated contrast agents. However, while nephrotoxicity can be
limited by minimising contrast agent volume and ensuring adequate hydration before and
after imaging, the benefit of acetyl-cysteine to limit nephrotoxicity is uncertain [2,13]. In
addition, severe calcification may overestimate stenosis severity, mostly in distal arteries.
Furthermore, the possibility of allergic reactions, the higher costs and the limited
availability of this imaging test should be taken into account.

Accuracy: The reported sensitivity and specificity of CTA to detect aorto-iliac stenosis
>50% were 96% and 98%, respectively, with similar sensitivity (97%) and specificity
(94%) for the femoropopliteal region [2,14,15].

Magnetic resonance angiography

Magnetic resonance angiography (MRA) provides functional and morphological

information that is useful to distinguish anterograde from retrograde perfusion and to
estimate stenosis severity. As with CTA, MRA examinations are indicated when a
revascularisation therapy is planned or when DUS results are inconclusive.

There are three MRA sequences for peripheral artery imaging: 1) flow-dependent
techniques without contrast agent based on proton inflow (time-of-flight), 2) phase shift of
the flowing protons (phase contrast angiography), and 3) contrast-enhanced (gadolinium)
MRA [10].

The non-contrast techniques (phase contrast and time-of-flight sequences) have inferior
resolution and are susceptible to motion artefacts and stenosis overestimation. For these
reasons, the contrast-enhanced MRA acquisition sequence is currently preferred.

Advantages: MRA is extremely useful in patients with mild to moderate chronic kidney
disease (CKD). Compared with CTA, MRA does not need iodine contrast and has higher
soft tissue resolution.

Pitfalls: Motion artefacts are more frequent, partly because acquisitions of MRA
sequences are more time-consuming and it is necessary that the patient maintain the
same position during the acquisition of the study. A relative disadvantage includes a
tendency to overestimate stenosis because of flow turbulence, and metal clips can cause
artefacts that mimic vessel occlusions [7]. Contraindications include claustrophobia,
pacemakers and implantable cardioverter defibrillators (except magnetic resonance
imaging compatible devices). Gadolinium contrast agents cannot be used in the case of
severe renal failure (GFR <30 mL/min/1.73 m²). In the latter case, the risk of nephrogenic
systemic fibrosis following gadolinium administration should not be underestimated [2,16].

Of note, MRA cannot visualise arterial calcifications, which may be a limitation for the
selection of the anastomotic site for a surgical bypass.

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Additionally, poor visualisation of steel stents, the higher cost of the method and its limited
availability are also limiting factors to consider [2].

Accuracy: The sensitivity and specificity of MRA are ~95% for diagnosing segmental
stenosis and occlusion [17,18].

Digital subtraction angiography

Not long ago, digital subtraction angiography (DSA) was considered the standard
reference in vascular imaging. Given its invasive character and risk of complications, it
has mostly been replaced by other less invasive imaging methods [2].

DSA is rarely required for diagnostic purposes and is used only in highly specific
situations with discordant non-invasive imaging results.

Currently, its main use is in combination with endovascular therapy. It is also often
needed to evaluate below-the-knee arteries in patients with chronic limb-threatening
ischaemia, given the limitation of other imaging tools to detect ankle/pedal segments
suitable for distal bypass [2].

In certain clinical settings, non-invasive imaging studies for anatomic assessment (i.e.,
DUS, CTA or MRA) may not be available due to lack of local resources or expertise,
hence DSA is the only option. In addition, there are clinical scenarios in which imaging
tests may be perceived as conferring greater risk to the patient than invasive angiography
(e.g., a patient with advanced chronic kidney disease for whom contrast dose for invasive
angiography would be lower than that required for CTA) [8].

Other imaging techniques: positron emission tomography

Positron emission tomography (PET) is useful for the diagnosis of arteritis (Takayasu
disease, giant cell arteritis) but not for assessment of atherosclerotic lesions in clinical
practice [2].

Test – selection process

The particular modality of choice depends on many factors, including patient
demographics and comorbidities, availability and modernity of respective imaging
equipment, level of training and confidence of the operating technologists, and local
interest and expertise of the vascular team. Each of these factors must be considered
when choosing the best imaging examination for an individual patient [19].

In general, DUS is the first imaging test chosen once LEAD has been diagnosed by
performing an ABI evaluation.

Next, fundamentally when it is necessary to know the entire vascular tree or in case of
aorto-iliac involvement, CTA is the method of choice. Likewise, MRA presents similar
diagnostic accuracy. In two studies with patients presenting intermittent claudication, it
has been shown that CTA provides the same information as MRA at a lower cost [10,20].

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Finally, invasive angiography is indicated when there are controversial results between
the different imaging methods or when an endovascular revascularisation strategy is
planned.

The accuracy of these imaging modalities is summarised in Table 1 [20] and their main
characteristics are shown in Table 2 [7].

Angiography, either non-invasive or invasive, should not be performed for the anatomic
assessment of patients with LEAD who do not evidence leg symptoms, since delineation
of anatomy will not change treatment for this population [8].

Table 1. Comparison between different imaging techniques for arterial stenosis

>50% in LEAD [9,14,17].

Imaging method Sensitivity (%) Specificity (%)

DUS >95

CTA aorto-iliac stenosis 96 98

CTA femoropopliteal stenosis 97 94

MRA 95 95

Table 2. Comparison of different imaging tests for patients with LEAD [7].

Imaging method DUS CTA MRA DSA

Availability +++ ++ ++ +++

Costs + ++ +++ +++

Operator expertise +++ + ++ ++

Diagnostic accuracy

Aorto-iliac ++ +++ +++ +++

Femoropopliteal +++ +++ +++ +++

Tibial + + ++ +++

CTA: computed tomography angiography; DSA: digital subtraction angiography; DUS:

duplex ultrasound; MRA: magnetic resonance angiography; +: low; ++: intermediate;
+++: high.

Special situations: acute limb ischaemia

When assessing acute limb ischaemia, the initial imaging test is chosen case by case,
based on the patient’s characteristics (renal function, allergy to iodinated contrasts) and
the availability of resources in each centre.

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The imaging method depends on its immediate availability, making DUS and DSA the
most frequently used techniques in these situations [2,8].

In case of associated neurological deficit, urgent revascularisation is mandatory and

imaging should not delay the intervention [2,8].

Conclusions

In individuals with clinically suspected LEAD, the ankle-brachial index is indicated as a

first-line test for diagnosis. In order to confirm and characterise the disease, DUS is
usually the preferred imaging test. When a revascularisation strategy is being planned,
accurate details of lesion distribution and distal run-off are necessary to plan
interventions. Magnetic resonance and computed tomography angiography replace
invasive catheter angiography for the mapping of peripheral occlusive arterial disease.

Finally, data from an anatomical imaging test should always be analysed in conjunction
with symptoms and haemodynamic tests prior to any treatment decision.

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Notes to editor

Authors:

Dr. Mariana Corneli, MTSAC; Dr. Gabriel Orlando Perea, MTSAC

Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina

Address for correspondence:

Dr. Mariana Corneli, Instituto Cardiovascular de Buenos Aires, Blanco Encalada 1543,
CP 1428, Buenos Aires, Argentina

Tel: +54 911-41057500

E-mail: cornelimariana@gmail.com

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Author disclosures:

The authors have no conflicts of interest to declare.

The content of this article reflects the personal opinion of the author/s and is not
necessarily the official position of the European Society of Cardiology.

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