Basic data underlying clinical decisionmaking in vascular surgery Section Editor--John M. Porter, MD, Portland, Oregon

Diagnostic Imaging in Peripheral Vascular Disease Blaine E. Kozak, MD,

Portland, Oregon

Diagnostic imaging for peripheral vascular disease includes multiple modalities. Computed tomography (CT), ultrasound, digital subtraction arteriography, special arteriographic techniques, and magnetic resonance imaging (MRI) now supplement clinical examinations and standard arteriography and, in selected cases, may replace them. Any evaluation and objective comparison of imaging modalities is made more difficult by interobserver variation, operator dependency, and the varying abilities of the physicians interpreting the studies. Further problems arise due to lack of standard diagnostic criteria, categories of disease, and methods of measurement. In ultrasound studies, for example, some authors require precisely equivalent matching of categories of stenosis in calculating the sensitivity and specificity of their examinations. Others accept variation of one stenosis category above or below the measurement made by arteriography as being equivalent.

From the Department of Diagnostic Radiology, Emanael Hospital and Health Center, Portland, Oregon. Reprint requests: Blaine E. Kozak, MD, Department of Diagnostic Radiology, Emanuel Itospital and Health Center, 2801 North Gantebein, Portland, Oregon 97227.

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Complications of imaging studies are difficult to compare because of the inherent subjectivity of both detection and severity assessment of adverse reactions and outcomes. Hematoma formation at an arterial puncture site is a typical example. No standard is recognized as being significant or reportable as a complication. This is clearly reflected in the reported numbers of local arteriographic complications, most of which are hematomas. Similarly, contrast media reactions are detected, described, and grouped differently in various studies. The adequacy of imaging techniques, such as arteriography, relies not only upon the radiologist's skills in performing and interpreting the exam, but also upon their detailed knowledge of the operative procedures that may be performed subsequently including detailed familiarity with the arteriographic information essential for planning surgery. Lack of the information required rather than the lack of available imaging techniques, appears to be the major obstacle to providing better preoperative arteriography. Major controversies exist concerning the use of nonionic and lower osmolar contrast agents even though their benefits in many risk categories, particularly a history of previous contrast agent reaction or significant asthma, have been clearly established. This review summarizes data relevant to clinical decision-making regarding imaging studies, including their risks, benefits and complications in patients with peripheral vascular disease.

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TABLE I.--Carotid artery imaging with ultrasound Detected lesion Stenosis 50%+ by diameter

Modality Duplex Color duplex

Comparison Arteriography Arteriography

Sensitivity (%) 92-98 90

Specificity (%) 92-93 79

Occlusion

Ultrasound only Duplex Color duplex

Arteriography Arteriography Arteriography

78 93-100 100

96 96-100 93

Plaque with hemorrhage

Ultrasound only Ultrasound only Duplex

Endarterectomy Endarterectomy Endarterectomy

91 93 94

65 84 88

82 87 90

[6] [4] [7]

Plaque with ulceration

Real-time B-mode Duplex

Arteriography Endarterectomy Endarterectomy

8 39-89 64

72-87

60-87 92

[2]d ,~ [4 ,o] [1,9]

83-92 91-98 71-96

[5,10~] [5,11'] [5,12g]

Accuracy of Duplex measurement Color duplex % stenosis Color duplex

Arteriography Duplex Arteriography

Inadequate studies

3-8 h 11-13 ~

Duplex Color duplex

Accuracy (%) 92-95 87

References [1 a,2b] [3~ [4] [1,2,4,5] [5]

[7,10] [5,12]

adiagnostic criteria not given b150 cm/sec peak systolic velocity internal carotid artery c125 cm/sec peak systolic velocity internal carotid artery dArteriography sensitivity: 59%, specificity: 73% in same series "Study in [t0] had accuracy 87%. Additional 10% differed by one stenosis group: accuracy fell to 83% for stenosis greater than 50% fin [11] accuracy was 91%. Additional 9% differed by one stenosis group gused intraarterial digital subtraction arteriography hReasons: calcifications, uncooperative ~Reasons: calcifications, body habitus, deep vessels, high bifurcation, unable to extend neck adequately

TABLE II.--Complications of carotid arteriography

Type of complications

Type of exam Various a Various c Femoraff Non-teaching Teaching Various e Various f Various g

No. cases 5,531 4,748 5,000 4,187 813 1,328 603 1,517

Total all complications % 26.3 1.4 0.9 3.9 12.5 2.3 8.5

CNS Death % 0.03 0.7 0.02 0.03 0.0 0.2 0.0 0.06

Non CNS % 21.7 b

Temp % 4.5

0.4 0.3 1.1 6.3 0.5 6.8

0.9 0.6 2.8 5.4 1.0 2.3

Perm % 0.6 0.48 0.04 0.6 0.0 0.3

CNS = central nervous system; temp = temporary; perm = permanent aFemoral approach 59.1%, direct carotid 37.8% bLocal hematoma accounted for 20.3%, Without hematoma would reduce total complications to 6.2% and local complications to 1.6%. CDirect carotid puncture in 82% of patients dFemoral approach used except in rare instances, percent not stated eFemoral approach 66%, direct puncture 23%, retrograde brachial 12% ~Femorai approach 77%, axitlary 22%, direct puncture 1,3%, 5 Fr. catheters gFemoral approach 96%, direct carotid 2,4%, retrograde brachial 4.6%, axillary 0.13%, 5 Fr. catheters

References [13] [14]

[15]

[16] [17]

[18]

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TABLE III.mCarotid artery digital subtraction arteriography

Type of injection IV

130 100

IV

IV IV tV IA

Complications (all non-CNS) Mild Severe 3.1 1.5

No. of patients

0

78 h 500 2,488 59

0

% Adequacy Both One None 26 a 48 ° 8 60 °

23 d

33-75 i 92.5 k 1.5 3.4

Compared to arteriography Sens Spec Accuracy

25 7.5

99 70 overall:

93

94

20 h

[19]

73 e 97 f 64 g 70

[20]

73-96 j 58-94 ~

[21] [22] [23] [24]

17 95 54

Reference

.24 m 0

93 n

CNS - central nervous system; Sens - ; Spec = ; IV = intravenous; IA = intraarterial aBoth bifurcation seen in two views, most stringent standard bOne bifurcation seen in two views; one in one view was 43,5% CBoth bifurcations seen in at least one view dOne bifurcation seen in at least one view eAccurecy for exact degree of stenosis match fAccuracy for being within one stenosis category match with good to excellent quality digital subtraction arteriograms (DSA) gWithin one stenosis category with poor quality DSA; 36% with exact match hExcluded unsatisfactory exams from study, approximately 20% 133% "optimal" in all views, 75% acceptable or optimal in all views Jlf exact match--73%; if within one stenosis category--96% ~AII bifurcations diagnostic or excellent in one view ~Accuracy for stenoses greater than 60%; fell to 58% for all arteries m65% complications were contrast related nBoth carotid arteries seen in two views, most stringent standard

TABLE I V . - - C o m p l i c a t i o n s of brachial arteriography

7 8 5 5 4

Catheter Size

No. of patients

Fr. Fr. sheath Fr. Fr. Fr.

4,5 Fr. 4 Fr.

Selective/ nonselective

Pulse loss (%)

1,820

selective

1.3-2.7

1,000 45 1,317

mixed nonselective nonselective

0.1 0.0 0.5-2.5 a 0.0-0.7 b 4 1.6a/0.2 b

72 73

mixed selective

Hemorrhage

Aneurysm

(%)

(%)

References [25,26]

0.1 2

9

[27] [28] [24,29-32]

3 1.8

[33] [34] °

aTemporary pulse }oss bPermanent pulse loss COne patient each (0.2%) with brachial stenosis and brachial dissection

TABLE V . m V a l u e of a o r t o g r a p h y in abdominal aneurysm resection

Arteriography studies 980 b

Involved (%) 4-9

Renal arteries Aberrant from Stenosis/ aneurysm occlusion (%) 2-7

(%) 3-34 average 20%

Visceral arteries Reconstructed

Stenosis celiac

Reconstructed

(%) 2-43 average t 0%

S M A (%) 6-27 average 15%

(%) 0-7 average 36%

Valuea change in plan (%)

Refs.

0-75

[35-44]

SMA = superior mesenteric artery aFive studies recommended preoperative arteriography in all patients. Of these three had a value (change in plan) 20%, 72%, and 75%. Two were not stated. The other studies recommended arteriography only for specific indications. bThree patients had major complications including one death [40,43]

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TABLE VI,--Accuracy of computed tomography and aortography in patients with abdominal aortic aneurysms Aneurysm detection

Proximal extent

Multiple renal arteries 2 3 4

lilac extent

lilac aneurysm

Diameter within 1 cm

Exam

(°/4 (%) (°/4 (%) (%) (%) (°/4 cm a 100 94 98 29 0 76 33 Arteriography a 96 100 100 100 100 100 100 CT = computedtomography a50 patients were studied with both CT and arteriography.All had surgery as the standard for comparison

Pseudoaneurysm detection

(%)

(%)

100

100

Ref [45]

42

0

[45]

TABLE Vll.--Accuracy of magnetic resonance imaging and aortography in patients with abdominal aortic aneurysms No. of patients 20

MRI 94 b

A c c u r a c y of prediction a n e u r y s m being supra- or infrarenal a A c c u r a c y prediction 81 a n e u r y s m distal e x t e n t with r e s p e c t to aortic bifurcation a A c c e s s o r y renal arteries 0 (0/5) identified S t e n o t i c or o c c l u d e d celiac, 35 (8/23) mesenteric, and renal arteries identified Retroaortic left renal vein 100 A n e u r y s m size within o n e c m 81 MRI = magnetic resonance imaging aFor those patients in study who went to surgery bThree patients did not have complete MRI; two claustrophobic,one with significant motion COne patient did not have arteriogram becauseof renal failure dStandardfor comparison

TABLE VIE--Lower

Number of arteriograms 200 52 °

100 45

limb

71 100 66 95 87 89

Surgery

(%)

Reference

1 O0c

d

[46]

100

d

[46]

not routinely determined not routinely determined

[46]

d d

[46] [46]

d d

0 (0/2) 47

[46]

arteriography and distal vessel visualization

Adequacy visualization distal vessels Special technique Standard (%) (%) 82.5 (165/200) 75 (15/20)

Arteriography

(%)

(25.35) ~. (52/52) ° (8/12) e. (19/20) T (174/200 legs) g (40/45) °

100 (4/4)'

Subsequent operative arteriograms Added Performed information 0.5

(%)

(%)

Reference

(I)b

0.5

[47]

[48] [49]

[50]

28 not r e p o r t e d 36 (16/44) i 64 (28/44) 0 [51] aselective catheter positioning, intraarterialtolazoline.One patient had better visualizationbut still neededoperativearteriogram;see footnoteb. bone patient with occlusion superficial femoral and popliteal arteries neededoperativearteriogram before bypass. Remaining patients had either no surgery or amputation. tEach patient had two arteriographicruns. %0 CCcontrast agent injected external iliac artery. %0 cc contrast agent injectedexternal lilac artery f60 cc contrast agent injected external iliac artery with inflow occlusion, This method gave better vessel opacificationthan method in footnote d, but no better diagnostic adequacy gLong injection time, large volumeof injection and late filming; 13% not seen on initial arteriogramdue to timing errors hOcclusion balloon in external lilac artery to block inflow. Four failures were due to timing errors and one becauseof equipment malfunction !Digital subtraction arteriograms(DSA) were used in 4 of the 5 initial failures in footnote h JDSA following standardarteriogramswhich detectedno bypassablerunoff vessels

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TABLE tX.--Complications of arteriography--overall complication rates

Transfemoral 83,068

Number of cases Total complications (as %)

Entry site T ransaxillary 4,590

1,441 (1.73)

Deaths (as %)

Translumbar 4,118

151 (3.29)

119 (2.89)

4

24 (0.03)

Total 91,776 11,402 1,711 (1.86) 413 (3.6) a 30

2

(0.05)

(0,09)

(0.03) 7

Reference [52] [55] [52] [55] [52]

[55]

(0.06) aMinor complications were 2.9%; local hematoma, contrast agent injection into vessel watl or perforation without sequelae. Major complications were 0.7%.

TABLE X.--Complications of arteriographympuncture site complications

Type of complication Hematoma Thrombosis/occlusion Pseudoaneurysm Arteriovenous fistula Limb loss Delayed hemorrhage Permanent neurologic deficit Total

Entry site Transaxillary (%) 0.68-1.18 0.51-0.76 0.17-0.22 0.02 0.02 0 0.17

Transfemoral (%) 0,26-0.9 a 1,14 0.05 0.01 0.01 1.2 0.47-2.24

1.7-2.1

Translumbar (%) 0.53 0 0.05 0 0

0.58

References [52-54] [52-54] [52,54] [52] [52] [53] [54] [52-54]

aLarge or pronounced. Moderate femoral hematoma was 3,1%, and moderate axillary hematoma 3.2% [52].

TABLE XIl.--Puncture of prosthetic vascular grafts

TABLE Xl.--Complications of arteriographymsystemic complications

Entry site Trans- Transfemoral axillary (%) (%) Cardiac 0.29 0.26 Cardiovascular 0.03 0.04 collapse Neuroiogic 0.17 0.46 Seizures 0,06 0.15

Translumbar (%) Reference 0.36 ~ [52] 0.07 ~ [52] 0.02 b 0.00 °

aNOt statistically different bStatistically significant differences among techniques p < 0.05. CStatistically significant differences among techniques p < 0.01.

[52] [52]

Number of graft punctures (Patient no.) 50 (41) 100 86 (58) 50 700

Graft complications (%) 0 0 3.5 a 2.0 b 0.3

aThree patients had graft thrombosis bone catheter separation during removal

Reference [56] [57] [58] [59] [57]

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TABLE Xlll.--Systemic heparinization during arteriography

Systemic heparin No No No Yes a No Yes b Yes °

Hematoma

Number of patients 93 173 200 200 25 57 525

Small (%)

Large (%)

Late bleed (%)

5.5 6.0

1.0 1.0

1.5 6.0

Pulse change or emboli (%) 8.6

Artery occlusion (%) 2.0 1.0 0.0

3.4 0.75 0.2

Entry site clot (%) 53.7 44 6.5 2.0

Reference [60] [61 ] [62] [63]

2.5

[64]

a45 units/kg body weight; average 3250 units bBolus 2000 units IV and 3000 units intraarterial infusion via sheath---Bolus of 1000 units given after each hour of elapsed time c45 units/kg body weight

TABLE XIV.--Patient radiation doses during arteriography

Type of study Abdominal aorta cut-film Renal DSA a Cerebral cut-film Cerebral DSA

Skin (mrad) 37,000

Testes (mrad) 900

Ovaries (mrad) 7,000

23,000 17,000 to 23,000 3,700

500 0-1

1,000 0-1

Red marrow (mrad) 2,800

Thyroid (mrad) 0-1

800 500 to 1,150 55

50 4,000 to 8,700 740

Uterus (mrad) 7,000 800 0-1

Lens (mrad)

320 15

References [65] [65] [65,66] [66]

DSA = digital subtraction arteriogram; 1,0 mrad = 0.01 mGy aRenal DSA should closely approximate DSA examination of the abdominal aorta

TABLE XV.--Recommendations for use of lower

osmolar contrast media American College of Radiology Clinical Standards of Patient Care [67] 1. Patients with previous significant adverse reaction to contrast material, strongly allergic history, or asthma. 2. Patients with cardiac dysfunction, severe arrhythmias, unstable angina pectoris, recent myocardial infarction, pulmonary hypertension, and congestive heart failure. 3. Patients with generalized severe debilitation. 4. Patients undergoing potentially painful examinations such as peripheral arteriography, external carotid arteriography, and lower limb phlebography. 5. Patients undergoing examinations such as digital arteriography where motion must be minimized to optimize image quality. TABLE XVl.---Complications of administration of contrast media

No. of exams 11,546,000 912,300 318,500 33,000 112,003 337,647 109,546 ° 13,176 `~

Deaths 99 15 8 1 11 2

Mortality rate 1:117,000 1:61,000 1:40,000 1:33,000 1:10,000 t :169,000

ADRs with ionic Very Total Severe severe (%) (%) (%)

ADRs with nonionic Very Total Severe severe (%) (%) (%)

4.95 12.66

3.13

4.1

0.1a 0.22 b 0.09 c 0.4 d

0.04

0.69

0.04 0.02 0.0

0.004

Reference [68] [69] [70] [71] [72] [73] [74] [75]

ADR = adverse drug reaction aSevere ADRs meant required hospitalization bSevere ADRs were dyspnea, sudden drop in blood pressure, loss of consciousness, cardiac arrest or a combination of these c72% received ionic contrast material and 28% received nonionic. Severe ADRs were urgent therapy and hospital admission, ~45.6% received ionic contrast media, 54.6% received nonionic. Severe ADRs inctuded cardiac arrest, shock, toss of consciousness, symptomatic cardiac arrhythmias

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TABLE XVII.--Risk of adverse reaction by history of prior contrast agent administration and prior reaction Prior contrast agent exposure

ADR with ionic

Yes

ADR with nonionic

Prior ADR

Total

Severe

Total

(%)

(%)

(%)

(%)

Reference

Yes No

44.04 9,02 13,71

0.73 0.13 0.26

11.24 2.21 3.03

O. 18 0.03 0.04

[73]

No ADR - adversedrug reaction

Severe

T A B L E X V I I I . - - R i s k of adverse reaction to contrast

media with history of asthma ADR with ionic agent Total ADR Severe (%)

(%)

ADR with nonionic agent Total ADR Severe (%)

(%)

Reference

19.68 1.88 7,75 ADR - adversedrug reaction

0.23

[73]

TABLE XlX.--Corticosteroid use to reduce reactions to contrast agents

Type of reaction

Percent change in ADRs with steroids pretreatment ~ All Low-risk High-risk patients patients patients

Reference

[76] All reactions 1 - 3 b -31 -29 -37 T y p e 1 reactions -33 -43 -31 T y p e 2 reactions -23 +1 -45 T y p e 3 reactions -62 -86 -34 Reactions n e e d i n g -42 -35 -37 treatment ADR = adversedrug reaction; Low-risk = no history of ADR or allergic history; High-risk = previousADR or allergic history aAII patients received ionic contrast material. Pretreatment consisted of a two dose regimen of methylprednisolone12 and 2 hours before contrast agent administration. bType 1 - one episodenausea,vomiting,sneezingor vertigo;Type 2 = hives,morethan one episodevomiting,fever and/orchilis; Type 3 = shock, laryngospasm, laryngeal edema, bronchospasm,loss of consciousness, seizures, change in blood pressure, angina, arrhythmias,angioedemaor pulmonaryedema.

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