THE ARTERIOGRAPHIC EXAMINATION OF THE LOWER EXTREMITY DARRELL A.
CAMPBELL, M.D.,
Ann
Arbor, Michigan
AND
R. GLENN
SMITH, M.D., Rockford, Ill.
Roentgenographic examination of the lumina of major arteries in the lower extremity by the introduction of a radiopaque material is an old procedure but has never become a popular examination. Reluctance to utilize this method is an outgrowth of early attempts at which time the procedure was complicated, requiring many assistants; time consuming; and carrying an element of danger from the use of impure or unstable contrast material. Years of progress have overcome these obstacles one by one until at the present time a simple method of carrying out the examination has been described (1) and acceptable results achieved. TECHNIQUE
details in
Special (1). Briefly, 1.
performing the examination have been described elsewhere the following points should be adhered to:
Equipment suitable for rapid injection of the radiopaque material should be used. simply of a 30 cc. Luer-Lok syringe and a sharp, short bevelled No. 18 gauge
This consists needle.
2. Thirty to thirty-five cc. of 35 per cent Diodrast (Winthrop-Stearns) is injected into the artery after first introducing the needle percutaneously into the arterial lumen. Local anesthesia is used in the skin and around the vessel. 3. The femoral artery must be occluded by digital compression 5. After releasing the occluded vessel for 6-8 seconds, meanwhile injecting the last 5-10 cc. of contrast material, the second exposure is made. 6. Changing the cassettes between exposures is facilitated by a specially constructed changer, described in a previous publication (1). 7. Roentgen factors are: 68 KV, 300 Ma, 2o second and a target skin distance of 6 feet. The entire lower extremity is exposed at one time. INDICATIONS
Any vascular tree which requires studies of any type to determine its ability to deliver blood to the tissues may be examined by this method. We would like to emphasize that this examination is not intended to supplant other methods now employed. It is, rather, a supplementary test that may be quite valuable in which other examinations imperfectly describe the ability of the blood more distal portions of the extremity. It has been pointed out to us that many examiners who are particularly interested in peripheral vascular diseases, and who have employed this method in earlier times, now find it unnecessary in many instances because of exceptional skill in the evaluation and clinical examination of an extremity. In this respect
in
cases
to reach the
From the
Department
of
Surgery, Wayne County General Hospital, Eloise, Michigan. 100
Downloaded from ang.sagepub.com at Purdue University on July 3, 2015
101 the method serves as an educational aid to younger and less experienced examiners. In general, diseases which by their nature have a tendency to occlude or obstruct the lumen of arteries lend themselves better to this examination. Arteriosclerosis, thrombo-angitis obliterans, aneurysms, and arterio-venous fistulas are among this group. CONTRAINDICATIONS
Technically, the following may be listed as contraindications: (a) a non-pulsatile vessel at the site of injection; (b) severe deformities or contractures which make roentgen exposure difficult; (c) sensitivity to the contrast material. Diseases of the vessels in themselves offer no contraindication other than in some cases there is simply a lack of indication. COMPLICATION
Though complications are minimal, those possible deserve mention.
that have occurred
or are
thought
to be
1. Injury to the vessel at the point of injection. It is quite possible that eventually an atheromatous plaque may be dislodged during the arterial puncture when the examination is being performed on arteriosclerotic patients. It can be assumed that such an accident would manifest itself in a manner similar to any arterial embolus. In our series of nearly 300 arteriograms on arteriosclerotic patients no such accident has occurred. 2. Perivascular infiltration with the contrast material. This has been done numerous times with no untow·ard effects. Occasionallv a mild neuritis of the femoral nerve is evident for a few days. 3. Hematoma at site of injection. This has occurred a few times but never has reached alarming proportions. Digital pressure over the site of arterial puncture for 2-3 minutes following the examination is usually sufficient to control bleeding. 4. Production of arterial spasm. In our series severe arterial spasm, manifest by severe pain and blanching of the extremity, has occurred three times. This cannot be considered an unimportant complication in patients whose ciruculation in an extremity is already borderline. Immediate relief, however, can be obtained by lumbar sympathetic block or the intravenous administration of an autonomic blocking agent. If it is promptly recognized and treated, no damaging effects should be anticipated. 5. Irritation of the intima. Arteriograms have been made from five minutes to three weeks prior to operation in patients requiring major amputations. In thirty-six such cases, the entire arterial tree has been dissected out and examined grossly and microscopically for evidence of fresh thrombosis or evidence of intimal irritation. In those vessels examined, no evidence to this effect has been found. Pharmacologically, this material is a non-irritating substance and it seems unlikely that its brief existence in the vessels would be sufficient to
produce significant damage.
6. Pain at time of injection. Sharp pain, coursing down the length of the leg, in various degrees of severity, occurs in about 25 per cent of the cases. It lasts only from a few seconds to one or two minutes, and except in cases of obvious arterial spasm, has never been severe enough to warrant medication for relief. In many instances, a flush follows injection which sometimes benefits those with ischemic pain. Such patients frequently request &dquo;another treatment.&dquo; WHAT DOES ARTERIOGRAPHY
OFFER?
As mentioned before, this examination probably is of less importance to those with years of experience in the peripheral vascular field, than to others less well
Downloaded from ang.sagepub.com at Purdue University on July 3, 2015
102
FIG. 1. PHOTOGRAPH
OF
ARTERIOGRAM
WITH
CORRESPONDING
DRAWING
FOR
CLARI-
FICATION
The following points are noted: (1) The vessels of the upper leg are well filled in the first exposure whereas those of the lower leg are filled in the second exposure; (2) a nearly complete occlusion exists in the lower femoral artery at the point where it passes through the hiatus in the aponeurosis of the adductor magnus; (3) There is complete occlusion of the posterior tibial in the lower third although both vessels are filled in the foot.
informed upon the subject. Despite this to such experienced examiners.
fact, other benefits
can
be
enumerated,
even
1. It is
a
direct method. In contrast to many other methods of estimating circulatory or points of obstruction. At the same
impairment, this method actually visualizes the point
Downloaded from ang.sagepub.com at Purdue University on July 3, 2015
103 time the degree of collateral development is seen. These, correlated with the physical examination and history. offer the most convincing evidence as to the exact state of the circulation in an extremity. Though estimation of the severity of circulatory impairment
FIG. 2. THIS PHOTOGRAPH AND DRAWINGS DEMONSTRATE COMPLETE OCCLUSION OF THE BIFURCATION OF THE POPLITEAL ARTERY There is good collateral development in the lower leg but probably not sufficient to permit lower leg amputation.
valuable, occasionally, the diagnosis itself can be more accurately made by arteriograph~-. For example, the confusing differential diagnosis between Buerger’s disease and arteriosclerosis during the third and fourth decades can be immediately clarified by arteriographic examination without resorting to histologic examination. 2. It is a visual method. Students often find it easier to explain symptoms of various peripheral vascular diseases if they can actually see the functioning outline of the vessels.
seems more
Downloaded from ang.sagepub.com at Purdue University on July 3, 2015
104 In this it-ay. it is of assistance to those with special interest in this field. Like all roentgenograms, it is also a graphic record, capable of being filed away for future reference or compared with a similar examination at some subsequent date.
FIG. 3. HIGH FEMORAL OCCLUSION Is DEMONSTRATED IN THIS .£RTERIOGR.%31, ALTHOUGH THERE Is GOOD FILLING OF THE PROFUNDA FEMORIS WHICH IN TURN FILLS, THROUGH COLLATERALS, THE LOWER FEMORAL ARTERY A second segmental occlusion exists in the popliteal artery. Large intraluminal atheromatous plaques are demonstrated in the mid-femoral artery. 3. Earlier estimate of prognosis. Patients often require some statement relative to the eventual outcome of the state of their disease. Though this examination is not infallible in this respect, a knowledge of the extent of the disease is of great help in predicting the
future
course
of the
extremity.
Downloaded from ang.sagepub.com at Purdue University on July 3, 2015
105 4. Assistance in determining the site of amputation. It is now generally conceded that the wound will heal, the more conservative the amputation the better. In patients with minimal gangrene of ulcers or digits, this examination is of inestimable value in deciding whether the amputation should be digital only, transmetatarsal, lower leg, or supracondylar. In our experience, major amputations with a reasonable assurance of wound healing should only be undertaken at a point where a major vessel is patent. Though collaterals alone may sufi~ce for long periods in the absence of trauma or infection or other increased circulatory requirements, they cannot be depended upon to insure wound healing even after the most careful atraumatic type of amputation. 5. Possible assistance in determining candidates for lumbar sympathectomy. If we can assume the removal of vasomotor tonus or perhaps even vasodilation of the arteriolar and capillary bed to result from lumbar sympathectomy, the existence of a functioning network of small vessels with reasonably satisfactory major vessels supplying them appears to be necessary. 6. Opportunity for new therapeutic efforts. Recent reports (2, 3) have suggested that small segmental occlusions in major vessels can be excised and the lumen restored by means of a vein graft. Such a case has also been successfully carried out by the authors and will be included in a subsequent report. Before considering this type of therapy, the exact location and extent of the occlusion must be accurately determined.
if
This method of examination will not solve all the problems that confront the surgeon interested in diseases of the vascular system. Like other similar examinations, its success or failure will depend upon the care and attention to detail in the technical aspects of the procedure and the interest and intelliinterpretation. Correlation with history and physical examination is essential. In general, the method does not lend itself well to the practioner for occasional use only. It is more suited to institutions with well organized peripheral vascular clinics.
performing
gence in its
SUMMARY
Arteriographic examination of the lower extremity is of assistance in assessthe circulatory state of that extremity. ing 2. The technique has been briefly reviewed. 3. Indications, contraindications, and complications have been enumerated. 4. The chief uses for the method have been discussed. 1.
REFERENCES 1.
SMITH, R. GLENN AND CAMPBELL, DARRELL A.: Some technical considerations in the arteriographic examination of the lower extremity. Surgery, 24: 655-661, October 1948.
2.
HOLDEN, WILLIAM: Report delivered before Central Surgical Association, Cleveland, Ohio, February 1949. 3. BAZY, L. AND CHAMPY: L’endarteriectomie dans les arterites obliterantes. Bull. Acad. Nat. Med., Paris, 132: 159-166, 1948.
Downloaded from ang.sagepub.com at Purdue University on July 3, 2015
CAMPBELL, M.D.,
Ann
Arbor, Michigan
AND
R. GLENN
SMITH, M.D., Rockford, Ill.
Roentgenographic examination of the lumina of major arteries in the lower extremity by the introduction of a radiopaque material is an old procedure but has never become a popular examination. Reluctance to utilize this method is an outgrowth of early attempts at which time the procedure was complicated, requiring many assistants; time consuming; and carrying an element of danger from the use of impure or unstable contrast material. Years of progress have overcome these obstacles one by one until at the present time a simple method of carrying out the examination has been described (1) and acceptable results achieved. TECHNIQUE
details in
Special (1). Briefly, 1.
performing the examination have been described elsewhere the following points should be adhered to:
Equipment suitable for rapid injection of the radiopaque material should be used. simply of a 30 cc. Luer-Lok syringe and a sharp, short bevelled No. 18 gauge
This consists needle.
2. Thirty to thirty-five cc. of 35 per cent Diodrast (Winthrop-Stearns) is injected into the artery after first introducing the needle percutaneously into the arterial lumen. Local anesthesia is used in the skin and around the vessel. 3. The femoral artery must be occluded by digital compression 5. After releasing the occluded vessel for 6-8 seconds, meanwhile injecting the last 5-10 cc. of contrast material, the second exposure is made. 6. Changing the cassettes between exposures is facilitated by a specially constructed changer, described in a previous publication (1). 7. Roentgen factors are: 68 KV, 300 Ma, 2o second and a target skin distance of 6 feet. The entire lower extremity is exposed at one time. INDICATIONS
Any vascular tree which requires studies of any type to determine its ability to deliver blood to the tissues may be examined by this method. We would like to emphasize that this examination is not intended to supplant other methods now employed. It is, rather, a supplementary test that may be quite valuable in which other examinations imperfectly describe the ability of the blood more distal portions of the extremity. It has been pointed out to us that many examiners who are particularly interested in peripheral vascular diseases, and who have employed this method in earlier times, now find it unnecessary in many instances because of exceptional skill in the evaluation and clinical examination of an extremity. In this respect
in
cases
to reach the
From the
Department
of
Surgery, Wayne County General Hospital, Eloise, Michigan. 100
Downloaded from ang.sagepub.com at Purdue University on July 3, 2015
101 the method serves as an educational aid to younger and less experienced examiners. In general, diseases which by their nature have a tendency to occlude or obstruct the lumen of arteries lend themselves better to this examination. Arteriosclerosis, thrombo-angitis obliterans, aneurysms, and arterio-venous fistulas are among this group. CONTRAINDICATIONS
Technically, the following may be listed as contraindications: (a) a non-pulsatile vessel at the site of injection; (b) severe deformities or contractures which make roentgen exposure difficult; (c) sensitivity to the contrast material. Diseases of the vessels in themselves offer no contraindication other than in some cases there is simply a lack of indication. COMPLICATION
Though complications are minimal, those possible deserve mention.
that have occurred
or are
thought
to be
1. Injury to the vessel at the point of injection. It is quite possible that eventually an atheromatous plaque may be dislodged during the arterial puncture when the examination is being performed on arteriosclerotic patients. It can be assumed that such an accident would manifest itself in a manner similar to any arterial embolus. In our series of nearly 300 arteriograms on arteriosclerotic patients no such accident has occurred. 2. Perivascular infiltration with the contrast material. This has been done numerous times with no untow·ard effects. Occasionallv a mild neuritis of the femoral nerve is evident for a few days. 3. Hematoma at site of injection. This has occurred a few times but never has reached alarming proportions. Digital pressure over the site of arterial puncture for 2-3 minutes following the examination is usually sufficient to control bleeding. 4. Production of arterial spasm. In our series severe arterial spasm, manifest by severe pain and blanching of the extremity, has occurred three times. This cannot be considered an unimportant complication in patients whose ciruculation in an extremity is already borderline. Immediate relief, however, can be obtained by lumbar sympathetic block or the intravenous administration of an autonomic blocking agent. If it is promptly recognized and treated, no damaging effects should be anticipated. 5. Irritation of the intima. Arteriograms have been made from five minutes to three weeks prior to operation in patients requiring major amputations. In thirty-six such cases, the entire arterial tree has been dissected out and examined grossly and microscopically for evidence of fresh thrombosis or evidence of intimal irritation. In those vessels examined, no evidence to this effect has been found. Pharmacologically, this material is a non-irritating substance and it seems unlikely that its brief existence in the vessels would be sufficient to
produce significant damage.
6. Pain at time of injection. Sharp pain, coursing down the length of the leg, in various degrees of severity, occurs in about 25 per cent of the cases. It lasts only from a few seconds to one or two minutes, and except in cases of obvious arterial spasm, has never been severe enough to warrant medication for relief. In many instances, a flush follows injection which sometimes benefits those with ischemic pain. Such patients frequently request &dquo;another treatment.&dquo; WHAT DOES ARTERIOGRAPHY
OFFER?
As mentioned before, this examination probably is of less importance to those with years of experience in the peripheral vascular field, than to others less well
Downloaded from ang.sagepub.com at Purdue University on July 3, 2015
102
FIG. 1. PHOTOGRAPH
OF
ARTERIOGRAM
WITH
CORRESPONDING
DRAWING
FOR
CLARI-
FICATION
The following points are noted: (1) The vessels of the upper leg are well filled in the first exposure whereas those of the lower leg are filled in the second exposure; (2) a nearly complete occlusion exists in the lower femoral artery at the point where it passes through the hiatus in the aponeurosis of the adductor magnus; (3) There is complete occlusion of the posterior tibial in the lower third although both vessels are filled in the foot.
informed upon the subject. Despite this to such experienced examiners.
fact, other benefits
can
be
enumerated,
even
1. It is
a
direct method. In contrast to many other methods of estimating circulatory or points of obstruction. At the same
impairment, this method actually visualizes the point
Downloaded from ang.sagepub.com at Purdue University on July 3, 2015
103 time the degree of collateral development is seen. These, correlated with the physical examination and history. offer the most convincing evidence as to the exact state of the circulation in an extremity. Though estimation of the severity of circulatory impairment
FIG. 2. THIS PHOTOGRAPH AND DRAWINGS DEMONSTRATE COMPLETE OCCLUSION OF THE BIFURCATION OF THE POPLITEAL ARTERY There is good collateral development in the lower leg but probably not sufficient to permit lower leg amputation.
valuable, occasionally, the diagnosis itself can be more accurately made by arteriograph~-. For example, the confusing differential diagnosis between Buerger’s disease and arteriosclerosis during the third and fourth decades can be immediately clarified by arteriographic examination without resorting to histologic examination. 2. It is a visual method. Students often find it easier to explain symptoms of various peripheral vascular diseases if they can actually see the functioning outline of the vessels.
seems more
Downloaded from ang.sagepub.com at Purdue University on July 3, 2015
104 In this it-ay. it is of assistance to those with special interest in this field. Like all roentgenograms, it is also a graphic record, capable of being filed away for future reference or compared with a similar examination at some subsequent date.
FIG. 3. HIGH FEMORAL OCCLUSION Is DEMONSTRATED IN THIS .£RTERIOGR.%31, ALTHOUGH THERE Is GOOD FILLING OF THE PROFUNDA FEMORIS WHICH IN TURN FILLS, THROUGH COLLATERALS, THE LOWER FEMORAL ARTERY A second segmental occlusion exists in the popliteal artery. Large intraluminal atheromatous plaques are demonstrated in the mid-femoral artery. 3. Earlier estimate of prognosis. Patients often require some statement relative to the eventual outcome of the state of their disease. Though this examination is not infallible in this respect, a knowledge of the extent of the disease is of great help in predicting the
future
course
of the
extremity.
Downloaded from ang.sagepub.com at Purdue University on July 3, 2015
105 4. Assistance in determining the site of amputation. It is now generally conceded that the wound will heal, the more conservative the amputation the better. In patients with minimal gangrene of ulcers or digits, this examination is of inestimable value in deciding whether the amputation should be digital only, transmetatarsal, lower leg, or supracondylar. In our experience, major amputations with a reasonable assurance of wound healing should only be undertaken at a point where a major vessel is patent. Though collaterals alone may sufi~ce for long periods in the absence of trauma or infection or other increased circulatory requirements, they cannot be depended upon to insure wound healing even after the most careful atraumatic type of amputation. 5. Possible assistance in determining candidates for lumbar sympathectomy. If we can assume the removal of vasomotor tonus or perhaps even vasodilation of the arteriolar and capillary bed to result from lumbar sympathectomy, the existence of a functioning network of small vessels with reasonably satisfactory major vessels supplying them appears to be necessary. 6. Opportunity for new therapeutic efforts. Recent reports (2, 3) have suggested that small segmental occlusions in major vessels can be excised and the lumen restored by means of a vein graft. Such a case has also been successfully carried out by the authors and will be included in a subsequent report. Before considering this type of therapy, the exact location and extent of the occlusion must be accurately determined.
if
This method of examination will not solve all the problems that confront the surgeon interested in diseases of the vascular system. Like other similar examinations, its success or failure will depend upon the care and attention to detail in the technical aspects of the procedure and the interest and intelliinterpretation. Correlation with history and physical examination is essential. In general, the method does not lend itself well to the practioner for occasional use only. It is more suited to institutions with well organized peripheral vascular clinics.
performing
gence in its
SUMMARY
Arteriographic examination of the lower extremity is of assistance in assessthe circulatory state of that extremity. ing 2. The technique has been briefly reviewed. 3. Indications, contraindications, and complications have been enumerated. 4. The chief uses for the method have been discussed. 1.
REFERENCES 1.
SMITH, R. GLENN AND CAMPBELL, DARRELL A.: Some technical considerations in the arteriographic examination of the lower extremity. Surgery, 24: 655-661, October 1948.
2.
HOLDEN, WILLIAM: Report delivered before Central Surgical Association, Cleveland, Ohio, February 1949. 3. BAZY, L. AND CHAMPY: L’endarteriectomie dans les arterites obliterantes. Bull. Acad. Nat. Med., Paris, 132: 159-166, 1948.
Downloaded from ang.sagepub.com at Purdue University on July 3, 2015
