Approach Considerations
In the workup for peripheral arterial occlusive disease (PAOD), laboratory studies are helpful only for identifying accompanying silent alterations in renal function and elevated lipid profiles. Angiography is the recommended imaging study. Other studies that may be considered are computed tomography (CT) angiography (CTA), magnetic resonance angiography (MRA), and duplex ultrasonography.
Standard Angiography
Angiography is still the criterion standard arterial imaging study for the diagnosis of PAOD (see the image below). However, this test is usually reserved for when an intervention (either an endovascular procedure or a traditional open surgical procedure) is planned.
Peripheral arterial occlusive disease. Angiogram shows superficial femoral artery occlusion on one side (with reconstitution of suprageniculate popliteal artery) and superficial femoral artery stenosis on other side. This is most common area for peripheral vascular disease.
Patients undergoing vascular surgery are known to be at high risk for cardiovascular complications and mortality. In a study comparing systematic (routine) coronary angiography with selective coronary angiography in patients undergoing surgical treatment of PAOD, Monaco et al found that routine angiography had a positive impact. [9] Routine coronary angiography improved survival significantly, and no deaths or cardiovascular events were reported. Multicenter trials are needed to confirm this finding in a larger population.
Magnetic Resonance Angiography
MRA is useful for imaging large and small vessels. Although it was initially considered to provide inadequate images, this is no longer the case. With improved imaging capabilities, MRA can be used not only to diagnose but also to help plan the type of indicated intervention.
A study that compared MRA with conventional angiography in regard to quality of life and cost-effectiveness found that although MRA was nearly 20% cheaper, there was no difference in quality of life. [10]
Computed Tomography Angiography
CTA is another modality used to image arterial disease. Unfortunately, it still requires a large amount of contrast media, and an upgraded CT scanner is needed to reconstruct helpful images.
CTA is another modality used to image arterial disease. It does have some pitfalls, such as the requirement for large amounts of contrast media, the necessity of synchronizing the image acquisition with the media administration, and the need for an upgraded CT scanner with postprocessing techniques to reconstruct helpful images. However, advances in technology now allow three-dimensional (3D) and four-dimensional (4D) reconstructions providing temporal information.
A small study that evaluated the diagnostic accuracy of “dynamic CTA” for lower-extremity PAOD found the sensitivity and specificity to be 98% and 97.1%, respectively, for diagnosing vessel stenosis, and 95.4% and 99.3%, respectively, for diagnosing vessel occlusion. [11] These figures may be compared with the standard CTA sensitivities and specificities of 96.6% and 92.2%, respectively, for vessel stenosis and 94.4% and 94.4%, respectively, for occlusion. The investigators demonstrated a clear improvement in diagnostic accuracy for PAOD with dynamic CTA over standard CTA, without increased radiation or contrast administration.
Duplex Ultrasonography
Duplex ultrasonography is performed to evaluate the status of a patient’s vascular disease. [12] Duplex scanning has the advantage of being noninvasive and requiring no contrast media or radiation. Unfortunately, it is highly technician-dependent.
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Peripheral arterial occlusive disease. Measuring segmental pressures.
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Peripheral arterial occlusive disease. Angiogram shows superficial femoral artery occlusion on one side (with reconstitution of suprageniculate popliteal artery) and superficial femoral artery stenosis on other side. This is most common area for peripheral vascular disease.
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Peripheral arterial occlusive disease. Procedures performed during acute admission for peripheral arterial disease in US from 1996 to 2005. Reprinted from Journal of Vascular Surgery, Vol 49(4), Rowe VL et al, Patterns of treatment for peripheral arterial disease in the United States: 1996-2005, Pages 910-7, Apr 2009, with permission from Elsevier.
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- Overview
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- DFA Guidelines on Management of Peripheral Arterial Disease in Diabetes-Related Foot Disease
- CCS Guidelines on Management of Peripheral Arterial Disease
- SVS/ESVS/WFVS Guidelines on Chronic Limb-Threatening Ischemia
- ESC/ESVS Guidelines on Lower-Extremity Arterial Disease
- AHA/ACC Guideline on Lower-Extremity Peripheral Arterial Disease
- SVS Guidelines on Atherosclerotic Occlusive Disease of Lower Extremities
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