Introdução: A angiografia por tomografia computorizada (AngioTC) é aceite como técnica para seleção de doentes com doença arterial periférica candidatos a terapêutica endovascular ou cirúrgica. Não existe suficiente evidencia em relação à sua acuidade em doentes com pé diabético e patologia infrapopliteia.
Objetivo: Avaliar a acuidade diagnóstica da AngioTC nas artérias infrapopliteias em doentes com pé diabético.
Métodos: Estudo unicêntrico retrospetivo dos achados AngioTC e da angiografia digital de subtração em 14 doentes submetidos a revascularização endovascular periférica com pé diabético. A sensibilidade e especificidade da AngioTC foram calculadas para cada segmento arterial de acordo com uma classificação modificada da classificação de Rutherford.
Resultados: A sensibilidade e especificidade global da AngioTC na deteção de lesões estenóticas significativas foi de 1 (95% C.I. 0.89-1) e 0.7 (95% C.I. 0.35-0.93), respetivamente.
Por segmento arterial a sensibilidade e especificidade foram de 0.96 (95% C.I. 0.88-0.99) e 0.86 (95% C.I. 0.57-0.98) na artéria tibial anterior, de 0.98 (95% C.I. 0.90-0.99) e 0.93 (95% C.I. 0.66-0.99) na artéria tibial posterior, de 0.93 (95% C.I. 0.83-0.98) e 0.72 (95% C.I. 0.42-0.92) na artéria peroneal, respetivamente.
Conclusão: A AngioTC tem excelente acuidade diagnóstica e permite a triagem de doentes diabéticos com doença arterial periférica infrapopliteia.info:eu-repo/semantics/publishedVersio

Bilhim, T

Neves, J

Sousa Pereira, JA

Vaz Costa, N

English

Repository of the Hospital Center of Central Lisbon

Diagnostic Accuracy of CT Angiography for A Infrapopliteal Lesions in Patientes with Diabetic Foot  Ulcers Undergoing Endovascular  Revascularization

Repositório do Centro Hospitalar de Lisboa Central, EPE

ACTA RADIOLÓGICA PORTUGUESASetembro-Dezembro 2015   nº 106   Volume XXVII   13-16DIAGNOSTIC ACCURACY OF CT ANGIOGRAPHY FOR INFRAPOPLITEAL LESIONS IN PATIENTS WITH DIABETIC FOOT ULCERS UNDERGOING ENDOVASCULAR REVASCULARIZATIONACUIDADE DIAGNÓSTICA DA ANGIOGRAFIA POR TC NAS LESÕES INFRAPOPLITEIAS DE DOENTES COM PÉ DIABÉTICO SUBMETIDOS A REVASCULARIZAÇÃO ENDOVASCULARJosé António Sousa Pereira1, Nuno Vaz Costa2, José Neves3, Tiago Bilhim21Serviço de Radiologia, Centro Hospitalar de Lisboa Central, Hospital Santo António dos Capuchos, Lisboa2Serviço de Radiologia, Centro Hospitalar de Lisboa Central, Hospital de São José, Lisboa3Serviço de Cirurgia, Centro Hospitalar de Lisboa Central, Hospital Santo António dos Capuchos, LisboaDirector da Área de Diagnóstico por Imagem do Centro Hospitalar de Lisboa Central: Dr. João ReisCoordenadora do Serviço de Radiologia do Hospital Santo António dos Capuchos:            Dra. Zita SeabraCorrespondênciaJosé António Sousa PereiraServiço de RadiologiaCentro Hospitalar de Lisboa CentralHospital Santo António dos CapuchosAlameda de Santo António dos Capuchos1169-050 Lisboae-mail: pereirajoseantonio@outlook.comRecebido a 21/09/2015Aceite a 27/01/201613ResumoIntrodução: A angiografia por tomografia computorizada (AngioTC) é aceite como técnica para seleção de doentes com doença arterial periférica candidatos a terapêutica endovascular ou cirúrgica. Não existe suficiente evidencia em relação à sua acuidade em doentes com pé diabético e patologia infrapopliteia.Objetivo: Avaliar a acuidade diagnóstica da AngioTC nas artérias infrapopliteias em doentes com pé diabético.Métodos: Estudo unicêntrico retrospetivo dos achados AngioTC e da angiografia digital de subtração em 14 doentes submetidos a revascularização endovascular periférica com pé diabético. A sensibilidade e especificidade da AngioTC foram calculadas para cada segmento arterial de acordo com uma classificação modificada da classificação de Rutherford. Resultados: A sensibilidade e especificidade global da AngioTC na deteção de lesões estenóticas significativas foi de 1 (95% C.I. 0.89-1) e 0.7 (95% C.I. 0.35-0.93), respetivamente.Por segmento arterial a sensibilidade e especificidade foram de 0.96 (95% C.I. 0.88-0.99) e 0.86 (95% C.I. 0.57-0.98) na artéria tibial anterior, de 0.98 (95% C.I. 0.90-0.99) e 0.93 (95% C.I. 0.66-0.99) na artéria tibial posterior, de 0.93 (95% C.I. 0.83-0.98) e 0.72 (95% C.I. 0.42-0.92) na artéria peroneal, respetivamente.Conclusão: A AngioTC tem excelente acuidade diagnóstica e permite a triagem de doentes diabéticos com doença arterial periférica infrapopliteia. Palavras-chavePé Diabético; Angiografia por tomografia computorizada; Revascularização endovascular.AbstractBackground: Computed tomography angiography (CTA) is an accepted technique for selecting patients with peripheral arterial disease for surgical and endovascular treatment. There is limited data regarding its accuracy for infrapopliteal vessels in patients with diabetic foot.Purpose: Evaluate the diagnostic accuracy of  CTA for below the knee arteries in patients with diabetic foot.Methods: Single-center retrospective analysis of  CTA and Digital Subtraction Angiography imaging findings in 14 patients that underwent peripheral arterial revascularization due to diabetic foot ulcers. The sensitivity and specificity of  CTA was assessed according to each arterial segment based on an adapted Rutherford Score of  disease impairment.Results: CTA overall sensitivity and specificity for the detection of  significant arterial lesions was 1 (95% C.I. 0.89-1) and 0.7 (95% C.I. 0.35-0.93), respectively.By arterial segment, the sensitivity and specificity for the anterior tibial artery were 0.96 (95% C.I. 0.88-0.99) and 0.86 (95% C.I. 0.57-0.98), for the posterior tibial artery were 0.98 (95% C.I. 0.90-0.99) and 0.93 (95% C.I. 0.66-0.99) and for the peroneal artery were 0.93 (95% C.I. 0.83-0.98) and 0.72 (95% C.I. 0.42-0.92), respectively.Conclusion: CTA has excellent diagnostic accuracy and allows screening of  diabetic patients with in-frapopliteal peripheral arterial disease.Key-wordsDiabetic foot; Computed tomography angiography; Endovascular revascularization.IntroductionDiabetic patients are particularly susceptible to foot infection because of  neuropathy, peripheral arterial disease (PAD) and diminished neutrophil function1. PAD and infection are the major causes of  lower leg amputation in persons with diabetes2,3. As a consequence, the incidence of  vascular lower limb amputation is eight times higher in diabetic than in nondiabetic individuals3. PAD in patients with diabetes has a number of  characteristics that renders it more difficult to treat. The atherosclerotic lesions are multilevel and particularly severe in tibial arteries, with a high prevalence of  long occlusions4. The predilection for multiple crural vessel involvement combined with extensive arterial calcification increases the technical challenges associated with revascularisation, but new techniques and technologies have been introduced for treating PAD, and encouraging results have been reported on endovascular approaches5,6.Artigo Original/ Original Article14Due to the complexity of  PAD in diabetic patients, procedural planning with non-invasive techniques is required. The reported values of  sensitivity and specificity for computed tomography angiography (CTA) in identifying significant stenoses and occlusions are in the range of  92–97% and 93–98%, respectively in patients with critical limb ischemia and intermittent claudication7. However, there is still limited data in patients with critical limb ischemia, specifically on the tibial arteries of  diabetic foot patients7. In this study we will assess the diagnostic accuracy of  CTA for below the knee arteries in patients with diabetic foot ulcers. Material and MethodsInclusion criteria for the study were patients with diabetic foot ulcers eligible for endovascular revascularization. From March to December of  2014 17 patients were screened for this study. Three patients were excluded due to glomerular filtration rate (GFR) < 45 mL/min/1.73m2 and therefore CTA was not performed. Fourteen patents were included in the study. The endovascular treatment of  these patients and the resulting diagnostic digital subtraction angiography (DSA) was performed within 15 days after the CTA was performed. Since all fourteen patients had unilateral foot ulcer, selective DSA of  the infrapopliteal vessels was only performed in the affected limb, therefore 14 limbs were assessed.Techniques of  CTA and DSACTA was performed using a 64-slice MDCT (LightSpeed VCT, GE Healthcare, Waukesha, WI, USA).  CTA scans were performed during i.v. administration of  125 mL of  non-ionic iodinated contrast medium with a concentration of  320 mg I/mL (Optiray,Mallinckdrot, Saint Louis, USA) by a double barrel injector at a rate of  3.5 mL/s through an 18-gauge i.v. cannula inserted into an antecubital vein. In order to synchronize the scanning with peak arterial opacification, the ‘‘smart prep’’ option of  the scanner was used, with a region of  interest (ROI) placed on the supraceliac abdominal aorta.Diagnostic selective DSA performed before the endovascular revascularization was employed as the gold standard. Contrast agent injection (Visipaque 270 mgI/mL, GE Healtcare) was performed by an automatic injector (4–10 mL/s according to the level of  injection) via 4-6 Fr sheaths or 5 Fr selective diagnostic catheters by either retrograde or antegrade common femoral approach. Image analysisThree arterial segments (anterior tibial artery, posterior tibial artery, peroneal artery) were assessed at each limb, for a total of  42 arterial segments. Each segment was blindedly assessed at CTA for the degree of  impairment (range, 1–4) following a score (Table 1) modified from a score proposed by Rutherford.CTA images were analysed at a workstation (Advantage Windows 4.3, GE Healthcare) by one radiologist, with 4 years of  experience in interpreting peripheral arterial disease. Assessment of  stenoses and occlusions were performed on axial images, maximum intensity projection (MIP) images, volume rendering and multiplanar reconstructions. Stenosis quantification was performed by subjective criteria, with optional use of  automatic vessel analysis tools.DSA images were interpreted by the same radiologist, with 3 years of  experience in interpretation of  DSA images, 3 months after the CTA and DSA were performed and blinded to the reports in order to avoid measurement bias.Statistical analysisSensitivity and specificity was calculated for overall CTA diagnostic accuracy but also for each of  the 3 arterial segments. Receiver operator characteristic (ROC) curves and area under the curve (AUC) were plotted and calculated for each arterial segment.ResultsTwelve patients were male and 2 were female. Mean age was 66.2 (range 56-79). Fourteen limbs for a total of  42 arterial segments were studied by CTA and DSA. The distribution and grade of  impairment of  the arterial segments in CTA and DSA is shown in tables 2 and 3, respectively.CTA detected significant lesions (score 1-4) in 35 of  the 42 arterial segments while DSA showed that significant lesions were present in 32 of  the 42 arterial segments. Therefore, CTA overall sensitivity and specificity for the detection of  significant arterial lesions was 1 (95% C.I. 0.89-1) and 0.7 (95% C.I. 0.35-0.93), respectively. Regarding the accuracy of  CTA identifying the grade of  impairment by arterial segment, the sensitivity and specificity for the anterior tibial artery were 0.96 (95% C.I. 0.88-0.99) and 0.86 (95% C.I. 0.57-0.98), for the posterior tibial artery were 0.98 (95% C.I. 0.90-0.99) and 0.93 (95% C.I. 0.66-0.99) and for the peroneal artery were 0.93 (95% C.I. 0.83-0.98) and 0.72 (95% C.I. 0.42-0.92), respectively.Score Type of  lesion0 No >50% stenosis1 Single >50% stenosis2 Multiple >50% stenoses or Single <5 cm occlusion3 Single >5 cm occlusion or Multiple <5 cm occlusions4 Multiple >5 cm occlusion or total occlusionTable 1Score for assessment of  arterial impairment (modified from Rutherford)Table 2 – Distribution and grade of  impairment by arterial segment according to CTAScore ATA PTA PA Total0 2 2 3 71 0 0 0 02 3 1 6 103 4 4 3 114 5 7 2 14Score ATA PTA PA Total0 3 2 5 101 0 0 0 02 3 1 4 83 3 3 3 94 5 8 2 15ATA= Anterior tibial artery; PTA=Posterior tibial artery; PA=peroneal arteryTable 3 – Distribution and grade of  impairment by arterial segment according to DSAATA= Anterior tibial artery; PTA=Posterior tibial artery; PA=peroneal artery15ROC curves are represented on figure 1. Calculated AUC for anterior tibial artery, posterior tibial artery and peroneal tibial artery were 0.91, 0.96 and 0.82, respectively.In 10 revascularization procedures an anterograde puncture of  the ipsilateral common femoral was performed, while in the remaining 4 patients a retrograde puncture of  the contralateral common artery was performed. A 4 Fr. sheath was used in 11 of  the 14 procedures, with a 6 Fr. sheath being used in the remaining 3 procedures.  DiscussionAs new therapeutical tools for lower extremity peripheral arterial disease have been developing, the importance of  obtaining high quality images to allow adequate procedure planning is paramount. Knowing the location, severity, and complexity of  occlusive disease allows accurate selection of  the appropriate approach to revascularization. CTA has the potential to provide a panoramic and accurate vascular mapping8. Its advantages compared to DSA include lower cost, its non-invasive nature and lower radiation dose. CTA allows visualization of  calcified plaques providing useful data for the endovascular treatment, thus allowing advance selection of  the best option for revascularization. Also, the presence of  heavily calcified lesions in CTA can predict clinical outcome9. Based on the information gathered by CTA, in 10 of  the 14 revascularization procedures an anterograde puncture of  the ipsilateral common femoral was performed, as CTA clearly indicated the origin of  superficial femoral artery was free of  stenosis that would deem impossible an ipsilateral approach. In all patients, the decision of  the diameter of  the sheath was based on CTA, with patients that presented only with lesions of  the below the knee vessels (11 of  14 patients) allowing the use of  a low profile 4 Fr. sheath. In all patients, the pre-procedural measurement of  target vessels on CTA enabled the opportunity to decide the diameter of  the angioplasty balloon used in the aid of  the catheterization procedure. Balloon diameter ranged between 2-3mm. In 4 patients, due to the presence of  heavily calcified lesions on CTA, the choice of  guidewire was altered, with specific guidewires with heavier tips being selected in those patients. In the present study the population consisted entirely of  diabetic patients and only the below the knee arteries were evaluated. When evaluating the tibial arteries the sensitivity ranged from 0.96-0.98. These results are slightly higher when compared to pooled results of  a recent meta-analysis in which the summary estimate of  sensitivity for tibial arteries was 0.95 (95 % CI, 91–97 %)7. The sensitivity regarding the peroneal artery was slightly lower at 0.93, and to our knowledge there are no specific values for this segment reported. However, this value is still in the range of  95% C.I. for the overall sensitivity of  CTA on the cited meta-analysis 96 % (95 % CI, 93–98 %)7. It is the author's opinion that the close proximity of  both leg bones may partially explain the lower sensitivity for peroneal artery lesions.The specificity values reported herein ranged from 0.72 to 0.93, which is lower than previously reported. Meta-analytic data7 reported a specificity value of  91 % (95 % CI, 60–98 %). This lower specificity is probably related to a selection bias, as our population is constituted entirely by diabetic patients with heavily calcified infrapopliteal arteries. This specific population often presents diffuse concentric calcification in the infrapopliteal vessels. This creates the ‘‘blooming’’ effect of  calcium with respect to the vessel’s lumen, making the evaluation of  stenosis very difficult10. It has been suggested that use of  dual source or dual-energy CT can overcome this limitation since it is possible to remove bones and intraluminal calcified plaques from angiography datasets on the basis of  spectral differentiation separating iodine from calcium11. However, this feature of  dual source seems to be limited in below the knee vessels, and thus far no study has shown advantage compared to non-dual-energy technique8.Figure 1 – ROC curves with respective AUC values for anterior tibial artery (A), posterior tibial artery (B) and peroneal artery (C).ABC16Our study was also in line with the expected pattern of  lesions in diabetic patients4. The most common type of  lesion was the most severe type (Score 4) which includes multiple > 5 cm occlusions or total occlusions. Also worth referring is the fact that no Score 1 pattern was found, thus reinforcing the multifocality of  lesions in the infrapopliteal vessels of  these patients (Figure 2).Figure 2 – Comparison between CTA and DSA. A. 3D MIP with calcification included B. 3D MIP excluding calcification C. 3D volume rendering D. DSA.  Note multiple occlusions of  the anterior tibial artery in the proximal segment (straight arrows).  Pathology is more severe with total occlusions on the peroneal artery (star) and posterior tibial artery (curved arrows). CTA also depicts a focal occlusion of  the proximal segment of  the posterior tibial artery (angled arrow).Our study has some limitations namely the small sample size. It was a retrospective analysis and selection bias was likely as only diabetic foot patients who had indication for endovascular treatment were included. Therefore, our results may not fully apply to the general population of  patients suffering from PAD, which includes patients who are candidates for surgery References1. Shah BR, Hux JE. Quantifying the risk of  infectious diseases for people with diabetes. Diabetes Care. 2003; 26:510-3.2. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of  diabetic foot disease. Lancet. 2005; 366:1719-24.3. Jeffcoate WJ, van Houtum WH. Amputation as a marker of  the quality of  foot care in diabetes. Diabetologia, 2004; 47:2051-8.4. Graziani L, Silvestro A, Bertone V, Manara E, Andreini R, Sigala A, Mingardi R, De Giglio R. Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of  disease severity. Eur J Vasc Endovasc Surg. 2007 Apr;33(4):453-60. 5. Faglia E, Mantero M, Caminiti M, Caravaggi C, De Giglio R, Pritelli C, Clerici G, Fratino P, De Cata P, Dalla Paola L, Mariani G, Poli M, Settembrini PG, Sciangula L, Morabito A, Graziani L. Extensive use of  peripheral angioplasty, particularly infrapopliteal, in the treatment of  ischaemic diabetic foot ulcers: clinical results of  a multicentric study of  221 consecutive diabetic subjects, J Intern Med. 2002; 252:225-32. 6. Jacqueminet S, Hartemann-Heurtier A, Izzillo R, Cluzel P, Golmard JL, Ha Van G, Koskas F, Grimaldi A. Percutaneous transluminal angioplasty in severe diabetic foot ischemia: outcomes and prognostic factors, Diabetes Metab. 2005;31:370-5.7. Jens S, Koelemay MJ, Reekers JA, Bipat S. Diagnostic performance of  computed tomograohy angiography and contrast-enhanced magnetic resonance angiography in patients with critical limb ischaemia and intermittent claudication: systematic review and meta-analysis. European Radiology. 2013 Nov;23(11):3104-14.8. Cina A, Di Stasi C, Semeraro V, Marano R, Savino G, Lezzi R, Bonomo L. Comparison of  CT and MR angiography in evaluation of  peripheral arterial disease before endovascular intervention. Acta Radiologica. 2015 pii: 0284185115595657. [Epub ahead of  print].9. McLafferty RB. Patient selection: lesion characteristics and predictors of  outcome. Perspect Vasc Surg Endovasc Ther. 2006;18:25–9.10. Kock MC, Adriaensen ME, Pattynama PM. DSA versus multi-detector row CT angiography in peripheral arterial disease: randomized controlled trial. Radiology. 2005; 237:727–37.11. Meyer BC, Werncke T, Hopfenmuller W. Dual energy CT of  peripheral arteries: effect of  automatic bone and plaque removal on image quality and grading of  stenosis. Eur J Radiol. 2008;68:414–22.and non-diabetic patients with CLI candidates to below the knee endovascular revascularization. Also, this study did not evaluate intra and inter observer variability and measurement bias is likely as the same radiologist evaluated both CTA and DSA images. However, there was a 2-month gap between CTA and DSA image interpretation to compensate for potential recall measurement bias.In conclusion, CTA allows excellent non-invasive diagnostic accuracy for the steno-occlusive involvement of  the infrapopliteal segment in diabetic patients with CLI. CTA can be used as the first line investigation tool for diabetic foot patients that are candidates for below the knee revascularization. 

http://repositorio.chlc.min-saude.pt/bitstream/10400.17/3169/1/Acta%20Radiol%20Port%202015_106_13.pdf

Diagnostic Accuracy of CT Angiography for A Infrapopliteal Lesions in Patientes with Diabetic Foot Ulcers Undergoing Endovascular Revascularization

Abstract

Similar works

Full text

Available Versions

Repository of the Hospital Center of Central Lisbon

Repositório do Centro Hospitalar de Lisboa Central, EPE