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Assessment of Critical Limb Ischemia in Patients with Diabetes: Comparison of MR Angiography and Digital Subtraction Angiography

¹ Service de Radiologie et d'Imagerie Médicale, Centre Hospitalier Universitaire Henri Mondor, 51 Avenue du Mal. De Lattre de Tassigny, 94010 Creteil Cedex, France.
² Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Henri Mondor Hospital, 94010 Creteil Cedex, France.

View larger version (92K): [in a new window]   Fig. 1A —48-year-old man with nonhealing ulceration of left calf. Anteroposterior bolus chase MR angiogram of calf shows marked venous enhancement (arrow) preventing adequate interpretation of distal arteries.

View larger version (56K): [in a new window]   Fig. 1B —48-year-old man with nonhealing ulceration of left calf. Anteroposterior volumetric interpolated breath-hold examination (VIBE) gadolinium-enhanced MR angiographic maximum-intensity-projection (MIP) image of left lower extremity shows patent but multistenosed anterior tibial artery (arrowheads). Dorsalis pedis artery appears to be patent and forms plantar arch. Venous enhancement (arrow) moderately affects interpretation based on this sole incidence. Lower two thirds of both peroneal artery and posterior tibial artery are not clearly identified.

View larger version (90K): [in a new window]   Fig. 1C —48-year-old man with nonhealing ulceration of left calf. Lateral VIBE gadolinium-enhanced MR angiographic MIP image confirms presence of left anterior tibial artery stenoses (arrowheads). Venous enhancement (arrow) is less present, allowing appropriate assessment of distal vessels. Lower two thirds of posterior tibial artery are patent and then are occluded above plantar arch. Peroneal artery is occluded at mid leg, and plantar artery is patent but has multiple stenoses.

View larger version (120K): [in a new window]   Fig. 1D —48-year-old man with nonhealing ulceration of left calf. Lower parts of anterior tibial artery and dorsalis pedis artery are not depicted on digital subtraction angiography (DSA), despite selective injection in left external iliac artery and delayed imaging. Correlation between MR angiography and DSA findings was graded as poor. G = left (gauche).

View larger version (134K): [in a new window]   Fig. 1E —48-year-old man with nonhealing ulceration of left calf. On the basis of MR angiography findings, percutaneous transluminal angioplasty (PTA) was performed. Lateral DSA of ankle and foot shortly after contrast injection in superficial femoral artery after PTA shows patency of both anterior tibial artery and dorsalis pedis artery (arrowheads). Posterior tibial artery remains occluded above ankle, and plantar arch does not fill.

View larger version (72K): [in a new window]   Fig. 2A —60-year-old diabetic woman with focal gangrene of right calf. Lateral volumetric interpolated breath-hold examination (VIBE) gadolinium-enhanced MR angiographic maximum-intensity-projection image shows diffusely diseased anterior tibial artery, with stenosis of both its upper (arrowhead) and mid (arrow) portions, classified by both observers as greater than 50% (group B). Tibioperoneal trunk and entire length of posterior tibial artery are occluded. Distal anterior tibial artery is occluded, and peroneal artery fills into foot.

View larger version (126K): [in a new window]   Fig. 2B —60-year-old diabetic woman with focal gangrene of right calf. Digital subtraction angiogram obtained after contrast injection in right external iliac artery confirms stenosis of upper anterior tibial artery (arrowhead) and occlusion of tibioperoneal trunk, but does not confirm findings regarding mid portion of anterior tibial artery (arrow), which is better depicted than on VIBE images. This segment was classified as belonging in group A by both observers. Marked calcifications were present along mid portion of anterior tibial artery.

View larger version (114K): [in a new window]   Fig. 3A —67-year-old diabetic man with nonhealing ulceration of left calf. Coronal 3D bolus chase MR angiograms of pelvis (A), thigh (B), and calf (C) compared with volumetric interpolated breath-hold examination (VIBE) (D) MR angiograms of left calf and ankle. Note venous contamination on MR angiograms of both left thigh and left calf (arrowheads, B and C). By comparison, no venous enhancement is seen on disease-free right calf (arrows, B and C). Because of early acquisition after bolus injection, venous overlay is not present on VIBE MR angiogram of left leg (D). Because of venous overlay, arterial vessels analysis was not possible on basis of bolus chase MR angiography findings but remained possible on VIBE angiography. Distal portion of anterior tibial artery is filled into foot, and pedal artery appears patent. Posterior tibial artery and distal portion of peroneal artery appear patent, but no plantar arch is filled.

View larger version (90K): [in a new window]   Fig. 3B —67-year-old diabetic man with nonhealing ulceration of left calf. Coronal 3D bolus chase MR angiograms of pelvis (A), thigh (B), and calf (C) compared with volumetric interpolated breath-hold examination (VIBE) (D) MR angiograms of left calf and ankle. Note venous contamination on MR angiograms of both left thigh and left calf (arrowheads, B and C). By comparison, no venous enhancement is seen on disease-free right calf (arrows, B and C). Because of early acquisition after bolus injection, venous overlay is not present on VIBE MR angiogram of left leg (D). Because of venous overlay, arterial vessels analysis was not possible on basis of bolus chase MR angiography findings but remained possible on VIBE angiography. Distal portion of anterior tibial artery is filled into foot, and pedal artery appears patent. Posterior tibial artery and distal portion of peroneal artery appear patent, but no plantar arch is filled.

View larger version (104K): [in a new window]   Fig. 3C —67-year-old diabetic man with nonhealing ulceration of left calf. Coronal 3D bolus chase MR angiograms of pelvis (A), thigh (B), and calf (C) compared with volumetric interpolated breath-hold examination (VIBE) (D) MR angiograms of left calf and ankle. Note venous contamination on MR angiograms of both left thigh and left calf (arrowheads, B and C). By comparison, no venous enhancement is seen on disease-free right calf (arrows, B and C). Because of early acquisition after bolus injection, venous overlay is not present on VIBE MR angiogram of left leg (D). Because of venous overlay, arterial vessels analysis was not possible on basis of bolus chase MR angiography findings but remained possible on VIBE angiography. Distal portion of anterior tibial artery is filled into foot, and pedal artery appears patent. Posterior tibial artery and distal portion of peroneal artery appear patent, but no plantar arch is filled.

View larger version (76K): [in a new window]   Fig. 3D —67-year-old diabetic man with nonhealing ulceration of left calf. Coronal 3D bolus chase MR angiograms of pelvis (A), thigh (B), and calf (C) compared with volumetric interpolated breath-hold examination (VIBE) (D) MR angiograms of left calf and ankle. Note venous contamination on MR angiograms of both left thigh and left calf (arrowheads, B and C). By comparison, no venous enhancement is seen on disease-free right calf (arrows, B and C). Because of early acquisition after bolus injection, venous overlay is not present on VIBE MR angiogram of left leg (D). Because of venous overlay, arterial vessels analysis was not possible on basis of bolus chase MR angiography findings but remained possible on VIBE angiography. Distal portion of anterior tibial artery is filled into foot, and pedal artery appears patent. Posterior tibial artery and distal portion of peroneal artery appear patent, but no plantar arch is filled.

View larger version (94K): [in a new window]   Fig. 4A —76-year-old diabetic women with focal gangrene of left calf. Coronal 3D bolus chase MR angiograms of thigh (A) and calf (B) compared with volumetric interpolated breath-hold examination (VIBE) MR angiogram of left calf and ankle (C) and selective digital subtraction angiograms (DSA) of thigh (D), calf (E), and ankle (F). Focal stenoses are seen in distal popliteal artery and tibioperoneal trunk (long arrows, A and C). Peroneal artery is patent into foot (short arrow, C). Proximal anterior tibial artery is diffusely diseased, reconstitutes above level of ankle, and becomes patent in foot. Note good correlation regarding short occlusion of distal left superficial femoral artery (arrowhead, A and D) depicted on both bolus-chase MR angiography (A) and selective DSA (D) and good correlation regarding popliteal artery stenoses depicted on both VIBE MR angiogram (arrows, C) and selective DSA (arrows, E). Left dorsalis pedis artery is depicted on VIBE MR angiograms (short arrow, C) and on selective DSA (short arrow, F; G = left [gauche]) but not on third-step bolus chase MR angiography (arrow, B). Note that because of calf pain, a slight change in patient's position between unenhanced and contrast-enhanced bolus chase MR angiography led to motion artifacts being clearly visible in soft tissues, diminishing accuracy of arterial vessel analysis (B).

View larger version (79K): [in a new window]   Fig. 4B —76-year-old diabetic women with focal gangrene of left calf. Coronal 3D bolus chase MR angiograms of thigh (A) and calf (B) compared with volumetric interpolated breath-hold examination (VIBE) MR angiogram of left calf and ankle (C) and selective digital subtraction angiograms (DSA) of thigh (D), calf (E), and ankle (F). Focal stenoses are seen in distal popliteal artery and tibioperoneal trunk (long arrows, A and C). Peroneal artery is patent into foot (short arrow, C). Proximal anterior tibial artery is diffusely diseased, reconstitutes above level of ankle, and becomes patent in foot. Note good correlation regarding short occlusion of distal left superficial femoral artery (arrowhead, A and D) depicted on both bolus-chase MR angiography (A) and selective DSA (D) and good correlation regarding popliteal artery stenoses depicted on both VIBE MR angiogram (arrows, C) and selective DSA (arrows, E). Left dorsalis pedis artery is depicted on VIBE MR angiograms (short arrow, C) and on selective DSA (short arrow, F; G = left [gauche]) but not on third-step bolus chase MR angiography (arrow, B). Note that because of calf pain, a slight change in patient's position between unenhanced and contrast-enhanced bolus chase MR angiography led to motion artifacts being clearly visible in soft tissues, diminishing accuracy of arterial vessel analysis (B).

View larger version (92K): [in a new window]   Fig. 4C —76-year-old diabetic women with focal gangrene of left calf. Coronal 3D bolus chase MR angiograms of thigh (A) and calf (B) compared with volumetric interpolated breath-hold examination (VIBE) MR angiogram of left calf and ankle (C) and selective digital subtraction angiograms (DSA) of thigh (D), calf (E), and ankle (F). Focal stenoses are seen in distal popliteal artery and tibioperoneal trunk (long arrows, A and C). Peroneal artery is patent into foot (short arrow, C). Proximal anterior tibial artery is diffusely diseased, reconstitutes above level of ankle, and becomes patent in foot. Note good correlation regarding short occlusion of distal left superficial femoral artery (arrowhead, A and D) depicted on both bolus-chase MR angiography (A) and selective DSA (D) and good correlation regarding popliteal artery stenoses depicted on both VIBE MR angiogram (arrows, C) and selective DSA (arrows, E). Left dorsalis pedis artery is depicted on VIBE MR angiograms (short arrow, C) and on selective DSA (short arrow, F; G = left [gauche]) but not on third-step bolus chase MR angiography (arrow, B). Note that because of calf pain, a slight change in patient's position between unenhanced and contrast-enhanced bolus chase MR angiography led to motion artifacts being clearly visible in soft tissues, diminishing accuracy of arterial vessel analysis (B).

View larger version (91K): [in a new window]   Fig. 4D —76-year-old diabetic women with focal gangrene of left calf. Coronal 3D bolus chase MR angiograms of thigh (A) and calf (B) compared with volumetric interpolated breath-hold examination (VIBE) MR angiogram of left calf and ankle (C) and selective digital subtraction angiograms (DSA) of thigh (D), calf (E), and ankle (F). Focal stenoses are seen in distal popliteal artery and tibioperoneal trunk (long arrows, A and C). Peroneal artery is patent into foot (short arrow, C). Proximal anterior tibial artery is diffusely diseased, reconstitutes above level of ankle, and becomes patent in foot. Note good correlation regarding short occlusion of distal left superficial femoral artery (arrowhead, A and D) depicted on both bolus-chase MR angiography (A) and selective DSA (D) and good correlation regarding popliteal artery stenoses depicted on both VIBE MR angiogram (arrows, C) and selective DSA (arrows, E). Left dorsalis pedis artery is depicted on VIBE MR angiograms (short arrow, C) and on selective DSA (short arrow, F; G = left [gauche]) but not on third-step bolus chase MR angiography (arrow, B). Note that because of calf pain, a slight change in patient's position between unenhanced and contrast-enhanced bolus chase MR angiography led to motion artifacts being clearly visible in soft tissues, diminishing accuracy of arterial vessel analysis (B).

View larger version (79K): [in a new window]   Fig. 4E —76-year-old diabetic women with focal gangrene of left calf. Coronal 3D bolus chase MR angiograms of thigh (A) and calf (B) compared with volumetric interpolated breath-hold examination (VIBE) MR angiogram of left calf and ankle (C) and selective digital subtraction angiograms (DSA) of thigh (D), calf (E), and ankle (F). Focal stenoses are seen in distal popliteal artery and tibioperoneal trunk (long arrows, A and C). Peroneal artery is patent into foot (short arrow, C). Proximal anterior tibial artery is diffusely diseased, reconstitutes above level of ankle, and becomes patent in foot. Note good correlation regarding short occlusion of distal left superficial femoral artery (arrowhead, A and D) depicted on both bolus-chase MR angiography (A) and selective DSA (D) and good correlation regarding popliteal artery stenoses depicted on both VIBE MR angiogram (arrows, C) and selective DSA (arrows, E). Left dorsalis pedis artery is depicted on VIBE MR angiograms (short arrow, C) and on selective DSA (short arrow, F; G = left [gauche]) but not on third-step bolus chase MR angiography (arrow, B). Note that because of calf pain, a slight change in patient's position between unenhanced and contrast-enhanced bolus chase MR angiography led to motion artifacts being clearly visible in soft tissues, diminishing accuracy of arterial vessel analysis (B).

View larger version (99K): [in a new window]   Fig. 4F —76-year-old diabetic women with focal gangrene of left calf. Coronal 3D bolus chase MR angiograms of thigh (A) and calf (B) compared with volumetric interpolated breath-hold examination (VIBE) MR angiogram of left calf and ankle (C) and selective digital subtraction angiograms (DSA) of thigh (D), calf (E), and ankle (F). Focal stenoses are seen in distal popliteal artery and tibioperoneal trunk (long arrows, A and C). Peroneal artery is patent into foot (short arrow, C). Proximal anterior tibial artery is diffusely diseased, reconstitutes above level of ankle, and becomes patent in foot. Note good correlation regarding short occlusion of distal left superficial femoral artery (arrowhead, A and D) depicted on both bolus-chase MR angiography (A) and selective DSA (D) and good correlation regarding popliteal artery stenoses depicted on both VIBE MR angiogram (arrows, C) and selective DSA (arrows, E). Left dorsalis pedis artery is depicted on VIBE MR angiograms (short arrow, C) and on selective DSA (short arrow, F; G = left [gauche]) but not on third-step bolus chase MR angiography (arrow, B). Note that because of calf pain, a slight change in patient's position between unenhanced and contrast-enhanced bolus chase MR angiography led to motion artifacts being clearly visible in soft tissues, diminishing accuracy of arterial vessel analysis (B).

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