AJR 2004; 183:113-117
© American Roentgen Ray Society
Three-Dimensional MDCT Angiography of the Extremities: Clinical Applications with Emphasis on Musculoskeletal Uses
Musturay Karcaaltincaba1,
Deniz Akata1,
Ustun Aydingoz1,
Gursel Leblebicioglu2,
Devrim Akinci1,
Barbaros Cil1,
Aytekin Besim1 and
Okan Akhan1
1 Department of Radiology, Hacettepe University School of Medicine, Sihhiye,
Ankara 06100, Turkey.
2 Department of Orthopedic Surgery, Hacettepe University School of Medicine,
Ankara 06100, Turkey.
Received December 20, 2003;
accepted after revision February 25, 2004.
Address correspondence to M. Karcaaltincaba
(musturayk{at}yahoo.com).
Introduction
MDCT angiography is becoming an alternative imaging technique to
conventional angiography because of its extensive thoracic and abdominal
applications. Extremity MDCT angiography has been described as an alternative
technique for evaluation of lower extremity atherosclerotic disease,
microsurgical reconstruction, fibular arterial mapping, musculoskeletal
masses, and traumatic arterial injuries in adult and pediatric patients
[1–11].
To our knowledge, the literature has no extensive series depicting
musculoskeletal applications of extremity MDCT angiography. We show various
musculoskeletal uses of this technique. Coverage, resolution, and table speed
are the most important parameters for establishing a protocol for extremity
MDCT angiography.
Materials and Methods
Extremity MDCT angiography studies were performed in 40 patients. Preferred
technical parameters for 4-MDCT (VolumeZoom, Siemens Medical Solutions) and
16-MDCT (Lightspeed Ultra16, GE Healthcare) extremity angiography were
respectively as follows: detector collimation, 4 x 1 mm and 16 x
1.25 mm; pitch, 1.75 and 1.75; slice thickness, 1.25 mm and 1.25 mm;
reconstruction interval, 1 mm and 1 mm; coverage, 30–44 cm and up to 120
cm; table speed, 14 mm/sec and 70 mm/sec; gantry rotation time, 0.5 sec and
0.5 sec. Injection to scanning delay was determined using either a timing
minibolus injection or a modified bolus tracking method
[7,
11]. Contrast dose for
extremity MDCT angiography studies varied between 75 and 150 mL, calculated by
multiplying injection rate and scanning time (e.g., 30 sec x 4 mL/sec =
120 mL). Nonionic iodinated contrast material (300 mg I/mL) was injected at a
rate of 4–5 mL/sec by a power injector. In general, two approaches can
be used with 16-MDCT in comparison with 4-MDCT. Acquisitions may be obtained
using either a high table speed (
7 cm/sec) and similar z-axis
millimeter-range resolution or a moderate table speed ( 3.5 cm/sec) and
high z-axis submillimeter-range resolution. In both scenarios, the
contrast dose can be reduced approximately two to four times with 16-MDCT
angiography compared with 4-MDCT angiography.
Three-dimensional images were obtained using volume rendering and maximum
intensity projections. Volume-rendered images were easy to obtain, and bone
segmentation was not required for most applications. For 4-MDCT angiograms,
Leonardo 3D postprocessing workstation (Siemens) with state-of-the-art
volume-rendering syngo software (Siemens) was used. For 16-MDCT angiograms, an
Advantage workstation 4.0 (GE) fully equipped with advanced volume-rendering
software was used. Regions of interest were selected by the volume-rendering
software presettings automatically customized for extremity and CT angiograms,
although in some cases further alterations to the volume-rendering presettings
were made manually.
We generally used a B30 or B10 kernel (Siemens) for CT angiography. The
reconstructions were performed by one of the investigators. During
postprocessing, we removed other anatomic structures from the extremity of
interest using volume-punching operations, we continued evaluation with thin
maximum-intensity-projection reconstructions of the vascular structures in the
coronal plane, and we reconstructed volume-rendered images using customized
presettings. Segmental evaluation can be performed by including slices through
only the thigh or leg regions instead of evaluating the whole data set if the
coverage is long, as it is in runoff studies.
In addition to displaying vascular anatomy, volume-rendered extremity MDCT
angiograms also show osseous anatomy, which is important for surgical
planning. Scanning took less than a minute in all patients.
Results
Diagnostic images were obtained in all patients who underwent extremity
MDCT angiography. We present examples of various applications of extremity
MDCT angiography performed to evaluate a wide range of diseases, including
atherosclerotic disease (n = 14), vasculitis (n = 2),
thoracic outlet syndrome (n = 5), musculoskeletal masses (n
= 6), traumatic injuries (n = 2), vascular complications of
osteomyelitis (n = 1), and congenital anomalies (n = 2) and
to assess vascularized bone grafts before (n = 5) and after (n
= 3) reconstructive surgery.
Trauma
CT angiography is an invaluable tool for the evaluation of trauma patients.
Extremity MDCT angiography has two major roles in musculoskeletal
trauma—to define or exclude a vascular injury and to determine the
extent of vascular injury and its relationship to fractured bones as an aid in
preoperative planning. In the setting of trauma, conventional angiographic
examinations are difficult to obtain because angiography suites are usually
not located close to emergency departments, and the procedures commonly
require the supervision of an interventional radiologist. MDCT angiography
allows the display of vascular anatomy, osseous anatomy, and fractures on the
same image, which obviates diagnostic delay, particularly in uncooperative
patients. In comparison to conventional angiography, MDCT angiography can be
performed in minutes, and the diagnosis can be made instantly while the
patient is in the scanning room, allowing vascular injuries to be diagnosed
with greater confidence and speed. Moreover, CT angiography can be helpful in
decision making for patients with bone fractures. If the vascularity of the
extremity is compromised, open reduction and reconstruction may be needed to
avoid malunions (Fig. 1A,
1B). Soto et al.
[2,
3] conducted studies on
patients in the emergency department and found they could determine most
vascular injuries using helical CT. In some patients, volume-rendered images
may reveal even more severe vascular or bone injury than the clinician
suspects [8] (Figs.
1A,
1B and
2).
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Fig. 1A. —26-year-old man with pulsatile shoulder mass that developed
after gunshot wound. Upper extremity MDCT angiogram obtained in anterior
projection shows giant pseudoaneurysm (long arrow) originating from
right subclavian artery (short arrow).
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Fig. 1B. —26-year-old man with pulsatile shoulder mass that developed
after gunshot wound. Upper extremity MDCT angiogram obtained in axial
volume-rendered projection shows pseudoaneurysm and subclavian artery
relationship better than A.
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Fig. 2. —30-year-old man with nonunion of multiple radius and ulna
fractures. Forearm MDCT angiogram obtained in anterior projection shows
traumatic occlusion of interosseal artery (arrow) distal to proximal
segment.
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Vasculitis
MDCT angiography is helpful in noninvasive diagnosis of patients with
vasculitis. Even mild forms of vasculitis can be diagnosed in the presence of
mild wall thickening and mild stenosis. Acute vasculitis can be differentiated
from atherosclerotic vascular disease by the absence of calcification changes
in the vessel wall (Figs. 3 and
4). MDCT angiography
acquisitions take less than a minute, and no specific hardware or software is
needed, which allows wider use than MR angiography. However, CT angiography
cannot be used in patients with impaired renal function or with a history of
reaction to contrast material.
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Fig. 3. —40-year-old man with Buerger's disease and right foot pain.
Leg and foot MDCT angiogram obtained in anterior projection shows occlusion of
right dorsalis pedis artery (arrowhead). Note patent left dorsalis
pedis artery (arrow).
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Fig. 4. —9-year-old boy with bilateral thenar erythema and
polyarteritis nodosa suspected of having arterial occlusion. Hand MDCT
angiogram obtained in anterior projection shows bilateral patency of distal
radial (long arrows), ulnar (short arrows), and superficial
palmar arch branch (arrowheads) of radial artery.
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Atherosclerosis
Extremity MDCT angiography has been used for evaluation of atherosclerotic
disease, mainly as a part of lower extremity runoff studies. Recent
comparative studies [1,
4,
5] emphasize the diagnostic
power of this technique as an alternative to the gold standard of conventional
angiography. Contrast dose can be decreased
(Fig. 5) using 16-MDCT
[6,
7]. Calcific plaques can be
shown on maximum-intensity-projection images (Fig.
6A,
6B).
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Fig. 5. —53-year-old man with left femoroanterior tibial bypass. Lower
extremity MDCT angiogram obtained in anterior maximum intensity projection
shows patency of left femoroanterior tibial bypass graft (long arrow)
and high-grade stenosis of right popliteal artery (short arrow).
Imaging was performed on 16-MDCT using only 30 mL of contrast material.
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Fig. 6A. —63-year-old man with diabetes and foot ulcers. Leg and foot
MDCT angiogram obtained in lateral slab maximum intensity projection shows
calcified nonocclusive plaque (arrow) of left posterior tibial
artery.
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Thoracic Outlet Syndrome
Thoracic outlet syndrome can be caused by compression of neurovascular
structures where they pass between musculoskeletal structures
(Fig. 7). An advantage of CT
angiography is its ability to depict in the same acquisition bone and
soft-tissue structures causing thoracic outlet syndrome and vascular
compression. Curved multiplanar reformatted images can be helpful for
evaluation of subclavian vessels.
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Fig. 7. —22-year-old woman with thoracic outlet syndrome. Shoulder
MDCT angiogram obtained in anterior projection shows compression of subclavian
artery at two levels: proximally between clavicula and cervical rib (long
arrow) and distally by subclavius muscle (short arrow).
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Musculoskeletal Masses
Extremity MDCT angiography can be used for the evaluation of
musculoskeletal masses [10].
The vascularity of the mass and its relation to vasculature can be defined,
which is important for preoperative planning. Early venous filling at the site
of a tumor indicates its vascularity
[10] (Fig.
8A,
8B). Also, biopsy of the
masses can be planned with extremity CT angiography to avoid hemorrhagic
complications.
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Fig. 8A. —34-year-old woman with distal radius mass. Forearm MDCT
angiogram obtained in lateral projection shows vascular supply of radial
malignant giant cell tumor from radial artery and its branches
(arrows).
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Fig. 8B. —34-year-old woman with distal radius mass. Forearm MDCT
angiogram obtained in anterior projection shows tumor (asterisk),
radial artery (short arrows), and early venous return (long
arrow).
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Assessment of Vascularity of Grafts Before and After Reconstructive Surgery
Assessment of vascularity of bone grafts is of utmost importance to
reconstructive surgeons [9].
Preoperative knowledge of vascular anatomy and its relation to osseous
structures allows precise planning (Figs.
9 and
10). Arterial mapping of
fibular grafts before surgery is important to avoid postoperative
complications that might result in ischemia.
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Fig. 9. —54-year-old man with mandibular tumor who later underwent
excision of mandibula and subsequent reconstruction with fibular graft. Lower
extremity MDCT angiogram obtained in anterior projection shows normal anatomy
and patent arteries in arterial mapping. This study was performed on 16-MDCT
using 75 mL of contrast material. Prototype automatic bone segmentation
software of GE Healthcare was used to remove bones from image. (Courtesy of
Foley DW, Milwaukee, WI)
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Fig. 10. —6-year-old girl with Volkmann's ischemic contracture. Upper
extremity MDCT angiogram obtained in anterior projection shows occlusion of
distal brachial artery and reconstitution of radial and ulnar arteries via
recurrent branch of deep brachial artery (short arrows) and small
antecubital collaterals (long arrows).
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After reconstructive surgery, any possible vascular complications related
to surgery can be evaluated easily on MDCT angiography as an alternative to
conventional angiography (Fig.
11). Moreover, changes in vascular anatomy can be displayed before
subsequent surgeries and particularly during multistep reconstructive surgical
procedures (Fig. 12A,
12B).
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Fig. 11. —30-year-old man who underwent surgical reconstruction with
vascular graft to treat chronic osteomyelitis sequelae. Leg MDCT angiogram
obtained in posterior projection shows implantation (arrow) of graft
artery and vein to proximal posterior tibial artery.
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Fig. 12A. —20-year-old woman with severe forearm injury treated by
vascular graft implantation. Forearm MDCT angiograms obtained in anterior
projection volume-rendered (A) and maximum intensity projections
(B) show patency of vascular graft (arrow) anastomosed to
distal brachial artery. Note absence of radial and ulnar arteries.
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Fig. 12B. —20-year-old woman with severe forearm injury treated by
vascular graft implantation. Forearm MDCT angiograms obtained in anterior
projection volume-rendered (A) and maximum intensity projections
(B) show patency of vascular graft (arrow) anastomosed to
distal brachial artery. Note absence of radial and ulnar arteries.
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Infection
The incidence of musculoskeletal infections is increasing, mainly due to
the growing population of immunocompromised patients, which includes persons
with AIDS, transplant recipients, renal dialysis recipients, and patients with
underlying malignancies [8].
MDCT angiography can be helpful in evaluating patients with complicated
infections requiring surgical débridement or before corrective
operations on sequelae of musculoskeletal infections. Vascular complications
caused by infections can be displayed as a roadmap for the orthopedic surgeon.
Osteomyelitis-related vascular complications can be diagnosed to help in
planning reconstructive surgery in these patients. Occlusion of arteries can
occur secondary to inflammatory changes or corrective surgical procedures
(Fig. 13A,
13B).
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Fig. 13A. —19-year-old man with chronic osteomyelitis sequelae-related
vascular complications. Leg MDCT angiogram obtained in posterior projection
shows occlusion of left peroneal artery (short arrow) down mid
segment secondary to chronic osteomyelitis and patency of posterior tibial
artery (long arrow).
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Fig. 13B. —19-year-old man with chronic osteomyelitis sequelae-related
vascular complications. MDCT angiogram obtained in left anterior oblique
projection shows occlusion of proximal and mid anterior tibial artery and
reconstitution of distal segment (arrow) via plantar arch.
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Congenital Anomalies
Technically, extremity MDCT angiography can be performed for any indication
in which vascular anatomy needs to be displayed and analyzed. Congenital
amniotic band–related changes such as constriction of arteries or
hypoplasia of arteries secondary to contractures can also be depicted on MDCT
angiography to help plan reconstructive surgery
(Fig. 14).
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Fig. 14. —6-year-old girl with contracture caused by amniotic band.
Forearm MDCT angiogram obtained in anterior projection shows hypoplasia of
ulnar (long arrow) and radial (short arrow) arteries
secondary to contracture.
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Conclusion
Although the resolution of extremity MDCT angiography is slightly less than
that of conventional angiography, the noninvasiveness, ease of use, and speed
(acquisition times of less than a minute) of the procedure and 3D
volume-rendered visualization of the relevant anatomy will allow it to become
a widely used application in adults and pediatric patients. Radiation dose of
peripheral runoff CT angiography studies has been reported to be lower with CT
angiography than with conventional angiography
[1]. Contrast volume required
for CT angiography studies decreases with 16-MDCT.
Acknowledgments
We thank Dennis W. Foley for his continuous support and review of this
manuscript.
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Introduction
Materials and Methods
