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Lower extremity CT angiography in peripheral arterial disease: from the established approach to evolving technical developments

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Abstract

With the advent of multidetector computed tomography (CT), CT angiography (CTA) has gained widespread popularity for noninvasive imaging of the arterial vasculature. Peripheral extremity CTA can nowadays be performed rapidly with high spatial resolution and a decreased amount of both intravenous contrast and radiation exposure. In patients with peripheral artery disease (PAD), this technique can be used to delineate the bilateral lower extremity arterial tree and to determine the amount of atherosclerotic disease while differentiating between acute and chronic changes. This article provides an overview of several imaging techniques for PAD, specifically discusses the use of peripheral extremity CTA in patients with PAD, clinical indications, established technical considerations and novel technical developments, and the effect of postprocessing imaging techniques and structured reporting.

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Fig. 1
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source CT scanner using 120 and 80 kV in a 77-year-old man who had undergone endovascular aneurysm repair and now presented with weak pulses. Virtual noncontrast images derived from the dual-energy CTA visualize the calcifications by virtually removing iodine. Depicted are calcifications in the external and internal iliac arteries without significant stenosis before (a) and after (b) virtual removal of the iodine contrast

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source images of the lower extremity CTA are shown (from left to right). Images of the right lower extremity show moderate stenosis of the distal right superficial femoral artery and popliteal artery, occlusion of the right anterior tibial artery distally, and patent right posterior tibial and peroneal arteries. Images of the left lower extremity show moderate stenosis of the distal left superficial femoral artery and left popliteal artery and occluded left anterior tibial artery. The proximal and mid portions of the left posterior tibial artery are patent, with the distal portion showing moderate stenosis. Additionally, there is moderate stenosis in the left peroneal artery proximally, with severe stenosis distally

Fig. 10

source CT scanner using 140 and 80 kV. a Maximum intensity projection of the full scan volume provides a first overview, but arteries are partially obscured by overlying bones. b Maximum intensity projection after automatic dual-energy‒based bone removal gives an impression of the location of calcifications, vessel patency, and distal run-off. In particular, a focal high-grade stenosis of the proximal superficial femoral artery (white arrow) followed by a total occlusion (black arrow) and distal reconstitution via collaterals are visualized. c Maximum intensity projection after automatic calcification removal improves the visual impression of vessel patency in areas with calcifications (e.g., the right external iliac artery). d Volume rendering is another visualization technique helpful for an overview of location of calcifications, vessel patency, and distal run-off. For example, a proximal occlusion of the right anterior tibial artery is clearly depicted (arrowhead)

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Authors and Affiliations

  1. Department of Interventional Radiology, Cleveland Clinic Main Campus, Cleveland, OH, USA

    Omar Shwaiki, Basem Rashwan, Sameer Gadani, Karunakaravel Karuppasamy, Dustin Thompson & Sasan Partovi

  2. Section of Emergency Radiology, Clinic for Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany

    Matthias A. Fink, Claudius Melzig & Fabian Rengier

  3. Department of Vascular Surgery, Cleveland Clinic Main Campus, Cleveland, OH, USA

    Levester Kirksey

  4. Department of Transplant Surgery, Cleveland Clinic Main Campus, Cleveland, OH, USA

    Giuseppe D’Amico

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  1. Omar Shwaiki
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Shwaiki, O., Rashwan, B., Fink, M.A. et al. Lower extremity CT angiography in peripheral arterial disease: from the established approach to evolving technical developments. Int J Cardiovasc Imaging 37, 3101–3114 (2021). https://doi.org/10.1007/s10554-021-02277-1

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  • DOI: https://doi.org/10.1007/s10554-021-02277-1

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