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Table of Contents
ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 2  |  Page : 45-52

Efficacy of color doppler imaging over CT angiography in peripheral arterial disease


1 Resident, Department of Radio-Diagnosis, Dhiraj General Hospital, SBKS Medical Institute & Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
2 Professor, Department of Radio-Diagnosis, Dhiraj General Hospital, SBKS Medical Institute & Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India
3 Professor and Head; Department of Radio-Diagnosis, Dhiraj General Hospital, SBKS Medical Institute & Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat, India

Date of Web Publication31-Aug-2018

Correspondence Address:
Chinmay Parikh
Resident, Department of Radio-Diagnosis, Dhiraj General Hospital, SBKS Medical Institute & Research Centre, Sumandeep Vidyapeeth, Piparia, Waghodia, Vadodara, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2347-6486.240245

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  Abstract 


Introduction : PAD is an atherosclerotic occlusive condition in which plaque builds up in the distal arteries. Until 10 years ago, conventional angiography and digital subtraction angiography were the only angiographic techniques used in peripheral vascular disease and are considered gold standard. However, the complications and patient discomfort associated with these techniques have prompted the need of less invasive means of assessing the peripheral arterial system. Aim of the study was to compare efficacy of USG and MDCT angiography for investigating the lower limb arterial disease.
Method: 40 patients suspected of lower limb PAD were included. Patients with previous amputation surgery were excluded. In all patients color Doppler sonography and multi-detector CT angiography was done. A comparative study of multi-detector CT angiography and color Doppler sonography was undertaken.
Result: 50% patients had complaints in left lower limb and 25% in right lower limb. 22% had bilateral lower limb pain which was more on the left side (12%). Three patients examined by angiography showed irregularity of arterial wall on both sides, which appeared as calcifications on CT angiography (sensitivity 100%) while only 2 of them appeared on color coded Doppler examination (sensitivity 75%).
Conclusions: Color Doppler USG is the initial modality of choice in PAD. CT Angiography is a better for segmental length assessment, collateral circulation along with a road map reproduction of the arterial system. USG is better than CT angiography in diagnosis of Grade 1 &2 cases, with better assessment of soft plaques, segmental flow and recanalization in PAD.

Keywords: peripheral arterial disease, color Doppler ultrasonography, MDCT angiography


How to cite this article:
Parikh C, Brahmbhatt P, Raychaudhuri C. Efficacy of color doppler imaging over CT angiography in peripheral arterial disease. J Integr Health Sci 2017;5:45-52

How to cite this URL:
Parikh C, Brahmbhatt P, Raychaudhuri C. Efficacy of color doppler imaging over CT angiography in peripheral arterial disease. J Integr Health Sci [serial online] 2017 [cited 2019 Jun 19];5:45-52. Available from: http://www.jihs.in/text.asp?2017/5/2/45/240245




  Introduction Top


PAD is an atherosclerotic occlusive condition in which plaque builds up in the distal arteries, constricting circulation and blood flow.[1] PAD has also been referred to previously as peripheral vascular disease or peripheral artery occlusive disease. Lower-extremity PAD refers to atherosclerosis of arteries distal to the aortic bifurcation and most commonly occurs in the legs.[2] The term PAD is also used more broadly to encompass a larger range of non-coronary arterial diseases or syndromes that are caused by the altered structure or function of arteries to the brain, visceral organs, and limbs.[3] Studies on the prevalence of PAD among general populations or unselected primary care populations use a low ABI as a surrogate for PAD. As such, the true prevalence of PAD in the general population is not known. The National Health and Nutrition Examination Survey (NHANES) provides recent data on the prevalence of low ABI (≤0.9) from large, community-based sampling of the indian population. From 1999 to 2004, 5.9 percent of the indian population age 40 years or older had a low ABI, which amounts to 7.1 million people.[4] Approximately 50% of patients with peripheral arterial disease (PAD) are asymptomatic, making it difficult to estimate its true prevalence. Available data from population-based studies, using noninvasive diagnostic tools, suggest a progressive increase in prevalence in patients older than 40 years of age, and an association with cardiovascular risk factors such as smoking, diabetes, hypertension, hypercholesterolemia and impaired kidney function.[5] Until as recently as 10 years ago, conventional angiography and digital subtraction angiography were the only angiographic techniques used in peripheral vascular disease and are considered to be a gold standard investigation. However, the complications and patient discomfort associated with these techniques have prompted the need of less invasive means of assessing the peripheral arterial system.[6] Doppler ultrasonography has shown to be one such widely available, noninvasive modality which involves no radiation and provides an early diagnosis. On the other hand, Multi detector CT angiography, which now is also reaching fairly large numbers in India, is minimally invasive, with fairly accurate results. Aim of the study was to compare the efficacy of color doppler sonography and MDCT angiography as fairly recent, non or minimally invasive techniques for investigating the lower limb arterial disease.[7]


  Methodology Top


This study included 40 patients. Patients suspected of lower limb peripheral arterial disease were included. Patients with previous amputation surgery were excluded. In all patients color Doppler sonography and multi-detector CT angiography was done. A comparative study of multi-detector CT angiography and color Doppler sonography was undertaken. Color Doppler sonography examinations were done using Phillips HD7 USG machine with a 3-5MHz convex probe & 3-12MHz linear probe.Color images were examined for peak systolic velocity ,waveform pattern, color bruits, and collateral vessels. Occlusions were diagnosed when no Doppler spectral signal was detected.Multi-detector CT Angiography was acquired with a 16 slice Multi- detector CT scan (Siemens). All patients were explained about breath holding, 6-8 hour prior fasting and their renal function tests were recorded. Non ionic contrast medium, 120-150 mL was used at a flow rate of 3–4ml/s.(Ultravist:300mgI/ml) CT was performed using a 2.5mm section thickness. Sections were then reconstructed at1mm.

Data Analysis

The lower limb arterial system was divided into 3 anatomical regions:

  1. AORTO-ILIAC REGION including Infra-renal aorta, common iliacarteries, external iliacarteries.
  2. FEMORAL REGION including common femoral artery, Superficial femoral artery, deep femoral artery and popliteal artery.3) TIBIAL REGION including tibio-peroneal trunk, anterior and posterior tibial artery and peroneal artery. Each and every anatomical segment of the arterial tree was assigned a grade for the disease extent as visualised using a five pointscale: 0=Normal, 1=Mild stenosis (1–49% diameterreduction), 2=Moderate stenosis (50–74% diameterreduction), 3=Severe stenosis (75–99% diameterreduction), 4=Occlusion.The findings of the modalities were then compared.



  Results Top


Age & Sex Distribution

This study included 40 patients (32 males & 8females). The age range was of 33–75years (Mean age =54years).
Table 1: Case distribution according to risk factors

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A majority of the patients (50%) had complaints in the left lower limb and 25% in the right lower limb. 22% of the patients had bilateral lower limb pain which was more so on the left side (12%).

Color Doppler Ultra Sonography (CDUSG) has a higher incidence of detection of Grade 1 &2 disease. In Grade 3 & 4 disease almost similar values were obtained
Table 2: Case Distribution according to site of complaint

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CDUSG has a higher no. of case detection in Grade 1disease. CT ANGIO detected 2 extra cases of Grade 3 disease, while in Grade 4 disease a similar detection rate was noted.

In Grade 1 & 2 disease a higher no. of cases were detected by CDUSG. In Grade 3 disease there was a marginal increase in cases detected by CT ANGIO.

There was a higher sensitivity of CDUSG in diagnosing Grade 1 & 2cases.A higher sensitivity of CT ANGIO in Grade 0 disease is an additional indirect pointer towards a lesser sensitivity of CT ANGIO in detecting Grade 1disease. CT ANGIO proved to be marginally better in Grade 3 cases while having an equal sensitivity in Grade 4 cases as with CDUSG.
Table 3: Case distribution in aorto-iliac region

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Table 4: Case distribution in femoral region

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Table 5: Case distribution in tibial region

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Table 6: Severity Grade

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Segmental length assessment and collateral circulation was better noted on CT Angiography. CDUSG scored over CT ANGIO in the flow related assessment of calcified segment, soft plaques, thrombosis and evaluation of recanalisation.
Table 7: CDUSG VS CT ANGIOGRAPHY

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Smoking , neuropathy, hyperlipidemia & diabetes were the leading risk factors noted in this study. Smoking had the highest incidence of association with Grade IV stenosis. A majority of the patients (50%) had complaints in the left lower limb and 25% in the right lower limb. 22% of the patients had bilateral lower limb pain which was more so on the left side (12%).Three of the patients examined by angiography showed irregularity of the wall of the arteries on both sides, which appeared as calcifications upon CT angiography (sensitivity 100%) while only 2 of them appeared on color coded Doppler examination (sensitivity 75%). Normal flow pattern on doppler study was found in all 3 cases while CT angiography flow assessment of the particular segment was not possible. In cases of Grade 1 & 2 stenosis, CDUSG showed a higher no. of patients, especially in Grade 1 disease with monophasic or biphasic wave form pattern. Equal or similar values were noted in both the modalities in Grade 3 & 4disease.Doppler failed to detect stenosis in two patients due to patient oedema & obesity resulting in 95% sensitivity as compared to 100% sensitivity in Multidetector CT angiography. Segmental length assessment and collateral circulation was better noted on CT Angiography. CDUSG scored over CT ANGIO in the flow related assessment of calcified segment, plaques, thrombosis and evaluation of recanalisation. CT angiography was better in assessment of segmental length and collateral circulation.
Figure 1: (a) CDUS - Flow within the left external iliac vein but no flow in the adjacent left EIA (b) and (c): CTANGIO - Complete left EIA occlusion with collateral filling

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Figure 2: (a) and (c) : CDUS- Echogenic embolus with absent color flow seen at periphery in left CIA (b) and (d): CT ANGIO - hypodense tubular shaped embolus in the left

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Figure 3: (a) and (c): CDUS - Left CIA stenosis monophasic waveform in the post stenotic segment (b) and(d): CT ANGIO -Atheromatous calcifications of the aortoiliac arteries with the CIA stenosis

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  Discussion Top


In all cases of peripheral arterial disease the purpose of any diagnostic modality is to define the anatomy, evaluate the severity of disease, assess the distal circulation, and identify unsuspected lesions. Here we attempted to compare two Non-invasive modalities of today's era which are now becoming easily available in rural as well as urban areas of India. After preliminary physical examination color Doppler ultrasonography is mostly indicated as a cost effective initial diagnostic modality, sometimes which is all that is required. The ultrasound findings provide information on the extent and severity of the disease, soft tissue plaques, thrombosis, Segmental flow analysis, Segmental length analysis, Collateral circulation, Recanalisation, Pre & post-operative flow evaluation With the advent of USG contrast agents (HIGH COST!!) it is now possible to have a better flow assessment in complicated cases complicated cases with the advantage of no radiation exposure and allergic reactions in comparison to CT Angiography.[8] The few limitations being operator dependency, time consumption, bowel gas, oedema and obesity. CT angiography on the other hand is minimally invasive, requiring only an intravenous injection of contrast medium but also involves radiation exposure and an inherent risk of allergic reactions.[9] Multiplanar reconstruction aids in the visualization of segment length of stenoses, better appreciation of collateral circulation and better reproduction of the arterial tree. Soft tissue plaques, early recanalisation, post op flow evaluations and comorbid conditions (renal disease) being important limitations of CT ANGIO.[17]


  Conclusion Top


Color Doppler USG is the initial modality of choice in any case of peripheral arterial disease. CT Angiography is a better modality for segmental length assessment, collateral circulation along with providing a road-map reproduction of the arterial system. Doppler sonography is better than CT angiography in the diagnosis of early onset (Grade 1 &2) cases, with better assessment of soft plaques, segmental flow and recanalization in peripheral arterial diseases. In the Indian healthcare sector where much is required to be done especially in rural sector, the impact of Color Doppler USG being a cost effective, noninvasive modality with a good clinical impact, it has a high potential to improve the overall rate of diagnoses in arterial diseases.



 
  References Top

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A.D.A.M. Medical Encyclopedia. Peripheral Artery Disease—Legs. 2013. PubMed Health. Accessed at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001223/ on 19 August 2013.  Back to cited text no. 6
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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