Influence of diabetes on diagnostic performance of computed tomography angiography of the calf arteries in acute limb ischemia

Abstract

Background

Patients with diabetes mellitus (DM) have a more extensive distal arterial occlusive disease compared to non-diabetic patients. Diagnostic imaging is a necessity to identify the location and extent of the arterial occlusion in acute limb ischemia (ALI). Computed tomography angiography (CTA) is the most commonly used modality and the diagnostic performance with CTA of calf arteries may be questioned.

Purpose

To evaluate diagnostic performance of CTA of calf arteries in ALI and to compare patients with and without DM.

Material and Methods

All thrombolytic treatments performed during 2001–2018 in patients with ALI were included. Initial digital subtraction angiography (DSA) and CTA of all patients were classified according to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II) below-the-knee arteries and compared to CTA. Two raters assessed the CTA images independently. Inter-rater reliability was expressed as intraclass correlation (ICC) with 95% confidence intervals (CI).

Results

Patients with (n = 23) and without (n = 85) DM had lower (P = 0.006) glomerular filtration rate. ICC between CTA and DSA was 0.33 (95% CI –0.22 to 0.56) and 0.71 (95% CI 0.38–0.68) in patients with and without DM, respectively. Sensitivity with CTA for TASC D lesions in patients with and without DM was 0.14 (95% CI –0.12 to 0.40) and 0.64 (95% CI 0.48–0.80), respectively.

Conclusion

The sensitivity of CTA for assessment of infra-popliteal TASC D lesions in patients with ALI was not acceptable in patients with DM in contrast to those without DM. Another imaging option at present times should be considered for patients with DM.

Keywords

Diabetes mellitus computed tomography angiography diagnostic accuracy acute limb ischemia

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References

Vemulapalli

Patel

Jones

WS.

Limb ischemia: cardiovascular diagnosis and management from head to toe. Curr Cardiol Rep 2015; 17:611.

Bjorck M, Earnshaw JJ, Acosta S, et al. Editor's Choice -- European Society for Vascular Surgery (ESVS) 2020 Clinical practice guidelines on the management of Acute Limb Ischaemia. Eur J Vasc Endovasc Surg 2020;59:173--218.

Butt T, Gottsater A, Apelqvist J, et al. Outcome of intra-arterial thrombolysis in patients with diabetes and acute lower limb ischemia: a propensity score adjusted analysis. J Thromb Thrombolysis 2017;44:475--480.

Graziani

Silvestro

Bertone

, et al. Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease severity. Eur J Vasc Endovasc Surg 2007; 33:453–460.

Claesson K, Kolbel T, Acosta S. Role of endovascular intervention in patients with diabetic foot ulcer and concomitant peripheral arterial disease. Int Angiol 2011;30:349--358.

Grubb

Nyman

Bjork

, et al. Simple cystatin C-based prediction equations for glomerular filtration rate compared with the modification of diet in renal disease prediction equation for adults and the Schwartz and the Counahan-Barratt prediction equations for children. Clin Chem 2005; 51:1420–1431.

Rutherford

Baker

Ernst

, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg 1997; 26:517–538.

Jaff

White

Hiatt

, et al. An Update on Methods for Revascularization and Expansion of the TASC Lesion Classification to Include Below-the-Knee Arteries: A Supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II): The TASC Steering Comittee(.). Ann Vasc Dis 2015; 8:343–357.

Bland

Altman

DG.

Cronbach’s alpha. BMJ 1997; 314:572.

10.

Mishra

Jain

Bhagwat

CT Angiography of peripheral arterial disease by 256-slice scanner: accuracy, advantages and disadvantages compared to digital subtraction angiography. Vasc Endovascular Surg 2017; 51:247–254.

11.

Al-Rudaini

HEA

Han

Liang

Comparison between computed tomography angiography and digital subtraction angiography in critical lower limb ischemia. Curr Med Imaging Rev 2019; 15:496–503.

12.

Kalisz

Buethe

Saboo

, et al. Artifacts at cardiac CT: physics and solutions. Radiographics 2016; 36:2064–2083.

13.

Mahnken

AH.

CT imaging of coronary stents: past, present, and future.

ISRN Cardiol 2012; 2012:139823.

14.

Klink

Wilhelm

Roth

, et al. Dual-energy CTA in patients with symptomatic peripheral arterial occlusive disease: study of diagnostic accuracy and impeding factors. Rofo 2017; 189:441–452.

15.

De Santis

De Cecco

Schoepf

, et al. Modified calcium subtraction in dual-energy CT angiography of the lower extremity runoff: impact on diagnostic accuracy for stenosis detection. Eur Radiol 2019; 29:4783–4793.

16.

Nyman

Almen

Aspelin

, et al. Contrast-medium-Induced nephropathy correlated to the ratio between dose in gram iodine and estimated GFR in ml/min. Acta Radiol 2005; 46:830–842.

17.

Rowe

Hawkins

Hamilton

, et al. Contrast-induced nephropathy in ischemic stroke patients undergoing computed tomography angiography: CINISter Study. J Stroke Cerebrovasc Dis 2019; 28:649–654.

18.

Pollak

Norton

Kramer

CM.

Multimodality imaging of lower extremity peripheral arterial disease: current role and future directions. Circ Cardiovasc Imaging 2012; 5:797–807.

19.

Leiner

Kessels

Nelemans

, et al. Peripheral arterial disease: comparison of color duplex US and contrast-enhanced MR angiography for diagnosis. Radiology 2005; 235:699–708.

20.

Zhou

, et al . Comparison of imaging value for diabetic lower extremity arterial disease between FBI and CE-MRA. Eur Rev Med Pharmacol Sci 2016; 20:3078–3086.

21.

Preuss

Elgeti

Hamm

, et al. Extravascular incidental findings in run-off CT angiography in patients with acute limb ischaemia: incidence and clinical relevance. Clin Radiol 2015; 70:622–629.