Combined evaluation of blood flow and tissue perfusion in diabetic feet by intra-arterial dynamic 4DCT imaging

Abstract

Critical limb ischemia is associated with high mortality and major amputations. Intra-arterial digital subtraction angiography (IADSA) has been the reference standard but has some shortcomings including the two-dimensional projection and the lack of tissue perfusion information. The aim of this exploratory study is to examine four-dimensional computed tomography (4DCT) angiography and perfusion imaging using low-volume intra-arterial contrast injections for an improved anatomic and hemodynamic assessment in patients with foot ulcers. Three patients underwent a low-volume (2 mL) intra-arterial contrast-enhanced 4DCT examination combined with a diagnostic IADSA. An automated assessment of blood flow and tissue perfusion from the 4DCT data was performed. Vascular structures and corresponding blood flows were successfully assessed and correlated well with the IADSA results. Perfusion values of the affected tissue were significantly higher compared to the unaffected tissue. The proposed 4DCT protocol combined with the minimal usage of contrast agent (2 mL) provides superior images compared to IADSA as three phases (arterial, perfusion, and venous) are captured. The obtained parameters could allow for an improved diagnosis of critical limb ischemia as both the proximal vasculature and the extent of the perfusion deficit in the microvasculature can be assessed.Relevance statementIntra-arterial 4DCT allows for assessing three phases (arterial, perfusion and venous) using minimal contrast (2 mL). This method could lead to an improved diagnosis of critical limb ischemia as both proximal vasculature and the extent of the perfusion deficit are assessed.Trial registrationISRCTN, ISRCTN95737449. Registered 14 March 2023—retrospectively registered, https://www.isrctn.com/ISRCTN95737449Key points• Three phases (arterial, perfusion, and venous) are obtained from 2 mL intra-arterial 4DCT.• The obtained hemodynamic parameters correlated well with the IADSA findings.• 4DCT surpassed IADSA in terms of assessment of venous blood flow and inflammatory hyperperfusion.• The assessment of tissue perfusion could lead to optimizing the revascularization strategy. Graphical Abstract

Repeatability of [15O]H2O PET imaging for lower extremity skeletal muscle perfusion: a test–retest study

“…To our knowledge, perfusion in feet has not previously been quantified with PET, and only a few studies using MRI or CT have been published. Arterial spin labeling MRI appears to yield perfusion approximately 10 times higher than the current study in both lower legs and feet [ 20 – 22 ], whereas a small dynamic CT study in patients with diabetic foot found perfusion values more in line with the current study (0.5–0.7 mL/min/100 mL in healthy tissue of the feet) [ 23 ]. In both lower legs and feet, the interindividual variation was larger than the intraindividual variation in muscle perfusion (coefficient of variation 37% vs. 29% and 71% vs. 40%, respectively).…”