Detection of multivessel calcific disease progression in a patient with chronic limb-threatening ischemia using fluorine-18 sodium fluoride positron emission tomography imaging

Abstract

Vascular calcification contributes to morbidity and poor clinical outcomes for patients with peripheral artery disease; however, the traditional assessment of the calcium burden using computed tomography (CT) imaging or angiography represents already established disease. In the present report, we describe a 69-year-old man with chronic limb-threatening ischemia who had undergone positron emission tomography/CT imaging with fluorine-18 sodium fluoride to evaluate the relationship between baseline levels of positron emission tomography-detectable active vascular microcalcification and CT-detectable calcium progression 1.5 years later. CT imaging at follow-up identified progression of existing lesions and the formation of new calcium in multiple arteries that had demonstrated elevated fluorine-18 sodium fluoride uptake 1.5 years earlier.

Keywords: Calcification; Chronic limb-threatening ischemia; Diabetes mellitus; Positron emission tomography; Sodium fluoride.

© 2023 The Author(s).

Figures

Fig 1

Angiographic evaluation of the affected limb revealed significant disease in the anterior tibial and peroneal arteries (A) with occlusion of both arteries below the knee (B).

Fig 2

Fluorine-18 (18F)-sodium fluoride (NaF) positron emission tomography (PET)/computed tomography (CT) imaging of multivessel calcific disease progression. A, Baseline PET/CT imaging at study enrollment revealing various levels of CT-detectable calcium deposition in the popliteal, posterior tibial, anterior tibial, and peroneal arteries (white arrows) with active microcalcification occurring in multiple vessels, as shown by 18F-NaF PET imaging (white arrows). B, Follow-up CT imaging 1.5 years later demonstrating new calcium or progression of existing calcium within vascular regions (yellow arrows) that were previously identified as having elevated levels of 18F-NaF uptake (ie, active disease). SUV, Standardized uptake value.

Fig 3

Fluorine-18 (18F)-sodium fluoride (NaF) positron emission tomography (PET)/computed tomography (CT) imaging of popliteal artery disease progression. A, CT imaging at study enrollment revealing minimal calcium deposition in the popliteal artery. In contrast, PET imaging demonstrated diffuse uptake of 18F-NaF, indicating an active process of popliteal artery microcalcification. B, Follow-up CT imaging demonstrated new calcium deposition in the popliteal artery where 18F-NaF PET imaging had revealed active microcalcification 1.5 years earlier. SUV, Standardized uptake value.

Fig 4

Positron emission tomography (PET)/computed tomography (CT) imaging revealing minimal uptake of fluorine-18 (18F)-sodium fluoride (NaF) in a region of the popliteal artery at baseline (A) that corresponded to no change in the calcium mass score (B) at 1.5-year follow-up. SUV, Standardized uptake value.

Fig 5

Serial photographs of the patient's chronic diabetic foot wound during the 1.5-year study timeline. Evidence of prior reconstructive surgery is apparent, with slow, but progressive, healing of the wound.