SPECT/CT Imaging: A Noninvasive Approach for Evaluating Serial Changes in Angiosome Foot Perfusion in Critical Limb Ischemia

Ting-Heng Chou, Said A Atway, Adam J Bobbey, Timur P Sarac, Michael R Go, Mitchel R Stacy, Ting-Heng Chou, Said A Atway, Adam J Bobbey, Timur P Sarac, Michael R Go, Mitchel R Stacy

Abstract

Objective: To investigate the feasibility of serial radiotracer-based imaging as a noninvasive approach for quantifying volumetric changes in microvascular perfusion within angiosomes of the foot following lower extremity revascularization in the setting of critical limb ischemia (CLI). Approach: A CLI patient with a nonhealing foot ulcer underwent single-photon emission computed tomography (SPECT)/computed tomography (CT) imaging of the feet before and after balloon angioplasty of the superficial femoral artery (SFA) and popliteal artery. SPECT/CT imaging was used to evaluate serial changes in angiosome perfusion, which was compared to quantitative changes in peripheral vascular anatomy and hemodynamics, as assessed by standard clinical tools that included digital subtraction angiography (DSA), ankle-brachial index (ABI), and toe-brachial index (TBI). Results: Following revascularization, upstream quantitative improvements in stenosis of the SFA (pre: 35.4% to post: 11.9%) and popliteal artery (pre: 59.1% to post: 21.7%) shown by DSA were associated with downstream angiosome-dependent improvements in SPECT microvascular foot perfusion that ranged from 2% to 16%. ABI measurement was not possible due to extensive arterial calcification, while TBI values decreased from 0.26 to 0.16 following revascularization. Innovation: This is the first study to demonstrate the feasibility of assessing noninvasive volumetric changes in angiosome foot perfusion in response to lower extremity revascularization in a patient with CLI by utilizing radiotracer-based imaging. Conclusion: SPECT/CT imaging allows for quantification of serial perfusion changes within angiosomes containing nonhealing ulcers and provides physiological assessment that is complementary to conventional anatomical (DSA) and hemodynamic (ABI/TBI) measures in the evaluation of lower extremity revascularization.

Keywords: angiography; angiosome; critical limb ischemia; diabetes mellitus; perfusion imaging; peripheral arterial disease.

Conflict of interest statement

No competing financial interests exist. The content of this article was expressly written by the author(s) listed. No ghostwriters were used to write this article.

© Ting-Heng Chuo et al., 2019; Published by Mary Ann Liebert, Inc.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/6985768/bin/wound.2018.0924_figure5.jpg
Mitchel R. Stacy, PhD
Figure 1.
Figure 1.
CT-based image segmentation approach for regional evaluation of angiosome foot perfusion. Volume rendering of the medial heel (orange), lateral heel (yellow), dorsal foot (green), medial plantar (blue), and lateral plantar (red) angiosomes overlaid on CT images, which are shown in the (A) lateral, (B) medial, and (C) posterior/plantar views. CT, computed tomography. Color images are available online.
Figure 2.
Figure 2.
Serial image registration of CT images for evaluating serial changes in angiosome foot perfusion. Lateral and medial views of volume rendered CT images are displayed for the (A) initial foot position at both study time points before image registration, (B) following global rigid registration, and (C) after nonrigid registration. The red images represent the foot position at the time of patient's pre-revascularization study visit, while the green images represent the change in foot position at the time of patient's follow-up post-revascularization visit. Color images are available online.
Figure 3.
Figure 3.
Digital subtraction angiography in a patient with CLI undergoing multivessel revascularization of the lower extremity. Angiographic images acquired (A) before and (B) after balloon angioplasty of the right popliteal artery, and (C) before and (D) after the balloon angioplasty of the right SFA demonstrate improvement in arterial patency following revascularization. Arrows denote segments of arterial stenosis targeted for balloon angioplasty. CLI, critical limb ischemia; SFA, superficial femoral artery.
Figure 4.
Figure 4.
SPECT/CT perfusion imaging in a CLI patient before and after revascularization. Coregistered and fused SPECT/CT images demonstrate increased radiotracer uptake and improved microvascular perfusion in the foot in the (A) axial, (B) sagittal, and (C) coronal views following balloon angioplasty of the SFA and popliteal artery. SPECT, single-photon emission computed tomography. Color images are available online.

References

    1. Global Burden of Disease Study 2013 Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2015;386:743–800
    1. Hirsch AT, Haskal ZJ, Hertzer NR, et al. . ACC/AHA 2005 practice guidelines for the management of patients with peripheral arterial disease (Lower extremity, renal, mesenteric, and abdominal aortic). Circulation 2006;113:e463–e654
    1. Norgren L, Hiatt WR, Dormandy JA, et al. . Inter-society consensus for the management of peripheral arterial disease. J Vasc Surg 2007;45:S5–S67
    1. Lejay A, Georg Y, Tartaglia E, et al. . Long-term outcomes of direct and indirect below-the-knee open revascularization based on the angiosome concept in diabetic patients with critical limb ischemia. Ann Vasc Surg 2014;28:983–989
    1. Huang TY, Huang TS, Wang YC, Huang PF, Yu HC, Yeh CH. Direct revascularization with the angiosome concept for lower limb ischemia. A systematic review and meta-analysis. Medicine (Baltimore) 2015;94:e1427.
    1. Iida O, Soga Y, Hirano K, et al. . Long-term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia presenting with isolated below-the-knee lesions. J Vasc Surg 2012;55:363–370
    1. Bosanquet DC, Glasbey JCD, Williams IM, Twine CP. Systematic review and meta-analysis of direct versus indirect angiosomal revascularisation of infrapopliteal arteries. Eur J Vasc Endovasc Surg 2014;48:88–97
    1. Shishehbor MH, Reed GW. Personalized approach to revascularization of critical limb ischemia. Circ Cardiovasc Interv 2014;7:642–644
    1. Alvelo JL, Papademetris X, Mena-Hurtado C, et al. . Radiotracer imaging allows for noninvasive detection and quantification of abnormalities in angiosome foot perfusion in diabetic patients with critical limb ischemia and nonhealing wounds. Circ Cardiovasc Imaging 2018;11:e006932.
    1. Stacy MR, Yu DY, Maxfield MW, et al. . Multimodality imaging approach for serial assessment of regional changes in lower extremity arteriogenesis and tissue perfusion in a porcine model of peripheral arterial disease. Circ Cardiovasc Imaging 2014;7:92–99
    1. Stacy MR, Qiu M, Papademetris X, Caracciolo CM, Constable RT, Sinusas AJ. Application of BOLD MR imaging for evaluating regional volumetric foot tissue oxygenation: a feasibility study in healthy volunteers. Eur J Vasc Endovasc Surg 2016;51:743–749
    1. Jiji RS, Pollak AW, Epstein FH, et al. . Reproducibility of rest and exercise stress contrast-enhanced calf perfusion magnetic resonance imaging in peripheral arterial disease. J Cardiovasc Magn Reson 2013;15:14.
    1. Grozinger G, Pohmann R, Schick F, et al. . Perfusion measurements of the calf in patients with peripheral arterial occlusive disease before and after percutaneous transluminal angioplasty using MR arterial spin labeling. J Magn Reson Imaging 2014;40:980–987
    1. Pollak AW, Meyer CH, Epstein FH, et al. . Arterial spin labeling MR imaging reproducibly measures peak-exercise calf muscle perfusion: a study in patients with peripheral arterial disease and healthy volunteers. JACC Cardiovasc Imaging 2012;5:1224–1230
    1. Bajwa A, Wesolowski R, Patel A, et al. . Blood oxygenation level-dependent CMR-derived measures in critical limb ischemia and changes with revascularization. J Am Coll Cardiol 2016;67:420–431
    1. Bhatti S, Hakeem A, Dhanalakota S, et al. . Prognostic value of regadenoson myocardial single-photon emission computed tomography in patients with different degrees of renal dysfunction. Eur Hear J Cardiovasc Imaging 2014;15:933–940
    1. Higley B, Smith F, Smith T, et al. . Technetium-99 m-tetrofosmin: human biodistribution, dosimetry and safety of a new myocardial perfusion imaging agent. J Nucl Med 1993;34:30–38

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