Arterial spin labeling perfusion cardiovascular magnetic resonance of the calf in peripheral arterial disease: cuff occlusion hyperemia vs exercise

David Lopez, Amy W Pollak, Craig H Meyer, Frederick H Epstein, Li Zhao, Arthur J Pesch, Ronny Jiji, Jennifer R Kay, Joseph M DiMaria, John M Christopher, Christopher M Kramer, David Lopez, Amy W Pollak, Craig H Meyer, Frederick H Epstein, Li Zhao, Arthur J Pesch, Ronny Jiji, Jennifer R Kay, Joseph M DiMaria, John M Christopher, Christopher M Kramer

Abstract

Background: Assessment of calf muscle perfusion requires a physiological challenge. Exercise and cuff-occlusion hyperemia are commonly used methods, but it has been unclear if one is superior to the other. We hypothesized that post-occlusion calf muscle perfusion (Cuff) with pulsed arterial spin labeling (PASL) cardiovascular magnetic resonance (CMR) at 3 Tesla (T) would yield greater perfusion and improved reproducibility compared to exercise hyperemia in studies of peripheral arterial disease (PAD).

Methods: Exercise and Cuff cohorts were independently recruited. PAD patients had an ankle brachial index (ABI) between 0.4-0.9. Controls (NL) had no risk factors and ABI 0.9-1.4. Subjects exercised until exhaustion (15 NL-Ex, 15 PAD-Ex) or had a thigh cuff inflated for 5 minutes (12 NL-Cuff, 11 PAD-Cuff). Peak exercise and average cuff (Cuff mean ) perfusion were compared. Six participants underwent both cuff and exercise testing. Reproducibility was tested in 8 Cuff subjects (5 NL, 3 PAD).

Results: Controls had greater perfusion than PAD independent of stressor (NL-Ex 74 ± 21 vs. PAD-Ex 43 ± 10, p = 0.01; NL-Cuff mean 109 ± 39 vs. PAD-Cuff mean 34 ± 17 ml/min-100 g, p < 0.001). However, there was no difference between exercise and Cuff mean perfusion within groups (p > 0.6). Results were similar when the same subjects had the 2 stressors performed. Cuff mean had superior reproducibility (Cuff mean ICC 0.98 vs. Exercise ICC 0.87) and area under the receiver operating characteristic curve (Cuff mean 0.992 vs. Exercise 0.905).

Conclusions: Cuff hyperemia differentiates PAD patients from controls, as does exercise stress. Cuff mean and exercise calf perfusion values are similar. Cuff occlusion hyperemia has superior reproducibility and thus may be the preferred stressor.

Figures

Figure 1
Figure 1
SSFP cine images were obtained pre- (A) and post-cuff inflation (B) to check for effective arterial occlusion (arrows). Pressure was increased up to 250 mmHg to achieve occlusion. SSFP = steady-state free precession.
Figure 2
Figure 2
Perfusion was measured by drawing regions of interest on the echo-planar images (A), which are then transferred to the perfusion maps (B) to obtain perfusion in ml/min-100 g.
Figure 3
Figure 3
Representative perfusion maps of each study group demonstrate the difference in perfusion patterns with exercise (A, C) compared to cuff occlusion hyperemia (B, D). During exercise perfusion is limited to the anterior compartment, lateral compartment (arrows) and gastrocnemius (arrow heads). Post-occlusion hyperemia tends to be more diffuse in healthy volunteers (B). However, in PAD patients (D) reactive hyperemia is of lesser magnitude and extent, generally limited to the soleus muscle (outlined).
Figure 4
Figure 4
The boxplots summarize muscle group perfusion results for all the study groups. Circles indicate outliers. NL = controls; Ex = exercise hyperemia; Cuff = post-occlusion hyperemia; PAD = Peripheral arterial disease.
Figure 5
Figure 5
Boxplot of maximal and average perfusion. Circles indicate outliers. NL = controls; Ex = exercise hyperemia; Cuffmax = maximal post-occlusion hyperemia; PAD = peripheral arterial disease; Cuffmean = average post-occlusion calf perfusion. ‡p < 0.05 vs. Max NL-Cuff; †p < 0.05 vs. Max NL-Ex; #p < 0.05 vs. Max PAD-Ex; ^p < 0.05 vs. Comp NL-Cuff.

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Source: PubMed

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