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ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 86-91

Role of color Doppler ultrasound and MDCT angiography in the evaluation of peripheral arterial disease


Department of Radiodiagnosis, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India

Date of Submission01-Apr-2020
Date of Acceptance30-May-2020
Date of Web Publication18-Jul-2020

Correspondence Address:
Dr. B Vijayalakshmi Devi
Department of Radiodiagnosis, SVIMS, Alipiri Road, Tirupati - 517 507, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_48_20

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  Abstract 


Background and Objective: The main objective is to study the correlation between color Doppler ultrasound and multidetector computed tomography (MDCT) angiography in evaluating peripheral arterial disease.
Settings and Design: Prospective observational study.
Materials and Methods: The study was conducted in the Department of Radio Diagnosis, SVIMS, over a period of 18 months from March 2018 to July 2019. All of the 80 consecutive patients who were referred to the Department of Radio Diagnosis with clinical suspicion of peripheral arterial disease (PAD) were studied. Color Doppler ultrasound followed by MDCT angiography were done in all of the patients.
Results: Out of the total 1680 vessel segments in 80 patients, color Doppler sonography (CDS) was able to detect 545 (32.4%) positive segments, in comparison to the CTA which was able to detect 732 (43.5%) bilaterally, with 11.1% of cases detected more on MDCT angiography predominantly grade-2, 3, 4, except for grade-1. On overall except for wall thickness, MDCT angiography was better in detecting wall calcification, occlusion, and thrombus on comparison with CDS.
Conclusion: CDS and MDCT angiography showed good agreement for grade-0, 1 PAD when compared to grade-2, 3, 4. CDS with an advantage of no risk of radiation, contrast related complications should be considered as a preliminary screening test in all patients with clinical suspicion of PAD. MDCT angiography should be considered for grade-2, 3, 4 stenosis assessments for selecting an appropriate treatment.

Keywords: Color Doppler sonography, multidetector computed tomography, peripheral arterial disease


How to cite this article:
Kondeti K, Devi B V, Lakshmi A Y, Chandra A. Role of color Doppler ultrasound and MDCT angiography in the evaluation of peripheral arterial disease. J NTR Univ Health Sci 2020;9:86-91

How to cite this URL:
Kondeti K, Devi B V, Lakshmi A Y, Chandra A. Role of color Doppler ultrasound and MDCT angiography in the evaluation of peripheral arterial disease. J NTR Univ Health Sci [serial online] 2020 [cited 2020 Aug 5];9:86-91. Available from: http://www.jdrntruhs.org/text.asp?2020/9/2/86/289890




  Introduction Top


Peripheral arterial disease (PAD) is the most common condition affecting the arteries of the lower extremity. Acute compromise of arterial flow due to the stenosis and occlusions can result in limb ischaemia resulting in amputation, myocardial infarction, and stroke. It is an independent risk factor for vascular disease in other regions. PAD adversely affects the functional status of the limb and is associated with the poor quality of life.[1] Among all crural region is the most commonly involved followed by femoropopliteal, aortoiliac regions.[2]

The most common cause of lower limb PAD is atherosclerosis. Others include thromboembolism, acute thrombotic occlusion, micro embolism, trauma, and vasculitis.[3] Arteriography is considered the standard investigation as it gives an accurate anatomical description of obstructive arterial lesions. However, it does not estimate the hemodynamic significance and also involves higher radiation risk.[4]

Color Doppler sonography (CDS) imaging provides a measurement of blood velocity through a vessel and enables the rapid localization of arterial stenosis and occlusions.[1]

Multidetector computed tomography (MDCT) angiography on the other hand shows the extent of the disease from the abdominal aorta till the arteries of feet and will help in planning treatment modality. Also, collaterals are best seen with MDCT.[2]

With this knowledge about various imaging modalities, we have planned a prospective study to evaluate the role of CDS and MDCT angiography in PAD.


  Materials and Methods Top


The study was conducted in the Department of Radio Diagnosis, SVIMS, over a period of 18 months from March 2018 to July 2019. Eighty patients (1680 arterial segments) were included in the study. All the patients were referred to the Department of Radio Diagnosis with symptoms of PAD such as lower limb intermittent claudication/rest pain, gangrene of lower limb, or absence of peripheral pulses in lower limb. CDS followed by MDCT angiography were done in all of the patients. One of the two experienced radiologists who were blinded to CDS findings reviewed the images and evaluated the findings of PAD in these patients.

Statistical analysis

Data entry is recorded on a predesigned proforma using Microsoft excel. All of the entries were double checked for any possible error. Categorical variables such as males, females, age were presented as counts and percentages. Comparison between two modalities was done using kappa[k] coefficient.

If k is 0, two measurements agree simply because of chance, while if it is 1, there is perfect agreement. If k value is less than 0, then there is no agreement, k value 0–0.4 is mild agreement, 0.4–0.6 moderate, 0.61–0.8 substantial/good agreement, and 0.8–1 is perfect agreement. The statistical software used is IBM SPSS statistics version 22.

Ethical Clearance

Ethical approval for this study (Ethical Committee IEC No 744) was provided by the Institutional Ethics Committee of Sri Venkateshwara Institute of Medical Science, Tirupati, on 12 April 2018


  Results Top


A total of 80 patients (54 males and 16 males) were included in this study. Among them 58 patients were presented with intermittent claudication, 12 patients had rest pain, and 10 patients were asymptomatic with a history of CAD, referred by clinicians for lower limb arterial system evaluation.

A total of 21 segments (1680 segments) of 80 patients in the lower limb were evaluated in the study, which included infrarenal aorta, rest of the segments bilaterally, i.e., CIA (2 segments), EIA (2 segments), IIA (2 segments, CFA (2 segments), SFA (2 segments), DFA (2 segments), PA (2 segments), ATA (2 segments), PTA (2 segments), and DPA (2 segments).

Further these individual segments were grouped into aortoiliac region (1 infra renal aorta, 2 segments of CIA, EIA, IIA each), totally 7 segments; femoropopliteal region (2 segments of CFA, SFA, DFA, PA each), totally 8 segments; and crural region (2 segments of ATA, PTA, DPA each), totally 6 segments.

All of the arterial segments were assessed for wall thickening, wall calcification, occlusion, and thrombus. Stenosis was graded as Grade-0: Normal, Grade-I: 0%–50%, Grade-2: 50%–75%, Grade-3: >75%, and Grade-4 (occlusion/thrombus) [Table 1] similar to that by Kishore et al.[1] in 2013 study.
Table 1: Grading of Stenosis

Click here to view


On overall in our study, out of the total 1680 vessel segments, CDS detected 545 (32.4%) positive segments of which wall thickening were 222 (13.7%), wall calcification were 120 (7.4%), occlusion were 101 (6.0%), thrombus were 102 (6.0%) [Table 2], in comparison to the CTA which was able to detect 732 (43.5%) of which wall thickening were 202 (12.0%), wall calcification were 178 (10.9%), occlusion were 168 (10.3%), and thrombus were 182 (10.8%) [Table 2]. CT detected 11.1% more no. of positive cases on overall.
Table 2: Overall Distribution of PAD

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In our study, the observed agreements between CDS and MDCT angiography in assessing wall thickening, wall calcification, occlusion, and thrombus were 90%, 90.8%, 86%, 87% with a P value < 0.05. This signifies a good agreement for PAD between these two modalities.

The agreements between CDS and MDCT angiography using kappa statistics are Kappa values for grade-0, 1 stenosis are 0.75 and 0.72, which means good agreement. Kappa value for grade-2 stenosis is 0.39, which is mild agreement. Kappa values for grade-3, 4 stenosis are 0.5, 0.6, respectively, which means a moderate agreement


  Discussion Top


Peripheral vascular disease is increasing in frequency with increase in life expectancy and increase in co-morbid conditions like advancing age, diabetes mellitus, and hypertension.[1] This is associated with a lot of morbidity due to its global involvement. Next to cancer and heart disease, complications of atherosclerosis leading to PAD are the third leading cause of death in the world.[5]

Doppler ultrasound, combining both high-resolution B mode imaging and Doppler spectrum analysis, has proved to be noninvasive, accurate, and cost-effective means of assessing peripheral vascular disease.

With the emergence of MDCT, clearly delineating the extent of arterial tree involvement in a noninvasive way and results are comparable to invasive cumbersome angiography. Hence, MDCT is the present modality of choice before any intervention. MDCT is safe, has faster acquisition, and is an independent observer, therefore reliable.[6]

In our study of comparison of MDCT with color Doppler ultrasound, 80 patients were evaluated for the extent of disease in the lower limb arterial system and the data was compared with existing studies available, and the following observations were made to find an agreement between color Doppler ultrasound with MDCTA.

Out of 80 patients, 54 (80%) were male patients and 16 (20%) were female patients. Similar results were seen in a study by Fisher et al.[7] in which males were more affected by PAD.

In a study by Cossman et al.[8], it was concluded that PAD is a disease that affects middle aged and elderly, which is comparable with our study; 54 (67.7%) patients in our study are in >50 years age group.

Smoking tobacco is a major risk factor in the development of PAD. In our study, 34 patients [43%] with smoking are diagnosed with PAD.

Other co-morbidities in our patients with PAD are hypertension, coronary artery disease, and Type 2 DM. We found that in our study the incidence of diabetes mellitus (23%) was most common in PAD than hypertension, which is similar to a study done by Premalatha et al.[9]

The present study was carried out to compare and show the efficacy of the CDS and MDCTA. A total of 1680 vessel segments were imaged by both CDS and MDCTA in 80 patients. The imaging characteristics were recorded in all patients and documented [Table 3]. The results were analyzed, studied, and compared with similar studies.
Table 3: Total Segments Involved and Their Stenosis

Click here to view


Grade-0 stenosis [Figure 1] and Grade-1 stenosis [Figure 2] were higher on CDS than MDCTA. Greater number of arterial segments with Grade-2, 3, 4 stenosis [Figure 3], [Figure 4], [Figure 5] was detected by MDCTA than CDS. CTA is more accurate modality in assessing the presence and extent of PAD.In our study, of the total 1680 vessel segments, CDS was able to detect 545 (32.4%) positive segments, when comparison to the CTA which was able to detect 732 (43.5%), i.e., 11.1% more no. of positive cases. In our study, we found that in comparison to MDCTA in detecting mild stenosis in the lower limb arterial systems, CDS was significantly better. Therefore, CDS can be a better modality for screening early onset PAD.
Figure 1: MIP images of CT angiogram in a patient with normal lower limb arteries representing Grade 0 (a,b) and normal color filling with triphasic wave pattern in femoral artery (c) and anterior tibial artery (d) on CDS

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Figure 2: CT angiogram (a,b)in asymptomatic 58 years male with known coronary artery disease showing mild stenosis in left external iliac artery () and in left posterior tibial artery respectively. CDS clearly shows intimal thickening causing mild stenosis in external iliac artery (c) () and moderate stenosis with spectral broadening in left PTA (d) ()

Click here to view
Figure 3: 52 years known hypertensive presented with chronic pain in left thigh .VRT image of CT angiogram (a) shows grade 3 stenosis in left SFA () and corresponding CDS images (b,c) show biphasic pattern in proximal SFA () and monophasic pattern in the popliteal artery () distal to the stenotic SFA

Click here to view
Figure 4: 52 year old diabetic came with acute right leg pain and swelling. CT angiogram MIP and VRT images (a,b) showing complete occlusion (Grade4 stenosis) of right CIA,EIA,CFA,SFA,PA,ATA,PTA () Corresponding CDS images (c,d) of right CFA and PTA showing no colour, no spectral pattern() .

Click here to view
Figure 5: 58 year old smoker and hypertensive with Acute pain in right thigh , CT angiogram with VRT and MIP images (5a,b) showing filling defect due to thrombus in right mid SFA ()with collateral reformation ().Corresponding CDS image(5c) showing no colour flow and no spectral pattern of right mid SFA()

Click here to view


In a study conducted by Rahul Shirol et al.[2], CDS is better than CT angiography in the detection of early onset Grade-I (0%–25%) and II (25%–50%) stenosis, with a better assessment of soft plaques, segmental flow, and re-canalization in PAD. CT angiography is more accurate in assessing grade-3 and grade-4 stenosis.

In our study, CDS showed more positive segments for grade-1 (<50%) stenosis than MDCTA. MDCTA showed more positive segments for grade-2 stenosis in contradiction to the above study. Also, MDCTA showed more segments positive for grade-3, 4 stenosis similar to Rahul Shirol et al.[2]

Hatsukami TS et al.[10] in 1992, Bergamini TM et al.[11] in 1995, and Sensier Y et al. 9 in 1996[12] found that CDS is an accurate screening tool for evaluation of the PAD. More number of calcified plaques were detected by CTA than CDUS. Joshi A, Nimbkar A, Merchant S, et al.[13] in 2004 also found CTA to be more accurate in the detection of calcified plaque. In our study, a total of 120 (7.1%) segments on CDS and 178 (10.5%) segments on CTA showed calcification similar to above studies.

For occlusion and thrombus MDCTA detected more number of positive segments than CDS

In a study by Romano et al.[14] in the evaluation of peripheral vascular disease in detecting the femoro-popliteal occlusion, CT was able to detect the disease to a statistically significant level. In our study, when color Doppler ultrasound was compared to MDCT in detecting the femoropopliteal region, lesser segments were identified for occlusion by CDS compared to MDCTA similar to the above study.


  Limitations Top


  1. Ours is a single center study.
  2. Inter observer variability was not assessed in our study



  Conclusion Top


CDS and MDCT angiography showed good agreement for grade-0, 1 PAD when compared to grade-2, 3, 4.

CDS having advantage of no risk of radiation, contrast-related complications, should be considered as a preliminary screening test in all patients with a clinical suspicion of PAD. MDCT angiography should be considered for grade-2, 3, 4 stenosis assessments for selecting an appropriate treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kishor Rajpal, Ajita Nawale, Arvind Borde, “Role of CT Angiography & Colour Flow Imaging (USG) in Evaluation of Peripheral Arterial Diseases”, International Journal of Science and Research (IJSR) 2016;5:580-91.  Back to cited text no. 1
    
2.
Shirol RJ, Shetty A, Chethan T. K. Role of MDCT in evaluation of peripheral vascular disease of the lower limb arteries and comparison with colour doppler. J Evol Med Dent Sci 2015;4:9336-46.  Back to cited text no. 2
    
3.
Catalano C, Fraioli F, Laghi A, Napoli A, Bezzi M, Pediconi F, et al. Infrarenal aortic and lower-extremity arterial disease: Diagnostic performance of multi-detector row CT angiography. Radiology 2004;231:555-63.  Back to cited text no. 3
    
4.
Bueno A, Acin F, Canibano C, Fernandez-Casado JL, Castillo E. Diagnostic accuracy of contrast-enhanced magnetic resonance angiography and duplex ultrasound in patients with peripheral vasculardisease. Vasc Endovascular Surg 2010;44:576-85.  Back to cited text no. 4
    
5.
Kohler TR, Nance DR, Cramer MM, Vandenburghe N, Strandness DE Jr. Duplex scanning for diagnosis of aortoiliac and femoropopliteal disease: A prospective study. Circulation 1987;76:1074-80.  Back to cited text no. 5
    
6.
Leiner T, Kessels AG, Nelemans PJ, Vasbinder GB, de Haan MW, Kitslaar PE, et al. Peripheral arterial disease: Comparison of color duplex US and contrast-enhanced MR angiography for diagnosis. Radiology 2005;235:699-708.  Back to cited text no. 6
    
7.
Fisher EK, Lawler LP. CT angiography principles, techniques and study optimization using 16 slice multidetector CT with isotropic datasets and 3D volume visualization. Crit Rev Comput Tomogr 2004;45:355-88.  Back to cited text no. 7
    
8.
Cossman DV, Ellison JE, Wagner WH, Carroll RM, Treiman RL, Foran RF, et al. Comparison of contrast arteriography to arterial mapping with colour-flow duplex imaging in lower extremities. J Vasc Surg 1989;10:522-9.  Back to cited text no. 8
    
9.
Premalatha G, Shanthirani S, Deepa R, Markovitz J, Mohan V. Prevalence and risk factors of peripheral vascular disease in a selected south Indian population. Diabetes Care 2000;23;1295-300.  Back to cited text no. 9
    
10.
Hatsukami TS, Primozich JF, Zierler RE, Harley JD, Strandness DE Jr. Color doppler imaging of infrainguinal arterial occlusive disease. J Vasc Surg 1992;16:527-33.  Back to cited text no. 10
    
11.
Bergamini TM, Tatum CM Jr, Marshall C, Hall-Disselkamp B, Richardson JD. Effect of multilevel sequential stenosis on lower extremity arterial duplex scanning. Am J Surg 1995;169:564-6.  Back to cited text no. 11
    
12.
Sensier Y, Hartshorne T, Thrush A, Handford H, Nydahl S, London NJ. The effect of adjacent segment disease on the accuracy of colour duplex scanning for the diagnosis of lower limb arterial disease. Eur J Vasc Endovasc Surg 1996;12:238-42.  Back to cited text no. 12
    
13.
Joshi A, Nimbkar V, Merchant S, Mhashelkar Y, Talekar K. Role of CT angiography in the evaluation of peripheral vasculature using MSCT-our initial experience. Indian J Radiol Imaging 2004;14:309-15.  Back to cited text no. 13
  [Full text]  
14.
Romano M, Amato B, Markabaoui K, Tamburrini O, Salvatore M. Multidetector row computed tomographic angiography of abdominal aorta and lower limb arteries. A new diagnostic tool in patients with PAOD. Minerva Cardioangiol 2004;52:9-17.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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