Advances in axial imaging of peripheral vascular disease

Peripheral artery disease (PAD) has become increasingly common in the US patient population and can be a highly symptomatic and significant source of morbidity. When PAD is suspected, the first-line screening study that is obtained is typically a noninvasive evaluation that includes the ankle brachial index (ABI). Following a positive screening study, invasive catheter digital subtraction angiography (DSA) has been historically used to image the peripheral artery system and still remains the gold standard. However, newer developments in axial imaging including computed tomography angiography (CTA) and magnetic resonance angiography (MRA) have in large part supplanted DSA for imaging the peripheral artery system in clinical practice. Benefits of CTA include rapid noninvasive acquisition, wide availability, high spatial resolution, and the ability to generate isotropic datasets on 64-detector row and higher CT scanners, thereby allowing for multiplanar 3D reformatting. Drawbacks of CTA include the exposure to both iodinated contrast and ionizing radiation, although the radiation dose exposure is lower than for DSA, and newer techniques such as using low tube voltage and rapid acquisition times allow for lower contrast doses. The presence of vascular calcification also limits the evaluation of small distal arteries using CTA, although the development of dual-energy CT techniques has significantly addressed this issue. Benefits of MRA include the avoidance of exposure to ionizing radiation and high diagnostic accuracy, while drawbacks include limited availability and increased cost along with the risk of nephrogenic systemic fibrosis that is associated with gadolinium-based contrast agents, although the latter can be mitigated by using newer non-contrast MR angiography techniques. Future technical advances in CT and MR hardware and software and MR pulse sequences will likely lead to the broader applicability and increased accuracy of noninvasive axial imaging in the evaluation of patients with peripheral artery disease.