Possibilities of the Hybrid Method (Three-Phase Scintigraphy-SPECT/CTAngiography) in the Diagnosis and Staging of Acute Lower Limb Ischemia

ABSTRACT Acute lower limb ischemia (ALLI) is a limb threatening condition with high risk of adverse outcomes. The timely and proper diagnosis of the severity of limb ischemia is crucial in selecting the optimal treatment method.

AIM OF STUDY To evaluate the advantages of hybrid imaging in diagnosis of ALLI, patient selection and its severity in order to choose an optimal revascularization method.

MATERIAL AND METHODS we examined 163 patients with grade 1–3A ALLI based on I.I. Zatevakhin et al. classification (2002) on a Discovery 670 NM/CT hybrid device, using X-ray (computed tomographic angiography) and radionuclide method (three-phase scintigraphy/single photon emission computed tomography with osteotropic or perfused radiopharmaceutical).

RESULTS CT angiography accurately showed level of acute occlusion as well as distal arterial blood flow in all ALLI cases, thus allowing optimal choice of possible revascularization. CT angiography findings alone did not allow optimal staging of ALLI, which is essential for choosing an optimal revascularization method and were considered as supplementary. Three-phase scintigraphy allowed to differentiate the degrees of ALLI based on the visual picture and calculated data, while studies with osteotropic radiopharmaceutical 99mТс-PYP provided information on viability of affected tissues showing the areas of muscle necrosis, compared to perfused radiopharmaceutical.

CONCLUSION 1. CT angiography makes it possible to assess in detail the level and severity of occlusive lesions of the arterial system and study the vascular anatomy of the lower limb to resolve the issue of the possibility of revascularization, and also indirectly characterizes the presence of ischemic changes in soft tissues. 2. The radionuclide method (three-phase scintigraphy with an osteotropic radiopharmaceutical/single photon emission computed tomography), performed in addition to computed tomographic angiography, allows not only to detect the presence of ischemic changes in soft tissues, but also to differentiate the degree of acute ischemia of the lower. 3. The hybrid method (three-phase scintigraphy in combination with computed tomographic angiography) contributes to an objective assessment of the state of blood flow in the lower extremities in acute ischemia, both at the main and at the microcirculatory

1. Dormandy J, Heeck L, Vig S. Acute limb ischemia. Seminar Vasc Surg. 1999;12(2):148–153. PMID: 10777242

2. Natsional’nye rekomendatsii po diagnostike i lecheniyu zabolevaniy arteriy nizhnikh konechnostey. Moscow; 2019. (In Russ.) Available at: https://www.angiolsurgery.org/library/recommendations/2019/recommendations_LLA_2019.pdf [Accessed Oct 12, 2022]

3. Dua A, Lee C. Epidemiology of Peripheral Arterial Disease and Critical Limb Ischemia. J Techniq Vasc Interv Radiol. 2016;19(2):91–95. PMID: 27423989 https://doi.org/10.1053/j.tvir.2016.04.001

4. Kharazov AF, Kalyev AO, Isaev AA. PAD prevalence in Russian Federation. Pirogov Russian Journal of Surgery. 2016;(7):58–61. (In Russ.). https://doi.org/10.17116/hirurgia2016758-61

5. Foroni Casas AL. Acute Arterial Embolism of the Lower Limb. In: Stawicki SP, Swaroop M, Firstenberg MS. (eds.) Embolic Diseases»– Evolving Diagnostic and Management Approaches. Norderstedt, Germany: BoD – Books on Demand; 2020. Ch.5. https://doi.org/10.5772/intechopen.84396 Available at: https://www.intechopen.com/chapters/66190 [Accessed Oct 12, 2022].

6. Padberg FT, Hobson RW II. Fasciotomy in acute limb ischemia. Semin Vasc Surg. 1992;5:52.

7. Kalogeris T, Baines CP, Krenz M, Korthuis RJ. Cell Biology of Ischemia/ Reperfusion Injury. Int Rev Cell Mol Biol. 2012;298:229–317. PMID: 22878108 https://doi.org/10.1016/B978-0-12-394309-5.00006-7

8. Nebylitsin YS, Lazuko SS, Kut’ko EA. Ischemia-Reperfusion Syndrome of Lower Limbs. Vitebsk Medical Jornal. 2018;17(6):18–31. (In Russ.) https://doi.org/10.22263/2312-4156.2018.6.18

9. Marshalov DV, Petrenko AP, Glushach IA. Reperfusion Syndrome: Notion, Definition, Classification. Circulation Pathology and Cardiac Surgery. 2008;3:67–72. (In Russ.)

10. Valko M, Leibfritz D, Moncol J, Cronin MT, Mazur M, Telser J. Free radicals and antioxidants in normal functions and human disease. Int J Biochem Cell Biol. 2007;39(1):44–84. PMID: 16978905

11. Chernyavsky MA, Neverov VA, Susanin NV, Soloviev VA, Belova YuK, Kazantsev AN. Revascularization in Lesion of Arteries of the Aortoiliac Arterial Segment. Literature Review and Clinical Examples. Russian Sklifosovsky Journal Emergency Medical Care. 2021;10(4):760–768. (In Russ.) https://doi.org/10.23934/2223-9022-2021-10-4-760-768

12. Prozorov SA, Belozerov GE. A Current Role of Endovascular Techniques in the Diagnosis and Treatment of Patients With Acute Aortic Pathology. Russian Sklifosovsky Journal Emergency Medical Care. 2013;(1):46–49. (In Russ.)

13. Fleischmann D, Hallett RL, Rubin GD. CT Angiography of Peripheral Arterial Disease. J Vasc Interv Radiol. 2006;17(1):3–26. PMID: 16415129 https://doi.org/10.1097/01.RVI.0000191361.02857.DE

14. Horehledova B, Mihl C, Milanese G, Brans R, Eijsvoogel NG, Hendriks, et al. CT Angiography in the Lower Extremity Peripheral Artery Disease Feasibility of an Ultra-Low Volume Contrast Media Protocol. Cardiovasc Intervent Radiol. 2018;41(11):1751–1764. PMID: 29789875 https://doi.org/10.1007/s00270-018-1979-z

15. Lim JC, Ranatunga D, Owen A, Spelman T, Galea M, Chuen J, et al. Multidetector (64+) computed tomography angiography of the lower limb in symptomatic peripheral arterial disease: Assessment of image quality and accuracy in a tertiary care setting. J Comput Assist Tomogr. 2017;41(2):327–333. PMID: 27753721 https://doi.org/10.1097/RCT.0000000000000494

16. Kudryavtseva AV, Trufanov GE, Erofeeva AA. Komp’yuternotomograficheskaya angiografiya v diagnostike obliteriruyushchikh zabolevaniy arteriy nizhnikh konechnostey. REJR. 2012;2(S2):291–292. (In Russ.) Available at: http://www.rejr.ru/past-issues.html [Accessed Oct 12, 2022].

17. Shorina YaE, Filippova IA. Spiral’naya komp’yuternaya tomografiya s angiografiey v diagnostike i planirovanii taktiki lecheniya zabolevaniy arteriy nizhnikh konechnostey. REJR. 2012;2(S2):674–674. (In Russ.) Available at: http://www.rejr.ru/past-issues.html [Accessed Oct 12, 2022].

18. Kudryashova NY, Sinyakova OG, Mikhaylov IP, Migunova EV, Leshchinskaya OV. Radionuclide Patterns of Ischemia in Acute Occlusive Diseases of Main Arteries of Lower Extremities. Russian Sklifosovsky Journal Emergency Medical Care. 2019;8(3):257–265. https://doi.org/10.23934/2223-9022-2019-8-3-257-265

19. Savel’ev VS, Zatevakhin II, Frolov VK, Vagner TE. Kriterii stepeni ishemii i otsenka zhiznesposobnosti tkaney nizhnikh konechnostey pri ostroy arterial’noy neprokhodimosti. Vestnik AMN SSSR. 1980;5:74–81. (In Russ.)

20. Svetlov KV, Svirshchevskij EB, Trofimov EI, Filippov VV, Adrianov SO, Rodionova TV. Estimation of regional blood flow in reimplanted segments of upper extremity. Pirogov Russian Journal of Surgery. 2015;(7):49–56. (In Russ.). https://doi.org/10.17116/hirurgia201574956

21. Matsuo S, Nakajima K, Kinuya S. Evaluation of Cardiac Mitochondrial Function by a Nuclear Imaging Technique using Technetium-99m-MIBI Uptake Kinetics. Asia Ocean J Nucl Med Biol. 2013;1(1):39–43. PMID: 27408841 https://doi.org/10.7508/aojnmb.2013.01.008

22. Blebea J, Kerr JC, Franco CD, Padberg FT Jr, Hobson RW 2nd. Technetium 99m pyrophosphate quantitation of skeletal muscle ischemia and reperfusion injury. J Vasc Surg. 1988;8(2):117–124. PMID: 2840521 https://doi.org/10.1016/0741-5214(88)90397-7