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Evaluation of Peripheral Arterial Bypass Grafts with Multi–Detector Row CT Angiography: Comparison with Duplex US and Digital Subtraction Angiography¹

¹ From the Institute of Diagnostic Radiology (J.K.W., L.M.D., B.M., D.W.), Division of Cardiovascular Surgery (D.M.), and Division of Angiology (M.B.), University Hospital Zurich, Rämistrasse 100, 8091 Zurich, Switzerland; University Institute of Applied Radiophysics, Lausanne, Switzerland (F.R.V.); and Department of Biostatistics, University of Zurich, Switzerland (B.S.). Received September 6, 2002; revision requested November 7; final revision received February 24, 2003; accepted March 28. Address correspondence to D.W. (e-mail: dominik.weishaupt@dmr.usz.ch).

View larger version (31K): [in a new window]   Figure 1. Volume-rendered multi-detector row CT angiogram (nominal section thickness, 2.5 mm; pitch, 1.5) of 67-year-old man with peripheral arterial occlusive disease and peripheral arterial bypass grafts in both legs. An autologous in situ saphenous vein femoropopliteal bypass graft was implanted in the left leg 10 months before imaging. An expanded polytetrafluoroethylene distal femoropopliteal bypass graft was implanted in the right leg 4 weeks prior to imaging. Angiogram shows patency of both peripheral arterial bypass grafts (large straight arrows). Note retrograde filling of the right distal superficial femoral artery (small straight arrow) and of the left popliteal artery (large arrowhead). The inflow (upper curved arrows) and outflow arteries (lower curved arrows) of both peripheral arterial bypass grafts in both legs were displayed to good advantage. Both readers rated image quality of all bypass graft segments, including the proximal anastomosis, the course of the body, and the distal anastomosis, as excellent (grade 4). Image quality was not degraded by clip material located near the proximal and distal anastomosis and along the body of the left autologous in situ saphenous vein femoropopliteal bypass graft (small arrowheads).

View larger version (19K): [in a new window]   Figure 2. Graph demonstrates luminal enhancement at five different locations along peripheral arterial bypass graft. Each box is centered at the mean CT attenuation value, and the box width is equivalent to the 95% CI of the mean. The vertical lines extending from the top and bottom of the boxes indicate the minimum and maximum CT attenuation values obtained. The lower boundary of the 95% CI of arterial enhancement is above 200 HU at all five locations. IA = inflow artery of the bypass graft, PA = proximal anastomosis of the bypass graft, MB = middle of the body of the bypass graft, DA = distal anastomosis of the bypass graft, OA = outflow artery of the bypass graft.

View larger version (43K): [in a new window]   Figure 3a. Images of a 58-year-old man obtained 14 months after bypass graft surgery with an expanded polytetrafluoroethylene proximal femoropopliteal bypass graft. (a) Left anterior oblique maximum intensity projection reconstructed angiogram obtained with multi-detector row CT demonstrates a short hemodynamically significant stenosis affecting the proximal anastomosis of the femoropopliteal bypass graft (arrow), which was graded as hemodynamically significant (grade 3, 50%-99% luminal narrowing) by both readers. Note additional hemodynamically significant stenosis of the proximal profundal femoral artery (arrowhead). (b) Left anterior oblique intraarterial angiogram obtained with conventional DSA in the same patient depicts stenosis of the proximal anastomosis of the bypass graft (arrow) and the proximal profundal femoral artery (arrowhead).

View larger version (77K): [in a new window]   Figure 3b. Images of a 58-year-old man obtained 14 months after bypass graft surgery with an expanded polytetrafluoroethylene proximal femoropopliteal bypass graft. (a) Left anterior oblique maximum intensity projection reconstructed angiogram obtained with multi-detector row CT demonstrates a short hemodynamically significant stenosis affecting the proximal anastomosis of the femoropopliteal bypass graft (arrow), which was graded as hemodynamically significant (grade 3, 50%-99% luminal narrowing) by both readers. Note additional hemodynamically significant stenosis of the proximal profundal femoral artery (arrowhead). (b) Left anterior oblique intraarterial angiogram obtained with conventional DSA in the same patient depicts stenosis of the proximal anastomosis of the bypass graft (arrow) and the proximal profundal femoral artery (arrowhead).

View larger version (16K): [in a new window]   Figure 4a. Images of a 40-year-old man with autologous in situ saphenous vein femorocrural bypass graft to posterior tibial artery. (a) Anteroposterior volume-rendered multi-detector row CT angiogram shows high-grade stenosis (grade 3, 50%-99% luminal narrowing) of distal course of the femorocrural bypass graft (straight arrow) and high-grade stenosis of bypass graft close to the distal anastomosis (curved arrow). In addition, aneurysmal change (large arrowhead) close to the distal anastomosis of the bypass graft with preceding hemodynamically insignificant arterial stenosis (grade 2, 10%-49% luminal narrowing) (small arrowhead) is noted. (b) Corresponding frontal DSA image shows three stenoses and aneurysmal change. (c) Longitudinal duplex US image shows aneurysmal change (arrowhead) and hemodynamically significant stenosis (arrow) close to distal anastomosis of peripheral arterial bypass graft. At duplex US, high-grade stenosis of distal course of the femorocrural bypass graft and hemodynamically insignificant stenosis were also identified (not shown).

View larger version (33K): [in a new window]   Figure 4b. Images of a 40-year-old man with autologous in situ saphenous vein femorocrural bypass graft to posterior tibial artery. (a) Anteroposterior volume-rendered multi-detector row CT angiogram shows high-grade stenosis (grade 3, 50%-99% luminal narrowing) of distal course of the femorocrural bypass graft (straight arrow) and high-grade stenosis of bypass graft close to the distal anastomosis (curved arrow). In addition, aneurysmal change (large arrowhead) close to the distal anastomosis of the bypass graft with preceding hemodynamically insignificant arterial stenosis (grade 2, 10%-49% luminal narrowing) (small arrowhead) is noted. (b) Corresponding frontal DSA image shows three stenoses and aneurysmal change. (c) Longitudinal duplex US image shows aneurysmal change (arrowhead) and hemodynamically significant stenosis (arrow) close to distal anastomosis of peripheral arterial bypass graft. At duplex US, high-grade stenosis of distal course of the femorocrural bypass graft and hemodynamically insignificant stenosis were also identified (not shown).

View larger version (93K): [in a new window]   Figure 4c. Images of a 40-year-old man with autologous in situ saphenous vein femorocrural bypass graft to posterior tibial artery. (a) Anteroposterior volume-rendered multi-detector row CT angiogram shows high-grade stenosis (grade 3, 50%-99% luminal narrowing) of distal course of the femorocrural bypass graft (straight arrow) and high-grade stenosis of bypass graft close to the distal anastomosis (curved arrow). In addition, aneurysmal change (large arrowhead) close to the distal anastomosis of the bypass graft with preceding hemodynamically insignificant arterial stenosis (grade 2, 10%-49% luminal narrowing) (small arrowhead) is noted. (b) Corresponding frontal DSA image shows three stenoses and aneurysmal change. (c) Longitudinal duplex US image shows aneurysmal change (arrowhead) and hemodynamically significant stenosis (arrow) close to distal anastomosis of peripheral arterial bypass graft. At duplex US, high-grade stenosis of distal course of the femorocrural bypass graft and hemodynamically insignificant stenosis were also identified (not shown).

View larger version (63K): [in a new window]   Figure 5a. Images of a 69-year-old woman with an arteriovenous fistula who underwent placement of an autologus in situ saphenous vein femoropopliteal bypass graft 1 week prior to imaging. (a) Detailed frontal volume-rendered angiogram obtained with multi-detector row CT demonstrates arteriovenous fistula (arrow) originating from the in situ saphenous vein bypass graft with early enhancement of the superficial and deep venous system. A portion of the arteriovenous fistula was partially clipped (arrowheads) during surgery. (b) Corresponding frontal angiogram of the same patient obtained with conventional DSA demonstrates arteriovenous fistula (arrow) with enhancement of the superficial and deep venous system. Note clip material (arrowheads).

View larger version (92K): [in a new window]   Figure 5b. Images of a 69-year-old woman with an arteriovenous fistula who underwent placement of an autologus in situ saphenous vein femoropopliteal bypass graft 1 week prior to imaging. (a) Detailed frontal volume-rendered angiogram obtained with multi-detector row CT demonstrates arteriovenous fistula (arrow) originating from the in situ saphenous vein bypass graft with early enhancement of the superficial and deep venous system. A portion of the arteriovenous fistula was partially clipped (arrowheads) during surgery. (b) Corresponding frontal angiogram of the same patient obtained with conventional DSA demonstrates arteriovenous fistula (arrow) with enhancement of the superficial and deep venous system. Note clip material (arrowheads).