Artlabeling Activity Major Arteries of the Lower Limb 1 of 3
Cardiovasc Diagn Ther. 2019 Aug; nine(Suppl one): S174–S182.
Lower extremity arteries
Received 2019 May 27; Accepted 2019 Jul 22.
Abstruse
Lower extremity arteries play vital part of supplying blood to the extremity bone, muscles, tendons and nerves to maintain the mobility of the body. These arteries may become involved with a number of disease processes which restrict the optimal performance of the limb. The knowledge of various diseases, clinical presentation, appearance on various imaging modalities and segments of involvement helps one to clinch the diagnosis. It is of paramount importance for imaging clinician to apply the correct imaging tool based on the clinical question which is facilitated by know how of the advantages and limitation of each of these imaging modalities. This article focuses on lower extremity arteries, its anatomy, diverse imaging modalities and mutual disease conditions affecting the lower limb arteries.
Keywords: Lower extremity arteries, ultrasound, doppler, computerized tomography, magnetic resonance imaging, digital subtraction angiography
Introduction
Lower extremities are an integral part of human body with prime function to provide mobility. Arterial system supplies blood to muscles and bones of lower limbs. Knowledge nearly beefcake and various imaging modalities available is of import in identifying various illness weather and its direction. Ultrasound and doppler is quick, noninvasive with no known adverse effects. Ultrasound is operator, equipment dependent and has a learning bend for its utilize and interpretation. CT angiogram is rapid, provide quick overview of the extremity arteries and is widely used especially in emergency situations like astute limb ischemia. Drawback of CT is use of iodinated contrast media and potential take a chance of Contrast induced nephropathy. MRI can provide vital information without utilise of contrast media. It can also evaluate vessel wall and dynamic disease processes. MRI written report is express past its availability and prolonged scanning time. Catheter angiography is golden standard for evaluation of peripheral arterial diseases and has therapeutic role; however, it is invasive and requires trained operator for its safe operation.
Anatomy of lower limb arteries
The lower extremity arteries start from common iliac avenue origins from trifurcation of abdominal aorta into common iliacs and median sacral avenue ( Effigy 1 ), towards anterior and left of the 4th lumbar vertebral body (ane). The common iliac arteries bifurcates into Internal and external iliac arteries. The external iliac artery continues into the lower limbs as mutual femoral artery. The artery in a higher place inguinal ligament is known as external iliac avenue and below is common femoral artery. The common femoral artery gives small-scale branches namely superficial epigastric artery, external pudendal avenue and the superficial circumflex avenue prior to its bifurcation (ii). The common femoral avenue bifurcates into superficial and deep femoral artery also known as profunda femoris artery. The profunda femoris gives ascent to medial and lateral circumflex femoral arteries and perforating branches to the thigh muscle (2). The superficial femoral artery continues along the medial side of the thigh through the adductor culvert also known as hunter's canal. The superficial femoral artery exits the adductor canal, courses posterior to the lower end of femur where it is known as popliteal artery afterward it exists the adductor hiatus in the region of popliteal fossa (two). The superficial femoral artery gives off the descending genicular branch prior to existing the adductor hiatus which gives supply to the knee and can also anastomose with other popliteal avenue branches (i). Popliteal artery provides rich collaterals to the articulatio genus articulation in the form of superior and inferior geniculate arteries on either side of the articulation autonomously from middle genicular branch and muscular branches ( Effigy 2 ). For interventional purposes the popliteal artery is divided into iii segments every bit follows: P1 segment, from intercondylar fossa to proximal edge of patella. P2 segment, from proximal role of patella to center of knee articulation. P3 segment (below knee popliteal avenue), from eye of articulatio genus space to origin of anterior tibial artery (3).
Digital subtraction angiogram at aortic bifurcation. (A) Digital Subtraction angiogram at the level of aortic bifurcation (black arrow) showing the partitioning of aorta into right and left common iliac arteries; (B) same DSA with magnification demonstrating the median sacral avenue (blue pointer).
Digital subtraction angiogram of a 64 years onetime patient with astringent calf claudication. Angiogram shows rich collateral network around the genu reforming the P2 segment of the popliteal avenue (black arrow).
Popliteal avenue bifurcates into anterior tibial artery and tibioperoneal torso approximately at the level of proximal tibiofibular joint ( Figure 3 ). The inductive tibial avenue courses along the lateral compartment of leg after piercing the interosseus membrane close to tibia and runs along anterior surface of interosseus membrane (two). The anterior tibial avenue continues in foot as dorsalis pedis artery. At the level of malleoli the avenue lies lateral to tendon of extensor hallucis longus which serves as anatomical landmark for clinical pulse palpation. Tibioperoneal trunk further divides into peroneal artery and posterior tibial artery which runs along posteromedial aspect of leg. The posterior tibial artery forms the medial and lateral plantar arches. The plantar arch gives rise to metatarsal and the plantar digital arteries. There are branches which communicate betwixt the arches to the dorsalis pedis artery which hypertrophy in diseased states and assistance in maintaining blood supply to toes. Peroneal avenue terminates into medial and lateral calcaneal branches to a higher place the talocrural joint joint. These branches freely communicate with dorsalis pedis avenue and posterior tibial artery and assist in collateralizing the foot in case of diseased weather (ii).
Angiogram demonstrating the anatomy of popliteal and tibial arteries. (A) Digital subtraction angiogram of left leg showing a normal popliteal artery (black arrow) and its sectionalization into anterior tibial (white arrows) and tibioperoneal trunk (blue pointer). The tibioperoneal torso farther divides into peroneal avenue (green arrows) and posterior tibial artery (yellowish arrows); (B) CT angiogram volume rendered technique posterior view demonstrating the popliteal artery and its sectionalization. Note the site of inductive tibial artery piercing the interosseous membrane to motility anteriorly (gray pointer); (C) DSA of beneath genu tibial vessels.
Ultrasound
Ultrasound is readily available, inexpensive, rapid, noninvasive and accurate (4). Ultrasound is operator dependent and test may be express past arterial wall calcifications. For stenosis greater than 50% diameter reducing past angiography, duplex scanning had a sensitivity of 82%, a specificity of 92%, a positive predictive value of 80%, and a negative predictive value of 93% (v). For accurate assessment of velocity by duplex the sample volume cursor should be on the vessel studied and should include at least half to i third of the artery studied (vi). The class of stenosis is quantified based on direct B mode appearance of the lesion, indirect data such as superlative systolic velocity, cease diastolic velocity and the wave blueprint of the spectral waveform. Monophasic waveform is a sign of significant lesion proximally which is characterized by the entire spectrum being on one side of the baseline, wearisome dispatch towards peak systolic velocity, depression aamplitude and continuous diastolic menstruum-parvus tardus moving ridge pattern (7).
CT angiography (CTA)
CTA has high spatial resolution, rapid, noninvasive, depicts the verbal anatomical location of lesions, length and extend of the lesions, probable diagnosis and etiology. Ionizing radiation is a concern in younger individuals and children and its utilise in pregnant females is restricted specially during starting time trimester. CTA is widely used for treatment planning, guides selection of hardware and access site. CTA demonstrates sensitivity of 87% and specificity of 93% in comparison to DSA in diagnosing occlusive peripheral arterial illness and a sensitivity of 92%, specificity of 91% and accurateness of 91% for detection of steno occlusive peripheral arterial disease (8).
CTA covers from level of diaphragm to toes in two phases. First phase helps in identification of proximal extent of apoplexy or stenotic affliction. Second phase helps in identification of reformation and distal runoff. Limitation from calcifications can be eliminated past using dual energy scans or plain mask images can be used to decrease from contrast images. The extent and severity of disease is characterized based on percentage reduction in the area of the lumen, number of lesions and also based on length of the diseased segment. Course I is characterized every bit no or mild stenosis (less than or equal to 49% stenosis), grade 2-moderate stenosis (50% to 69% stenosis), grade iii-severe stenosis (70% to 99% stenosis) and grade 4-occlusion (100% luminal obliteration). Grade 3 and four are considered to be clinically significant (nine). Based on length and degree of stenosis the lesions are classified into the diverse TASC II categories which are used every bit guide for revascularization (x).
MR angiography (MRA)
MRA is safety, noninvasive investigation with high tissue resolution. It is safe in patients with balmy renal dysfunction, pregnant patients and children. MRA can likewise be performed without contrast using time of flight (TOF) angiography, Quiescent-Interval single-shot unenhanced MRA (QISS) (11) and T1 weighted dark blood MRA (12). Contrast MRA provides adequate information on distal reformation and runoff which is comparable to CTA. TOF has sensitivity of 43–67% and specificity of 74–89% for detection of significant (75%) stenosis (xiii). Contrast MRI has sensitivity of 96.6–97% and specificity of 95.ii–96.1% (14).
Digital subtraction angiography
Digital subtraction angiography is invasive, highly authentic imaging technique with therapeutic implications. It involves use of iodinated contrast media all the same techniques like carbon dioxide angiography helps in limiting the use of iodinated contrast media. Carbon dioxide angiography is also preferred in patients with limited cardiac reserve equally it does not increase intravascular volume since it gets rapidly dissolved in blood and excreted through lungs.
Specific diseases of extremity arteries
Atherosclerotic illness
Atherosclerotic diseases involve elderly individuals with risk factors like chronic Diabetes Mellitus and Hypertension. The disease is typically characterized past eccentric plaques ( Effigy iv ) which may or may not take calcifications with reduction in compliance of vascular arrangement resulting in biphasic wave pattern on doppler imaging. Clinically it manifests as gradually worsening claudication pain in the limbs, residue pain or every bit nonhealing ulcer in the limb with or without major tissue loss (10).
Atherosclerotic affliction on imaging. (A) CT plain Sagittal reformat of hip and thigh region of a 65 years old lady with poorly controlled diabetic and chronic renal failure patient showing severe vessel wall calcifications in common femoral, superficial femoral and profunda femoris avenue (white arrows); (B) DSA of some other 71 years old patient with diabetes and hypertension showing diffuse atherosclerotic changes in the form of multiple eccentric plaques (black arrows); (C) below knee angiogram of same patient equally (B) showing single vessel runoff in the form of anterior tibial artery, peroneal artery is occluded merely beyond its origin and posterior tibial avenue shows lengthened disease.
At that place are a number of collateral pathways in limb arteries. In iliac avenue occlusions the lumbar arteries get recruited which further communicate with deep circumflex iliac artery and reform external iliac artery. In case of aortic and iliac interest at that place is recruitment of intercostal collaterals through which the superior intercostal, internal mammary arteries and lumbar vessels anastomose via junior epigastric and deep circumflex iliac arteries to reform the external iliac artery (15). There are rich collaterals inside pelvis betwixt branches of internal iliac arteries which gets recruited in case of common iliac artery or internal iliac artery proximal occlusions. These branches collateralize via obturator arteries, internal pudendal arteries, superior and heart rectal arteries (16). In case of mutual femoral avenue apoplexy there are collaterals from internal iliac branches namely obturator artery, internal pudendal avenue, inferior and superior gluteal arteries which anastomose with medial and lateral collateral branches of profunda femoris which reforms profunda femoris and superficial femoral arteries (17). In cases of superficial femoral artery occlusions there are collateral pathways from profunda femoris artery which reforms distal part of superficial femoral artery or popliteal artery through descending geniculate artery or via genicular branches of popliteal artery.
Popliteal artery aneurysms ( Figure 5 ) are either true or false (pseudoaneurysm). True aneurysms have all 3 layers in their wall which are abnormally dilated and pseudoaneurysm have deficiency in at least one of the layers. Popliteal avenue size of more than than 7 mm is classified every bit aneurysm (18). The popliteal avenue aneurysms are establish to have loftier clan with intestinal aortic aneurysms. Tuveson et al. reported popliteal artery aneurysm prevalence of 19.1% in patients of intestinal aortic aneurysms on radiological examination (19). They used size definition of more than 12 mm size to classify as popliteal aneurysm. Aneurysms clinically manifest with either rupture when they present with painful acute swelling in region of popliteal fossa or with distal thromboembolic miracle with astute limb ischemia or minor gangrenous or pre-gangrenous changes in toes.
CT angiogram of 65 years old patient who presented with acute pain in right leg. (A) Popliteal artery aneurysm (black arrow) as seen on axial CT image and (B) in sagittal CT MIP paradigm. Note the apoplexy of the artery only beyond the popliteal aneurysm.
Popliteal avenue entrapment syndrome ( Figure 6 ), at that place is abnormal compression of popliteal artery due to aberrant course of popliteal artery, abnormal insertion of Medial head of gastrocnemius, or accessory slip or due to compression from popliteus muscle (eighteen). Information technology causes repeated trauma to artery and tin can result in thrombosis or distal thromboembolic phenomenon from microthrombi generated.
Thirty-4 years old female with correct lower extremity claudication. (A) MRA coronal in dorsiflexion position showing severe compression of popliteal artery from gastrocnemius musculus; (B) axial fs spgr showing beefy gastrocnemius muscle (white pointer).
Cystic adventitial disease of popliteal avenue ( Figure 7 ) is described as formation of mucoid cysts in adventitia of avenue causing luminal compression. Ultrasound typically shows anechoic or hypoechoic cystic structures in close relation to popliteal artery. MRI is considered to exist extremely useful in suspected cases every bit the cysts appear hyperintense on T2 and variable intensity on T1 due to diverse caste of proteinaceous content within the cysts which are located in arterial wall and produce luminal narrowing on MR angiography (18).
Fifty-nine years old male with claudication, Cystic adventitial affliction of popliteal artery (A) CT VRT showing occlusion of the right popliteal avenue (white arrow), absence of atherosclerotic affliction in residuum of the vasculature; (B) coronal MIP of the CT angiogram showing well defined cystic lesion causing extrinsic severe compression (yellow arrow); (C) sagittal MIP of CT angiogram showing non enhancing cystic lesion causing extrinsic pinch (yellow arrow).
Arteriovenous malformations
Arteriovenous malformations are built disorder characterized by abnormal connectedness between the arteries and veins known every bit nidus with absenteeism of intervening capillary bed. Arteriovenous fistula is characterized by direct advice betwixt the artery and vein. Arteriovenous fistulas are either congenital or caused due to trauma, penetrating injuries or iatrogenic. They are seen in young or middle age individuals and present with symptoms of pain, swelling or torrential haemorrhage. Long continuing arteriovenous malformations or fistulas may present with hypertrophy of the limb ( Effigy 8 ) and may be associated with cardiac failure. Ultrasound shows dilated lower limb veins and bunch of serpiginous vascular structures with arterial moving ridge pattern. The feeding arteries show depression resistance monophasic wave pattern of loftier velocity which differentiates information technology from pattern of parvus tardus which is typically low velocity catamenia. CT or MR angiogram confirms the diagnosis and demonstrates feeding arteries and outflow veins. DSA delineates the site of fistula or nidus, forth with information on the arterial feeders and venous outflow. DSA demonstrates early filling of the venous system which is diagnostic of an arterial venous malformation.
CT angiogram book rendered technique of a 31 years old male with lengthened angiomatosis of left lower limb with multiple arteriovenous malformations in the limb. (A) Dilated left lower limb arteries and veins (white arrow), note the filling of the left lower limb veins whereas the right lower limb veins are not opacified all the same. The size of the left lower limb arteries is grossly enlarged compared to normal sized contralateral vessels. Multiple sites of arteriovenous malformation and arteriovenous shuntings (yellowish arrow) (B) note the big venous sac in the draining vein (blueish arrow); (C) grossly hypertrophied left lower limb compared to the normal right lower limb.
Vasculitis
A number of vasculitis conditions including substance abuse affect lower limb arteries (20). These weather typically announced as arterial wall thickening in acute stage associated with thrombosis of vessels ( Figure nine ) which later on lead to stenotic lesions, dissections and aneurysm germination. Doppler is an early, rapid effective tool for diagnosis of vasculitis and CT, MRI (vessel wall imaging) or PET CT helps in identification of affliction action based on contrast enhancement or radiotracer uptake respectively (21).
Imaging (CT) in vasculitis. (A) CT axial venous phase shows occlusion of infrarenal aorta with wall thickening and enhancement of the wall (blackness arrow); (B) CT angiogram VRT showing the infrarenal aortic occlusion (white arrows) with distal reformation of bilateral external iliac artery (blue arrows).
Buerger disease
Thromboangitis obliterans is a segmental occlusive inflammatory disease of small and medium sized arteries and veins of the extremities affecting young adults below the age of 45, history of tobacco corruption is a consistent finding. Superficial thrombophlebitis and Reynaud'due south phenomenon occur in approximately twoscore% of patients (22). Radiologically information technology involves below knee vessels, proximal vessels are essentially normal and there is no calcification of involved vessels. Angiographically there are corkscrew collaterals ( Figure 10 ) along occluded vessels (23).
Thromboangitis obliterans. (A) Digital Subtraction angiogram of a 27 years onetime patient, smoker with right great toe ulcer and remainder hurting. Occlusion of the inductive tibial artery with cork screw collaterals (blackness arrow); (B) occlusion of posterior tibial artery with cork screw collaterals (white arrow).
Conclusions
Cognition of bones anatomy of lower extremity arteries and various imaging methods available for its evaluation helps one to select advisable imaging modality to answer specific clinical questions and reach a confident diagnosis.
Acknowledgments
The authors would like to thank Dr. Sandeep S Hedgire, MD for his contribution towards this article in the form of Images for subsection on cystic adventitial affliction of popliteal artery and popliteal entrapment syndrome.
Notes
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of whatsoever role of the work are appropriately investigated and resolved.
Footnotes
Conflicts of Interest: The authors have no conflicts of interest to declare.
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