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As discussed, the main indication for pedal MRA is work-up of ischemic pedal disease, typically in diabetic patients, and typically to determine whether limb salvage is possible. In general, some other im aging of the aorto-iliac and outflow vessels (either DSA or moving table CE-MRA) will have already been performed, and information regarding the pedal vasculature is sub-optimal, incomplete, or angiographically occult vessels are being sought in attempt to avoid amputation.

Figure 5c, d demonstrates the case of a 68 year old male with diabetes and a right Charcot foot. There was no tissue loss, and he underwent the pedal MRA as part of an evaluation for a pedal fluid collection eventually determined to be a hematoma. The MRA demonstrates normal appearing distal peroneal as well as anterior and posterior tibial arteries, a relatively intact lateral plantar (some mild disease), and an occluded dorsalis pedis artery. There are good collaterals, and portions of the primary as well some probable secondary arches are seen.

Figure 6 demonstrates a right pedal MRA for a 58 year old male with diabetes, vascular disease, and a history of a prior left below-knee and right trans-metatarsal amputations. He presented with ulcerations and osteomyelitis at the metatarsal amputation site. Pedal MRA demonstrates relatively good outflow in the peroneal, anterior and posterior tibial, and dorsalis pedis arteries. Although the medial and lateral plantar arteries are

Dorsalis Pedis Stenosis

Fig. 6. Right foot sagittal (a) and coronal (b) MIP's from a 58 year old male diabetic status post trans-metatarsal amputations with amputation site ulcers and osteomyelitis. The pedal inflow is relatively normal (peroneal, anterior and posterior tibial arteries). The dorsalis pedis is somewhat attenuated distally, and there is a severely diseased primary plantar arch (short arrow). The lateral plantar terminates proximally into a region of ulcer blush (long arrows)

Fig. 6. Right foot sagittal (a) and coronal (b) MIP's from a 58 year old male diabetic status post trans-metatarsal amputations with amputation site ulcers and osteomyelitis. The pedal inflow is relatively normal (peroneal, anterior and posterior tibial arteries). The dorsalis pedis is somewhat attenuated distally, and there is a severely diseased primary plantar arch (short arrow). The lateral plantar terminates proximally into a region of ulcer blush (long arrows)

Posterior Tibial Artery Mra

Fig. 7. Right foot sagittal MIP from a CE-MRA (a) and a sagittal frame from a DSA (b) in a non-diabetic 82 year old male with right 5th toe necrosis. Both modalities demonstrate the pedal arterial anatomy well, but the pedal arch is better visualized with MRA (longarrows) - an example of the "angiographically occult" vessel. Stenoses in the distal posterior tibial artery (short arrows in (a) and (b)) are visualized with both techniques, but an oblique subvolume MIP (c) shows this stenosis (longarrow) and a stenosis of the proximal medial tarsal artery (short arrow) to better advantage as compared to the single view planar DSA (d). This study was performed in arterial phase using the gadolinium blood pool agent MS-325 (EPIX Medical, Cambridge, MA)

Fig. 7. Right foot sagittal MIP from a CE-MRA (a) and a sagittal frame from a DSA (b) in a non-diabetic 82 year old male with right 5th toe necrosis. Both modalities demonstrate the pedal arterial anatomy well, but the pedal arch is better visualized with MRA (longarrows) - an example of the "angiographically occult" vessel. Stenoses in the distal posterior tibial artery (short arrows in (a) and (b)) are visualized with both techniques, but an oblique subvolume MIP (c) shows this stenosis (longarrow) and a stenosis of the proximal medial tarsal artery (short arrow) to better advantage as compared to the single view planar DSA (d). This study was performed in arterial phase using the gadolinium blood pool agent MS-325 (EPIX Medical, Cambridge, MA)

occluded, significant ulcer blush is seen in the arch region, and this was not felt to be an outflow problem that could be remedied with a graft. The patient received a below-knee amputation.

A non-diabetic 82 year old male with right fifth toe necrosis is demonstrated in Figures 7a and 7b, showing a sagittal CE-MRA MIP and DSA, respectively. Note both modalities demonstrate the pedal arterial anatomy well, but the pedal arch is better visualized with MRA - an example of the "angio-

graphically occult" vessel. Also seen with both modalities is a stenosis of the distal posterior tibial artery. Figure 7c, however, demonstrates a significant advantage of 3D MRA - subvolume MIP's allow for viewing different projections, better defining the distal posterior tibial and proximal medial plantar artery stenoses as compared to DSA (7d). This patient had significant proximal disease (not shown - an occluded right superficial femoral artery), and underwent a right fem-pop bypass and amputation of the fifth toe.

Fem Pop Bypass

Fig. 8. Coronal (a) and sagittal (b) left foot CE-MRA MIP's from a 77 year old diabetic male with non-healing foot ulcers. The dorsalis pedis artery is occluded, with a short distal segment reconstituting (arrow), but no patent pedal arch. Diffuse multivessel disease is seen, particularly involving the posterior tibial artery, which is better seen on the coronal (c) and sagittal (d) zoomed subvolume MIP's

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Femoral Dorsalis Pedis Bypass

Fig. 8. Coronal (a) and sagittal (b) left foot CE-MRA MIP's from a 77 year old diabetic male with non-healing foot ulcers. The dorsalis pedis artery is occluded, with a short distal segment reconstituting (arrow), but no patent pedal arch. Diffuse multivessel disease is seen, particularly involving the posterior tibial artery, which is better seen on the coronal (c) and sagittal (d) zoomed subvolume MIP's b

Figure 8 shows a coronal (a) and sagittal (b) left foot CE-MRA MIP from a 77 year old diabetic male with non-healing foot ulcers. Note the dorsalis pedis is occluded, with some focal distal reconstitution but no patent pedal arch, and there is diffuse multivessel disease, particularly involving the posterior tibial artery (better seen on the zoomed views (c) and (d)). Because of the diffuse disease and lack of a good target vessel, the patient was treated medically.

Fig. 9. Sagittal MIP from a right foot CE-MRA in an 85 year old male with multiple foot ulcers. The anterior tibial and dorsalis pedis arteries are occluded. The distal posterior tibial artery has a short segmental occlusion circumvented by well-formed collaterals (arrows) reconstituting just proximal to the bifurcation into the plantar arteries

Fig. 9. Sagittal MIP from a right foot CE-MRA in an 85 year old male with multiple foot ulcers. The anterior tibial and dorsalis pedis arteries are occluded. The distal posterior tibial artery has a short segmental occlusion circumvented by well-formed collaterals (arrows) reconstituting just proximal to the bifurcation into the plantar arteries

Figure 9 demonstrates another patient with foot ulcers. This study shows occlusion of the anterior tibial and dorsalis pedis arteries, with an occlusion of the distal posterior tibial artery circumvented by well-formed collaterals reconstituting the posterior tibial just proximal to the bifurcation into the plantar arteries. As there were no major functional obstructions suitable for bypass, and the circulation was deemed adequate for healing, the patient was treated medically.

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Diabetes 2

Diabetes 2

Diabetes is a disease that affects the way your body uses food. Normally, your body converts sugars, starches and other foods into a form of sugar called glucose. Your body uses glucose for fuel. The cells receive the glucose through the bloodstream. They then use insulin a hormone made by the pancreas to absorb the glucose, convert it into energy, and either use it or store it for later use. Learn more...

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