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50
History
Segmental BP
Impr
ARTIFACTUALLY HIGH PRESSURES
ex
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Fig. 4.1 Sample report of
segmental pressures with
ABIs and toe pressures. Only
the left dorsal pedis is
compressible, and the ABI is
calculated based on this
pressure. The three other
tibial vessels are
noncompressible due to
calcication, consistent with
the tibial disease seen in
patients with diabetes. This
patient was found to have a
toe pressure of 0 on the right
and 60mmHg on the left
N. J. Swerdlow and A. D. Hamdan
RIGHT 3RD TOE NECROSIS
Right Left
Brachial:
Ankle (PT):
Ankle (DP):
Digit:
essions
SIGNIFICANT RIGHT MULTI LEVEL DISEASE AND LEFT TIBIAL DISEASE
138
Index
>254 -NC-
>254 -NC-
0 0.00
Brachial:
Ankle (PT):
Ankle (DP):
Digit:
139
Ind
>254 -NC-
74 0.53
60 0.43
30 mmHg correlates with poor diabetic foot ulcer healing
[19]. Other thresholds, specically 40 and 55mmHg, have
also been proposed to dene inadequate perfusion for healing diabetic foot ulcers [18, 20]. Beyond an absolute cutoff,
the toe pressure can be used to dene the ischemia score in a
patient’s WIfI score [14].
Doppler Waveform Analysis
A normal peripheral artery is dened by its triphasic waveform on Doppler waveform analysis—a brisk upstroke of
forward ow during systole, reversal of ow in early diastole, and nally a component of forward ow in late diastole.
With upstream stenosis or occlusion, the waveform initially
loses its reversal of ow, leading to a biphasic waveform, and
as the upstream disease becomes more severe, it ultimately
widens and dampens to a monophasic waveform [21]. During
a Doppler waveform exam, the waveform is depicted visually at various arterial levels from the common femoral
artery to the ankle or toe (Fig.4.2). Doppler waveforms are
not affected by medial calcication, and thus they can be
used to demonstrate normal perfusion at the level of the
ankle even with noncompressible tibial vessels. Changes in
the nature of the waveform can also aid in the determination
of the level of hemodynamically signicant occlusive disease, including the ability to exclude severe aortoiliac occlusive disease in patients with triphasic common femoral artery
waveforms.
Pulse Volume Recordings (PVRs)
Plethysmography measures changes in volume in a limb
caused by arterial ow. Pulse volume recordings (PVRs) use
plethysmography to create a visual representation of the
changes in limb volume that occur at various levels of the
limb with each heartbeat (Fig.4.3). To obtain a PVR, a pneumatic cuff is placed at various levels of the lower extremity
(most commonly high thigh, low thigh, calf, ankle, and
metatarsal) and inated to ~60mmHg. An oscillating waveform is produced as changes in volume at each level are
detected with each beat [22]. A normal PVR has a brisk
upstroke and rapid downslope. With upstream arterial disease, the slope of the up- and downstroke decreases, as well
as the overall amplitude. While attempts have been made to
quantify PVR, it largely remains a qualitative exam, particularly useful for interlimb comparisons within the same
patient. However, it has been shown that PVRs in conjunction with ABIs add to the accuracy of PAD diagnosis in comparison to ABI alone [23].
Transcutaneous Oxygen Tension (TcPO2)
Transcutaneous oxygen tension (TcPO2) measurements
assess the metabolic state of the underlying tissue by estimating the partial pressure of oxygen. The test is performed
by placing an electrode on the dorsal aspect of the proximal
foot and heating the tissue to 42–45°C.After allowing equilibration, the local oxygen tension is recorded in mmHg [11,
24]. Typically, a value less than 20mmHg is associated with
severe ischemia and poor wound healing, while values
greater than 60mmHg are normal. However, varying different cutoffs have been proposed, and the optimal cutoff to
predict adequate tissue perfusion for healing remains unclear.
Additionally, many factors besides arterial circulation can
affect the results, including age, edema, and infection [25,
26]. Nevertheless, TcPO2 measurement is an important
adjunct in the diagnosis of PAD in patients with diabetes and
can be used to determine the grade of ischemia when calculating the WIfI score [14].
Arterial Duplex Ultrasound
The above noninvasive modalities for the assessment of PAD
in patients with diabetes all focus on the assessment of the
4 Clinical Features andDiagnosis ofPeripheral Arterial Disease
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51
Fig. 4.2 Sample report of lower extremity Doppler waveform analysis.
This patient has normal, triphasic waveforms in the bilateral common
femoral and mid-supercial femoral arteries. On the left, the patient has
a triphasic popliteal waveform and monophasic posterior tibial and dor-
adequacy of tissue perfusion. An arterial duplex ultrasound,
on the other hand, begins to give information on the patient’s
arterial anatomy and the specic lesions contributing to the
patient’s PAD.Duplex scanning is traditionally comprised of
dual modalities, B-mode imaging, and pulsed wave Doppler
spectral frequency analysis. In actuality, most modern duplex
scans are “triplex,” also including color-ow imaging.
B-mode allows for the measurement of vessel diameter as
salis pedis waveforms consistent with tibial disease. On the right, the
popliteal waveform is also monophasic, suggesting concurrent distal
supercial femoral and/or popliteal disease
well as identifying characteristics of atherosclerotic disease,
such as intima-media thickening and plaque composition.
Doppler spectral analysis quanties the velocity of ow in a
specic segment of the vessel. Based on well-dened criteria,
the peak systolic velocity correlates to the degree of stenosis.
Finally, color ow imaging can be used to conrm the direction of ow and identify areas of turbulence or elevated or
reduced velocities within a segment of a specic artery [27].
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N. J. Swerdlow and A. D. Hamdan
Fig. 4.3 Sample pulse volume recording report. The thigh waveforms
are normal with a sharp upstroke and diachronic notch. Distally, waveforms become more blunted, suggesting an upstream arterial disease.
While used as a primary screening and operative planning
modality in carotid disease, the role of arterial duplex in the
screening and initial assessment of PAD is more limited. In
patients with diabetes specically, the results of duplex ultrasound may be limited by heavy arterial calcication. The
results are also operator dependent and time-consuming, further limiting their utility in the initial evaluation of
PAD.However, duplex ultrasound is an excellent modality to
follow the characteristics and severity of a specic lesion and
The right metatarsal and digital waveforms are essentially at, a suggestion of severe ischemia
also makes up the mainstay of surveillance following both
open and endovascular lower extremity revascularization
[27, 28].
Computed Tomographic Angiography
Computed tomographic angiography (CTA) provides
high- quality axial imaging, specically timed and proto-
4 Clinical Features andDiagnosis ofPeripheral Arterial Disease
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abc
53
Fig. 4.4 Coronal reconstructions of a CTA aortoiliac with runoff. (a)
The peripheral arterial system from the abdominal aorta through the
proximal tibial vessels. Calcic atherosclerotic disease can be seen at
multiple levels bilaterally. (b and c) Representative images of the right
coled for the assessment of arterial anatomy. When used
to evaluate lower extremity PAD, the scan includes the
full extent of the lower extremity circulation from the
infrarenal aorta to the toes (Fig.4.4). Overall, CTA is an
excellent tool to evaluate the overall burden of PAD and
and left tibial vasculature. The extent of stenosis in calcic atherosclerotic tibial lesions can be difcult to evaluate due to the small caliber of
the tibial arteries
the location and anatomic features of specic atherosclerotic lesions. It is particularly useful for the assessment of
suprainguinal disease and disease in the common femoral
artery and proximal supercial femoral artery. However,
the assessment of luminal patency is limited by calcica-
54
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N. J. Swerdlow and A. D. Hamdan
tion, especially in smaller vessels. Therefore, the assessment of infrapopliteal vessels in patients with diabetes
can be severely limited. Additionally, the quality of imaging is dependent on the timing of contrast injection and
contrast ow, and thus severe proximal disease or slow
forward ow due to heart disease can lead to poor opacication of the distal vessels and thus studies that are difcult to interpret.
In addition to these limitations, unlike the above noninvasive modalities, which are essentially risk-free, CTA
does carry some risks due to the need for contrast injection
and thus the risk of contrast-induced nephropathy (CIN).
The awareness of and concern regarding CIN increased in
the 1980s concurrent with increases in the use of both diagnostic tests and interventional procedures using intravenous contrast administration. It was quickly identied that
patients with both chronic kidney disease and diabetes are
at elevated risk for CIN [29]. However, more recent studies
have suggested that earlier assessments of the risk of CIN
may have been overestimated. The risk of CIN in patients
with normal renal function, with or without diabetes, is
now believed to be negligible. However, patients with an
estimated glomerular ltration rate of less than 30 mL/
min/1.73m2 or less than 45mL/min/1.73m2 with diabetes
do remain at an elevated risk of CIN [30]. Additionally,
there is also a risk of contrast allergy and radiation exposure in patients undergoing repeated CT scans. Therefore,
CTA should be used with caution in diabetic patients with
coexisting renal dysfunction and should be avoided in
patients with renal dysfunction and without concern for
signicant suprainguinal disease.
Invasive Diagnostic Testing
Despite advances in the noninvasive assessment of PAD,
angiography, and specically digital subtraction angiography (DSA), remains the gold standard for the anatomic
assessment of PAD (Fig. 4.5). While it provides excellent
images for the entire lower extremity vasculature, it provides
particularly high-quality images of the tibial and pedal vessels, especially compared to noninvasive modalities such as
duplex ultrasound and CTA. DSA images are also not compromised by arterial calcication, even in small caliber vessels, and thus it is of particular benet in the pattern of
infrapopliteal disease seen frequently in patients with diabetes. DSA does require the use of contrast and thus carries a
risk of CIN when iodinated contrast is used. However, in
patients at increased risk for CIN, carbon dioxide can be
used as an alternate contrast agent. It is safe, provides excellent quality imaging—especially of larger caliber vessels—
and eliminates the risk of CIN [31, 32]. While its utility in
the assessment of the infrapopliteal vascular can be limited,
carbon dioxide angiography can be supplemented with dilute
iodinated contrast for the most distal images, resulting in a
complete, high-quality lower extremity angiogram completed with minimal iodinated contrast use.
Overall, DSA is the gold standard for the anatomic assessment of PAD, especially in patterns of disease typical for
patients with diabetes, and is critical for revascularization
planning. It also allows for endovascular treatment in the
same setting if deemed appropriate. DSA and both endovascular and open lower extremity revascularization are discussed in detail in Chap. 24.
4 Clinical Features andDiagnosis ofPeripheral Arterial Disease
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55
a
bcd
Fig. 4.5 Digital subtraction angiography (DSA) images of a left lower
extremity angiogram demonstrating (a) the common femoral artery,
profunda femoris artery, and proximal supercial femoral artery; (b)
the distal supercial femoral artery and above-knee popliteal artery; (c)
the proximal tibial vessels; and (d) the distal tibial vessels and pedal
vessels. This pattern of disease with minimal atherosclerotic disease in
the femoral and popliteal segments with severe tibial disease, in this
case specically anterior and posterior tibial artery occlusion, is frequently seen in patients with diabetes
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N. J. Swerdlow and A. D. Hamdan
Algorithm
Figure 4.6 depicts a basic algorithm for the initial assessment
of PAD in patients with diabetes. All patients with diabetes
should undergo a thorough history and physical exam. The
history should specically assess for symptoms of ischemia
and prior ulcers and wound healing. The physical exam
should include a full lower extremity pulse exam, assess for
signs of ischemia, and include a detailed description of any
ulcers, gangrene, and evidence of infection. All patients
should undergo measurement of ABI every 5years, as per the
Fig. 4.6 Algorithm depicting
the initial evaluation of
peripheral arterial disease.
ABI ankle-brachial index,
WIfI wound, ischemia, and
foot ischemia
American Diabetes Association consensus panel on PAD
[12]. If this is normal, it should be repeated every 5years. All
patients with evidence of PAD based on ABI and/or history
and physical exam should undergo a further assessment of
lower extremity perfusion. At our institution, we begin with
segmental pressures, including toe pressure with Doppler
waveforms and PVRs (Figs.4.1, 4.2, and 4.3). Based on these
results, all patients should have the WIfI score calculated
(Table4.1). Patients who are likely to benet from revascularization should subsequently proceed to DSA for detailed anatomic assessment, operative planning, and concurrent
endovascular revascularization if deemed appropriate.
4 Clinical Features andDiagnosis ofPeripheral Arterial Disease
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57
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Imaging ofInfection in
https://t.me/med1917
the Diabetic Foot
MaryG.Hochman andCaitlinConnolly
5
Abstract
Information derived from imaging studies can play an
important role in the management of complicated foot
problems in a diabetic patient. This chapter reviews the
various modalities available for the imaging of infection
in the diabetic foot—radiography; nuclear medicine studies such as bone scans, labeled leukocyte scans, bone
marrow scans, and ourine-18-ourodeoxyglucose
positron- emission tomography (FDG PET) scans; crosssectional studies such as magnetic resonance imaging
(MRI), MR spectroscopy, computed tomography (CT),
and ultrasound—and highlights their relative strengths
and weaknesses for the diagnosis of osteomyelitis, soft
tissue infection, and neuroarthropathy. A suggested imaging algorithm for the diagnosis of osteomyelitis in the diabetic foot is presented.
Introduction
Foot infections are among the most common causes of hospitalization in the diabetic population, accounting for 20% of
all diabetes-related admissions. Complicated foot infections
may require treatment by amputation—as many as 6–10% of
all diabetic patients will undergo amputation for the treatment of infection [1–3], accounting for 57% of nontraumatic
lower extremity amputations [4–6]. The scope of the problem is compelling [7]. In 2016, 130,000 hospital discharges
for lower extremity amputation in the United States were
associated with a diagnosis of diabetes [8]. The Centers for
Disease Control and Prevention (CDC) estimated the annual
treatment cost of amputees related to infection and complicated vascular diabetic foot problems at $1.2billion for the
year 1997, not including the cost of rehabilitation, prosthetic
devices, or lost income. These treatment costs are likely to
grow as the prevalence of diabetes is on the rise. The estimated prevalence of diagnosed and undiagnosed diabetes is
24.2 million people, representing 10.5% of all US adults,
with a prevalence of 26% among US adults 65years or older
[8]. In 2013, the prevalence of diabetes was estimated to be
382 million people worldwide, and this number was projected to rise to 592million by 2035 [9].
Information derived from imaging studies can play an
important role in the management of complicated foot problems in the diabetic patient. Soft tissue abnormalities such as
abscesses and cellulitis can be identied, osteomyelitis can
be detected, the extent of abnormal marrow can be depicted,
neuroarthropathic changes can be diagnosed and followed
over time, the distribution of atherosclerotic lesions can be
mapped, and the effectiveness of revascularization procedures can be evaluated. A variety of studies are currently
available for imaging the diabetic foot. In order to use these
imaging studies effectively, it is important to understand the
specic strengths and weaknesses of each modality as they
apply to the particular clinical problem in question. The goal
of this chapter will be to review the modalities available for
the imaging of diabetic foot infection and to highlight their
relative utilities in the context of clinical problem-solving.
M. G. Hochman (*)
Department of Radiology, Harvard Medical School,
Musculoskeletal Imaging and Intervention, Beth Israel Deaconess
Medical Center, Boston, MA, USA
e-mail: mhochman@bidmc.harvard.edu
C. Connolly
Nuclear Medicine, Department of Radiology, Mount Auburn
Hospital, Cambridge, MA, USA
e-mail: Caitlin.Connolly@mah.harvard.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. Veves et al. (eds.), The Diabetic Foot, Contemporary Diabetes, https://doi.org/10.1007/978-3-031-55715-6_5
Infection intheDiabetic Foot
Risk Factors
Many factors contribute to infection in the diabetic foot,
including peripheral neuropathy [10] and vascular insufciency [11]. Repetitive minor trauma to an insensitive neuro-
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