CASE 8027 Published on 30.11.2009

Non Invasive Imaging of Diabetic foot ulcer-an alternative?

Section

Cardiovascular

Case Type

Clinical Cases

Authors

Dwivedi AN, Shukla RC.

Patient

2 years, male

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Clinical History

The study is based on 19 patients who were referred with complaint of non healing ulcer of lower limb of more than 6 weeks duration. This study was carried out in Sir Sunderlal Hospital during between of December 2004 and December 2006.

Imaging Findings

The patients were subjected to plain radiographs, Duplex scanning with colour flow imaging and MR angiography (non contrast enhanced). The modalities were used to detect vascular calcifications, osteomyelitis, bone resorption, deformities, thickening of arteries, plaques, spectral waveforms and collaterals. MRA was used to assess subjective calibre of vessels and presence of stenosis.
The patients were categorised according to age and a note of ulcer duration made
Grade of ulcer was determined (Wagner’s criteria) and note was made of severity of stenosis (Cossman).
Statistical analysis used in our study was subjected to calculation of Mean, standard deviation and Pearson’s Chi square test.

Discussion

In this study known diabetic patients with diabetic foot ulcer (n =19) were selected. Out of these 52.63% had positive plain radiographs (which included osteomyelitis, neuropathic foot and vascular calcification).Yuh, Baraniewski et al reported a sensitivity and specificity of 75% each. The study also showed that 57.89% of diabetic foot ulcer had gross arterial calcification. This suggests lower extremity arterial disease in these patients. In a university group diabetes program (UGDP) 16.1% reported as having arterial calcification. In a study by Young , Adams et al medial arterial calcification was reported to be significantly higher in neuropathic diabetic patients with history of foot ulceration.
Duplex scanning was positive in all patients, giving vital information like degree of stenosis, abnormal waveforms, luminal narrowing and plaques, collaterals, neovascularisation, varicosities, and abnormal venous channels.
Duplex scanning with colour flow imaging was 100% sensitive in demonstrating these abnormalities. It also showed that with increasing severity of disease the frequency and number of collaterals increased with Duplex scanning.
In our study of 19 patients of diabetic foot ulcer 47.3% presented with Grade III ulcer, 15.79% presented with Grade IV and 36.84% with Grade II ulcer. It was also found that on comparison of ulcer grade of 19 patients with corresponding peak systolic velocity p< 0.05. This means grade of ulcer has a statistically significant relation with PSV. All patients of grade IV ulcer had peak systolic velocity >4m/s that is stenosis of more than 75%.
In our study MR angiography proved to be only 60% sensitive when compared to Doppler studies .A comparison done to evaluate sensitivity of MRA in patients of diabetic foot ulcer with severity of ulcer(grade) and corresponding stenosis, assessed by Doppler. Out of 19 patients 9 had grade III ulcer and only 2 of which showed abnormal MRA (66.67%). Seven patients presented with grade II ulcer and 1 of which showed (50%) abnormal MRA. All 3 patients of grade IV ulcer had abnormal MRA (100%). On comparing MRA of 19 patients with ulcer grade, p>0.05 that is no statistical significance was noted within the two variables. On comparing MRA with peak systolic velocity, p>0.05 that is no statistical significance noted.
Carpenter et al found that MRI was 94% accurate in evaluating lower extremity vessels when compared to conventional angiography. Owen and co-workers found MRA to be more sensitive than conventional arteriography for visualising both run off vessels and arterial stenosis.
In our study 19 patients subjected to MR examination, with 0.2 T magnetic field without any contrast enhancement.
The modality was able to pick up gross cases but unable to match colour flow duplex scanning in other parameters like collaterals, early arterial stenosis, flow abnormalities and neoangiogenesis. In a multicenter trial evaluating MRA and contrast angiography it was found that both are approximately equivalent in diagnostic accuracy. In another study by Sommerville, Jenkins et al MRA had a sensitivity of 72% and specificity of 90% in differentiating high grade (>50%) versus low grade stenosis (<50%).

Differential Diagnosis List

MRA can be tailored in patients which are economically constrained.

Final Diagnosis

MRA can be tailored in patients which are economically constrained.

References

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