0:00

This patient came in with left foot pain, and we're going to

0:04

focus

0:06

on our runoff vessels.

0:09

So as I'm scrolling down, we can see that all the vessels so

0:13

far are patent.

0:15

As I'm scrolling down more and more and more, we also have to pay

0:18

attention to our soft tissues.

0:21

So you can see that the degree of opacification

0:25

of the arteries in that right lower extremity, so this proximal anterior

0:29

tibial and

0:30

tibioperoneal trunk, is much lesser than the degree of

0:33

opacification in the left lower extremity.

0:37

And although I don't see much venous enhancement at this point, you can definitely

0:41

see that these arteries are enhancing

0:45

faster than these ones. Now, there can be a couple of explanations.

0:49

One is that these ones are thrombosed.

0:51

But if you look at the vessels, there's a

0:54

graded gradual kind of decrease in the

0:58

opacification, and that's not very typical of a thrombus.

1:02

Next

1:04

is that

1:09

there's a higher degree of opacification here, so it

1:13

can't be an outrunning of bolus because

1:17

at least one of the arteries has the bolus reaching it.

1:20

So what other reason could there be as to why there is brighter

1:23

opacification in the arteries of one compared to the other?

1:27

If you look at the soft tissues here, that's where the clue lies.

1:30

So this limb is asymmetrically enlarged compared to the right side.

1:34

There's a lot more edema. There's a lot

1:37

more subcutaneous fluid, fat stranding.

1:40

You can see all of this edema and fluid and fat stranding, and this is

1:44

resulting in a faster arteriovenous transit in

1:48

this lower extremity. Important to look at the bones.

1:51

This person didn't have any cortical erosions to suggest osteomyelitis, but those

1:55

are important

1:57

things in your checklist that you must look at.

1:59

You can see that there is quite a significant amount of soft tissue

2:03

swelling here. If you have the capability, you can even make

2:06

volume-rendered imaging.

2:09

Even just kind of looking at the soft tissues, and you can see how much more

2:12

swollen that left foot is compared to the right

2:16

side.

2:18

Looking at that immediate delayed phase now.

2:21

So here you can see, as I'm scrolling through the immediate

2:25

delayed phase, which is a little bit more later than usual, but because of that

2:29

faster arterial transit time,

2:32

the veins in this left lower extremity, they enhanced

2:35

earlier than the veins in the right lower extremity.

2:38

Now, that doesn't mean that there is an arteriovenous fistula as we've seen in the

2:42

prior cases because of a couple of things.

2:44

A, there is no one vein that is

2:47

implicated, which is showing the enhancement.

2:51

All of the veins here are showing the enhancement, which suggests a more diffuse

2:55

process.

2:56

Second is that the vein is not markedly dilated.

3:00

Third, the degree of opacification of the vein doesn't match the degree of

3:04

opacification of the arteries as much.

3:08

So the artery is definitely a little bit brighter than the veins.

3:12

And so all of these findings are seen in hyperemia, and you want to make sure you

3:16

don't overcall arteriovenous fistula or hyperemia or

3:20

vice versa in an appropriate setting.