0:00

All right. This next case is atherosclerosis in the outflow.

0:04

We're going to go over mild, moderate, and severe degrees of

0:08

stenosis on this scan. Now, as I was saying, I like

0:12

having one screen, which is non-contrast, and the other screen, which

0:16

is arterial. And it's really helpful

0:19

when I link them and I go over them in parsing out

0:23

especially the infrapopliteal segments and knowing which areas

0:27

are calcified and which areas are not calcified.

0:31

So,

0:32

a quick rundown

0:37

just to see how calcified, especially the

0:41

infrapopliteal vessels are, is specifically

0:44

helpful. So I'm going to move my crosshairs here so it's not in our

0:48

field of view. But essentially, you can see that there aren't that many

0:51

calcifications, just specks of calcifications

0:55

in the left lower extremity and scattered ones in the right

0:58

anterior tibial artery, as well as the left anterior tibial artery.

1:02

But for the most part, not heavily calcified

1:06

infrapopliteal vessels. So then we can focus on just the

1:09

arterial phase scan, starting as we do all the way from the top, looking at

1:13

the inflow.

1:15

Coming down, we can see that there's a large amount of atherosclerosis involving

1:19

the descending thoracic aorta as well as the abdominal

1:23

aorta, but it's only causing up to a mild amount

1:27

of stenosis of the aorta itself in this case.

1:30

As we proceed down and as it's bifurcated, we're going to focus first

1:34

on the left side. And so looking at that left side

1:38

and at this common iliac artery, we can see that

1:42

there is

1:44

moderate stenosis of that left common iliac artery.

1:47

And sometimes knowing the degrees of stenosis can be difficult.

1:51

And using multiplanar reconstructions and having this thin image data set

1:55

can be really valuable. So then I would just put my crosshair to that

1:59

area of interest, and I would line up and make a

2:03

double oblique plane, which means that on using two planes,

2:06

the coronal and the sagittal, I make a perfect short axis

2:10

to the area of interest. And so here you can see that

2:14

the area of lumen that's opacified is only this much, as

2:18

opposed to the vessel, which is this much.

2:20

And so since this is approaching about 50% reduction in the lumen,

2:25

there is moderate stenosis of this left common iliac

2:28

artery.

2:30

As we proceed down,

2:32

looking at this left common iliac artery, and now

2:36

that the internal iliac artery has come off of it, this is the

2:40

proximal external iliac artery. And again, looking at it

2:44

in its proximal ostium, we can see that there's barely any lumen

2:48

that is patent over here.

2:51

And so there is severe stenosis and ulcerative plaques

2:55

of that

2:56

external iliac artery resulting in severe stenosis.

3:00

Now, if you topsy-turvy yourself out, you can always reset your images and

3:04

come back to your area of interest after noting

3:08

that moderate stenosis in that left common iliac and severe

3:12

stenosis in the external iliac artery.

3:16

We're going to go down. We can see that there are some prominent collaterals right

3:19

here, again, indicating that these degrees of stenosis were

3:23

indeed hemodynamically significant.

3:26

Moving on down, no significant stenosis or mild stenosis

3:30

of the common femoral artery. We can see that

3:33

really the degree of stenosis is under

3:36

49%. And as we're scrolling down, we have

3:40

the deep and the superficial femoral arteries.

3:43

Looking at that superficial femoral artery and focusing on that superficial femoral

3:47

artery, there's partially calcified plaque here resulting in mild stenosis.

3:52

All the way down here, the vessel actually spans all the way from

3:56

here to here, and you can see that that's the vessel part and that's all plaque.

4:01

So there is moderate stenosis of this

4:04

superficial femoral artery, and we're all the way in that distal thigh.

4:08

So this is the distal superficial femoral artery with moderate

4:11

stenosis.

4:13

And then moving on now to the popliteal artery right here.

4:20

And then right here as well, there was just above its

4:23

bifurcation, moderate stenosis.

4:25

It came off the anterior tibial artery and the tibioperoneal

4:29

trunk. And if we look at all of these three vessels,

4:33

there are some plaques, and we can focus first on this anterior

4:37

tibial artery. Here you see that

4:41

you kind of barely and you kind of blink and you miss it, kind of a lesion there in

4:44

this anterior tibial artery suggesting severe stenosis of the vessel right

4:48

here. There's no contrast.

4:50

And then it comes back again. It was just a small focal

4:54

severe stenosis of that mid anterior tibial

4:58

artery, as you can see on this coronal view.

5:01

We were in the mid-calf at that level.

5:03

The rest of the artery is patent, just some mild stenosis.

5:07

It continues as the dorsalis pedis, which again, right here,

5:12

you can see it was nice and patent here, and we lose it.

5:14

There's severe stenosis of that dorsalis pedis

5:18

just before it drips down between the two heads of the metatarsal.

5:22

Going back up and focusing on the tibioperoneal trunk,

5:26

which only shows some mild stenosis.

5:30

You can see that there's some blooming from the calcified plaque, but even so, the

5:33

degree of opacification on the contrast fill lumen is

5:37

only mild.

5:40

Then we have the peroneal and the posterior tibial arteries, and both

5:44

of them

5:45

are patent

5:48

all the way down to some mild stenosis in both of these

5:52

arteries, and no high-grade stenosis.

5:56

And so really, if I was to look at this

5:59

entire left lower extremity, we would

6:03

just say that for the left lower extremity- That there is moderate

6:07

stenosis of that distal superficial femoral

6:10

artery. And then there is three-vessel runoff with focal

6:14

severe stenosis of the mid anterior tibial

6:18

and the dorsalis pedis arteries.

6:21

Moving on to the right side.

6:23

So on the right side, if we look over here, again, there is

6:27

focal borderline moderate stenosis of this right common iliac

6:31

artery. It's really kind of approaching to be a 50%

6:35

degree area

6:37

stenosis. As you're going down again, we have

6:41

the internal and external iliac arteries.

6:43

The external iliac artery has plaque but only shows mild

6:46

stenosis,

6:48

as does the common femoral artery.

6:51

As we're going down, the superficial femoral artery,

6:54

again, is patent. There's some plaque along it, but

6:58

it's still mild stenosis along its entire length as we're

7:02

coursing down.

7:04

So still mild stenosis. And then as it comes out and it

7:08

becomes the popliteal artery right here, there is at least a

7:12

50% luminal narrowing right

7:16

here, as seen on this sagittal view.

7:21

And then there's another spot of moderate stenosis

7:25

just above the bifurcation right here.

7:28

And you can see how different that more cranial lesion looked, where it

7:32

was much easier to see that moderate stenosis because of the non-calcified plaque,

7:37

compared to this one, where maybe the degree of confidence is a little bit

7:40

lower because of these parallel specks of calcification.

7:44

But nevertheless, there's definitely stenosis

7:48

here as well.

7:50

It then branches off, and then we're going to focus one by one on the anterior

7:54

tibial, peroneal, and posterior tibial arteries.

7:56

There's plaque along the anterior tibial artery, and

8:00

it's

8:02

resulting in

8:03

severe stenosis right here, where we kind of lose it.

8:06

So distally, we have

8:09

some degree of high-grade stenosis.

8:13

And then as we're looking at the posterior tibial and the peroneal arteries, as

8:16

we're going back up, everything looks patent.

8:20

And so for the impression here, for our right lower

8:23

extremity, we would say that there is

8:27

moderate stenosis of the popliteal

8:31

artery. In terms of focality, we found two, so we can say

8:34

tandem moderate, or we can say multifocal

8:38

moderate stenosis of the popliteal artery.

8:42

Looking at the inflow vessels, which we didn't comment upon for that first line in

8:47

our impression, we're going to say severe aortoiliac

8:49

atherosclerosis with moderate stenosis

8:53

of both the common femoral arteries and severe

8:57

stenosis of the left external iliac artery.

9:00

And so because these were not heavily calcified lesions, they were a

9:04

relatively short segment, this patient underwent

9:08

bilateral common iliac artery stenting with extension of that

9:12

stent into the external iliac artery as their

9:16

revascularization management plan.