AJR 2004; 182:1435-1442
© American Roentgen Ray Society
Contrast-Enhanced MR Angiography of the Foot: Anatomy and Clinical Application in Patients with Diabetes
Sébastien Chomel1,
Philippe Douek2,3,
Philippe Moulin4,
Mathieu Vaudoux2 and
Bruno Marchand1,3
1 Department of Radiology, Hôpital de la Croix Rousse, 103 Grande Rue de
la Croix Rousse, Lyon 69004, France.
2 Department of Radiology, Hôpital Cardiovasculaire Louis Pradel, 28
Avenue Doyen Lepine, Bron 69500, France.
3 Laboratoire Creatis, UMR 5515, INSA 502, Villeurbanne 69621, France.
4 Department of Diabetes and Metabolic Disease, Hôpital Cardiovasculaire
Louis Pradel, Bron 69500, France.
Received May 5, 2003;
accepted after revision October 21, 2003.
Address correspondence to B. Marchand.
Introduction
Surgical revascularization remains the most important therapeutic option
for limb salvage in patients with severe arterial occlusive disease,
particularly those with diabetes
[1]. Digital subtraction
angiography has traditionally been used for the precise preoperative imaging
of the foot arteries that is required when a surgical revascularization
technique is indicated
[1–3].
However, 3D contrast-enhanced MR angiography is rapidly gaining acceptance as
a versatile noninvasive alternative to conventional angiography. Recently, 3D
contrast-enhanced MR angiography has been reported as an accurate technique
for analyzing the foot arteries in patients with diabetes
[4]. Therefore, indications for
3D contrast-enhanced MR angiography of the foot will be likely to increase for
diabetic patients referred for surgical revascularization. The purpose of this
article is to illustrate the arterial anatomy of the normal foot and the
typical appearance of arterial lesions in the diabetic foot.
Technique
MR angiography was performed with a Magnetom Vision 1.5-T scanner (Siemens
Medical Solutions) equipped with high-performance gradients (25 mT/m) that
allow a rapid (300-msec) rise time. Both feet were positioned in the head
surface phased array coil so that the entire foot could be covered in the
imaging volume.
MR angiography images were acquired in an oblique coronal plane using a 3D
radiofrequency spoiled fast low-angle shot (FLASH) sequence with the following
parameters: TR/TE, 4.6/1.8; flip angle, 30°; rectangular field of view,
420 mm; matrix size, 310 x 512; slab thickness, 92 mm subdivided into 46
partitions; voxel size, 1.67 mm3; and acquisition time, 52 sec. A
set of unenhanced 3D mask images was acquired before the IV injection of
contrast medium. A double dose (0.2 mmol/kg) of gadodiamide (Omniscan,
Amersham Health) was administered via power injection at 1 mL/sec to image
both feet. The delay between the start of the injection and the acquisition of
a 3D MR angiography sequence was based on the contrast medium transit time. To
measure this transit time at the ankle, we analyzed the arrival of contrast
medium in the supramalleolar arteries using the bolus test technique, in which
a single axial slice was acquired each second over a period of 70 sec after
the IV contrast medium injection with a sagittal 2D FLASH MRI sequence.
Subsequently, a 3D MR angiography sequence was acquired after injection of
contrast medium at two successive times to allow the arterial imaging of both
feet, even when the arterial perfusion was asymmetric. The unenhanced data set
was then subtracted from each of the contrast-enhanced data sets. The
resultant subtracted image was treated with a maximum-intensity-projection
algorithm that allowed serial angiograms at 15° rotational increments. The
interpretation was based on native and maximum-intensity-projection
images.
Normal Arterial Anatomy of the Foot
The normal vascular anatomy of the foot is composed of the anterior
circulation, the posterior circulation, and the pedal arches (Fig.
1A,
1B,
1C).
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Fig. 1A. —Normal pedal artery anatomy. Drawing in dorsal view shows
anterior circulation: distal anterior tibial artery (1) gives rise to two main
vessels, dorsal artery of foot (2) and lateral tarsal arteries (3). Arcuate
artery (4) is small vessel that arises from dorsal artery of foot. Deep
perforating artery (5) communicates with plantar circulation in first
metatarsal space. First dorsal metatarsal artery for hallux (6) ends at
anterior circulation in first space.
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Fig. 1B. —Normal pedal artery anatomy. Drawing in plantar view shows
posterior circulation: common plantar artery (i.e., end of posterior tibial
artery) (7) gives rise to two main vessels, lateral (8) and medial (9) plantar
arteries. Pedal arch (10) constitutes anastomotic pathway between anterior and
posterior circulations by deep perforating plantar artery (5) in first
metatarsal space.
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Fig. 1C. —Normal pedal artery anatomy. Drawing in lateral view outlines
anterior circulation: distal anterior tibial artery (1), dorsal artery of foot
(2), lateral tarsal artery (3), and deep perforating artery (5); and posterior
circulation: lateral (8) and medial (9) plantar arteries; and pedal arch (10).
Distal posterior tibial artery (11) becomes common plantar artery (7) in
retromalleolar space. This view also allows evaluation of distal fibular
artery (12).
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Anterior Circulation
At the ankle, the anterior tibial artery courses medially and crosses the
ankle joint dorsally, to give rise to two main vessels under the extensor
retinaculum: the dorsal and lateral tarsal arteries
(Fig. 1A). The dorsal artery of
the foot is the main artery of anterior circulation, traveling along the
dorsal medial aspect of the foot to the first metatarsal space. It gives rise
to the arcuate artery, which in turn gives rise to small dorsal digital
arteries supplying the toes. The arcuate artery is commonly not seen on MR
angiography because of its small size. At its most distal extent, the dorsal
artery of the foot supplies the perforating deep plantar artery, which
communicates with the plantar (i.e., posterior) circulation in the first
metatarsal space.
Posterior Circulation
The posterior tibial artery becomes the plantar common artery in the
retromalleolar space (Fig.
1B).
The medial and lateral plantar arteries are the two main branch vessels of
the common plantar artery. The lateral plantar artery courses along the
lateral side of the midfoot and follows a curved pathway on the forefoot to
join the first plantar space. It then communicates with the anterior
circulation through the perforating deep artery. The medial plantar artery
runs straight along the medial side of the foot, ending at the first
metatarsal head, where it becomes the hallux digital arteries.
Pedal Arches
The relationship between the anterior and posterior circulation is well
characterized on lateral and oblique views
(Fig. 1C). The dorsal artery of
the foot and the lateral plantar arteries communicate through the deep
perforating artery to create the pedal arch, which is also called the plantar
arch. The patency of the pedal arch is critically important for preoperative
planning. Actually, this arterial arch creates an anastomotic pathway between
the two main foot arteries—the dorsal artery and lateral plantar
arteries. The plantar metatarsal vessels arise from the plantar arch, which
provides essential collateral circulation in the distal foot.
Arterial Lesions in the Diabetic Foot
MR Angiography Patterns
Complications in the diabetic foot are a source of significant morbidity
and mortality in this population and include callus formation, foot ulcer,
cellulitis, osteomyelitis, and gangrene
[5,
6]. For patients with diabetes,
peripheral vascular disease carries a 10- to 20-times greater risk for limb
amputation than it does for other patients. Commonly, diabetic peripheral
vascular disease corresponds to diffuse, severe, and often bilateral disease
that affects the proximal vessels
[7]. Diabetic peripheral
vascular disease preferentially involves arteries below the knee
[5,
7], with late involvement of
the pedal arteries (the dorsal artery of the foot and the pedal arch).
In the past, vascular diabetic foot lesions have been well characterized on
conventional angiography [8].
Recently, MR angiography has been emphasized as a suitable noninvasive tool
for analyzing the arteries of the diabetic foot
[4] (Figs.
2A,
2B,
2C,
3A,
3B,
4A,
4B,
4C,
5A,
5B), in particular for
evaluating nonhealing ulcers. In patients with diabetic foot, assessment of
the vascular supply can help delineate the relative contribution of neurologic
and vascular abnormalities causing the lesion.
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Fig. 2A. —30-year-old man with diabetes, normal anterior circulation,
and no arterial occlusive disease. MR angiogram obtained in lateral view is
optimal for evaluating distal anterior tibial artery (1) and dorsal artery of
foot (2). This view may also depict lateral tarsal artery (3).
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Fig. 2B. —30-year-old man with diabetes, normal anterior circulation,
and no arterial occlusive disease. MR angiogram in oblique view is sometimes
useful to separate and better analyze anterior tibial artery (1) and
bifurcation between dorsal artery of foot (2) and lateral tarsal arteries
(3).
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Fig. 2C. —30-year-old man with diabetes, normal anterior circulation,
and no arterial occlusive disease. MR angiogram obtained in frontal view
clearly shows distal end of anterior tibial artery (1), dorsal artery of foot
(2), and lateral tarsal arteries (3).
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Fig. 3A. —74-year-old man with diabetes, normal posterior circulation,
and no clinical problem in left foot. MR angiogram obtained in lateral view
outlines distal posterior tibial artery (11) and its division into lateral (8)
and medial (9) plantar arteries. Distal fibular artery (12) can be seen with
corresponding arterial heel network (curved arrow). Note patency of
pedal arch (10).
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Fig. 3B. —74-year-old man with diabetes, normal posterior circulation,
and no clinical problem in left foot. MR angiogram obtained in frontal view
shows bifurcation of common plantar artery (7) into lateral (8) and medial (9)
plantar arteries. Frontal view shows distinct hallux plantar artery (6),
plantar medial artery (9), and pedal arch (10).
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Fig. 4A. —65-year-old man with diabetes and left femoropopliteal bypass
graft with normal pedal arches. MR angiograms obtained in lateral view
(A) and oblique view at 60° (B) are best for depicting pedal
(i.e., plantar) arch (10). Communication between lateral plantar artery (8)
and dorsal artery of foot (2) by deep perforating artery (5) is usually
depicted well on oblique views. Note presence of plantar metatarsal arteries
(double arrows, B) arising from pedal arch (10).
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Fig. 4B. —65-year-old man with diabetes and left femoropopliteal bypass
graft with normal pedal arches. MR angiograms obtained in lateral view
(A) and oblique view at 60° (B) are best for depicting pedal
(i.e., plantar) arch (10). Communication between lateral plantar artery (8)
and dorsal artery of foot (2) by deep perforating artery (5) is usually
depicted well on oblique views. Note presence of plantar metatarsal arteries
(double arrows, B) arising from pedal arch (10).
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Fig. 4C. —65-year-old man with diabetes and left femoropopliteal bypass
graft with normal pedal arches. MR angiogram obtained in frontal view
superimposes both anterior (i.e., dorsal artery of foot
[2]) and posterior circulation
(i.e., lateral plantar artery
[8]). Pedal arch (10) is
imperfectly shown on this view.
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Fig. 5A. —74-year-old man with diabetes and calf and foot rest pain. MR
angiogram obtained in comparative frontal view shows right distal posterior
tibial artery occlusion (11) extending to common (7) and lateral (8) plantar
arteries. MR angiography reveals probable retrograde flow in medial plantar
artery (9) by anterior circulation (via pedal arch [10]) that would explain
the reason that anterior circulation (13) in right foot is more effective than
that in left.
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Fig. 5B. —74-year-old man with diabetes and calf and foot rest pain. MR
angiogram obtained in lateral view shows predominant anterior circulation (13)
compensating for posterior tibial artery occlusion (11). Irregular pedal arch
(10) is supplied by dorsal artery of foot (2). Note distal fibular artery (12)
with heel tributaries in hindfoot.
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In diabetic pedal vascular disease, extensive and multisegmental
involvement of the normal collateral circulation is common (Figs.
6A,
6B and
7), and the diffuse medial
vascular calcifications of arteriosclerosis are typical
[5,
7] (Fig.
8A,
8B). Tortuous distal vessels
and microaneurysms are also typical of diabetic peripheral vascular disease
(Fig. 9A,
9B). The worst complication is
diabetic forefoot gangrene [8],
which is commonly caused by obstruction of the interosseous or collateral
arteries (Fig. 10A,
10B). MR angiography sometimes
shows an abnormal vascular tree with a rich arteriocapillary network
surrounding a trophic ulcer (Fig.
11A,
11B). According to Cecile et
al. [8], this kind of trophic
ulcer is not due to ischemia but may be related to neuropathy or infection.
Faglia et al. [3] pointed out
that neuroischemic foot ulcer is the most prevalent clinical feature. In such
cases, the extent and severity of diabetic peripheral vascular disease are
variable and involve segments, occluded arteries, and degrees and numbers of
stenoses (Fig. 12A,
12B).
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Fig. 6A. —82-year-old man with diabetes and ischemic trophic ulcers of
forefoot due to severe diabetic peripheral vascular disease. MR angiogram
obtained in frontal view reveals significant lesions of anterior and posterior
circulation with occlusion of lateral plantar artery (8) and dorsal artery of
foot (2). Short segment of pedal arch (10) is vascularized by compensatory
hypertrophic lateral tarsal artery (3). No collaterals for toes arise from
pedal arch, except for hallux (6).
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Fig. 6B. —82-year-old man with diabetes and ischemic trophic ulcers of
forefoot due to severe diabetic peripheral vascular disease. MR angiogram
obtained in lateral view shows long segment involvement of posterior
circulation (multiple stenoses of distal posterior tibial [11], common plantar
[7], and medial plantar [9]
arteries) associated with occlusion of dorsal artery of foot (2).
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Fig. 7. —62-year-old man with diabetes, severe diabetic peripheral
vascular disease, and nonhealing ulcers of heel and forefoot. MR angiogram
obtained in lateral view reveals that long segments of anterior (13) and
posterior (14) circulation are involved. Long and short stenoses are clearly
visible in distal dorsal artery of foot (2), deep perforating artery (5), and
pedal arch (10). Note diffuse and severe lesions of plantar arteries
(double arrows).
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Fig. 8A. —58-year-old man with diabetes and nonhealing neuroischemic
ulcer on plantar surface of hallux. Radiogram shows arterial calcifications
("rails") of arteriosclerosis (arrows), typical of
diabetic peripheral vascular disease.
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Fig. 8B. —58-year-old man with diabetes and nonhealing neuroischemic
ulcer on plantar surface of hallux. Magnified MR angiogram obtained in oblique
view shows corresponding mural irregularities (double arrows).
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Fig. 9A. —75-year-old man with diabetes and diabetic peripheral
vascular disease (limb rest pain without trophic ulcer). Angiograms obtained
in lateral view (A) and oblique view (B) depict anterior
circulation (13), posterior circulation (14), and pedal arch (10) with
numerous irregularities but no significant stenoses. Plantar medial artery
occlusion (9) is well depicted. Typical microaneurysm (curved arrow,
B) on irregular distal lateral tarsal artery (3) is shown and is
particularly visible on lateral view.
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Fig. 9B. —75-year-old man with diabetes and diabetic peripheral
vascular disease (limb rest pain without trophic ulcer). Angiograms obtained
in lateral view (A) and oblique view (B) depict anterior
circulation (13), posterior circulation (14), and pedal arch (10) with
numerous irregularities but no significant stenoses. Plantar medial artery
occlusion (9) is well depicted. Typical microaneurysm (curved arrow,
B) on irregular distal lateral tarsal artery (3) is shown and is
particularly visible on lateral view.
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Fig. 10A. —67-year-old man with diabetes and right forefoot gangrene in
second and third toes. MR angiogram obtained in lateral view shows only patent
distal tibial posterior artery (arrow), with no other vessel
visible.
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Fig. 10B. —67-year-old man with diabetes and right forefoot gangrene in
second and third toes. MR angiogram obtained in magnified frontal view of
forefoot shows avascular gangrene involving second and third toe of right foot
(double arrows). Gangrene extended to whole foot several days after
MR angiogram was obtained.
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Fig. 11A. —68-year-old woman with diabetes and purely neuropathic dorsal
ulcer of second toe. MR angiograms in frontal view (A) and oblique view
(B) show normal appearance of vascular tree of right foot, with rich
arteriocapillary network (curved arrow) from trophic ulcer
(single arrow) and rapid venous outflow (double arrows).
B reveals patency of anterior (13) and posterior circulation (14).
Distal lateral plantar artery (8) and pedal arch (10) are irregular but show
no significant stenoses.
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Fig. 11B. —68-year-old woman with diabetes and purely neuropathic dorsal
ulcer of second toe. MR angiograms in frontal view (A) and oblique view
(B) show normal appearance of vascular tree of right foot, with rich
arteriocapillary network (curved arrow) from trophic ulcer
(single arrow) and rapid venous outflow (double arrows).
B reveals patency of anterior (13) and posterior circulation (14).
Distal lateral plantar artery (8) and pedal arch (10) are irregular but show
no significant stenoses.
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Fig. 12A. —77-year-old man with diabetes and nonhealing neuroischemic
ulcer of fifth toe. MR angiogram obtained in lateral view shows multiple
stenoses with long segment involvement of distal plantar lateral artery (8)
extending to pedal arch (10), and patency of anterior (13) and posterior
circulation (14).
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Fig. 12B. —77-year-old man with diabetes and nonhealing neuroischemic
ulcer of fifth toe. MR angiogram obtained in frontal view shows value of
metatarsal plantar arteries (double arrows) that arise from pedal
arch (10), particularly fifth metatarsal plantar artery superimposed on venous
outflow from trophic ulcer (curved arrow).
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MR Angiography in Therapeutic Management
Therapeutic options in the ischemic foot ulcer range from distal
revascularization to microvascular free-tissue transfer, or a combination of
the two [1,
2,
4,
5,
7]. Paramalleolar and pedal
revascularization by distal bypass has been greatly improved by new surgical
techniques [1,
2,
4,
5,
7]. Key preoperative
information needed for such techniques includes analysis of the patency of the
pedal arches, documentation of the presence and degree of collateral pathways,
and accurate depiction of target vessels suitable for surgical bypass
[2,
4]; all of this information is
afforded on MR angiography (Fig.
13A,
13B,
13C).
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Fig. 13A. —65-year-old woman with diabetes and nonhealing neuroischemic
trophic ulcer of hallux plantar space (hallux valgus) who underwent MRI during
preoperative planning. MR angiograms obtained in frontal view (A) and
lateral view (B) show patency of anterior circulation, particularly in
dorsal artery of foot (2), which is suitable for surgical bypass. Thrombosis
of common plantar artery (7) is associated with multiple stenoses and short
occlusions of its two branches (double arrows). Plantar arch (10),
which is well depicted on both views, is supplied only by anterior
circulation.
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Fig. 13B. —65-year-old woman with diabetes and nonhealing neuroischemic
trophic ulcer of hallux plantar space (hallux valgus) who underwent MRI during
preoperative planning. MR angiograms obtained in frontal view (A) and
lateral view (B) show patency of anterior circulation, particularly in
dorsal artery of foot (2), which is suitable for surgical bypass. Thrombosis
of common plantar artery (7) is associated with multiple stenoses and short
occlusions of its two branches (double arrows). Plantar arch (10),
which is well depicted on both views, is supplied only by anterior
circulation.
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Fig. 13C. —65-year-old woman with diabetes and nonhealing neuroischemic
trophic ulcer of hallux plantar space (hallux valgus) who underwent MRI during
preoperative planning. Magnified MR angiogram of forefoot obtained in lateral
view shows tortuous collateral pathways (single straight arrow) to
enhancement of hallux plantar space corresponding to trophic ulcer (curved
arrow) and rapid venous outflow (double arrows).
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Conclusion
Various factors may influence the outcome of foot complications in diabetic
patients [3]. Noninvasive
evaluation of the ischemic component of foot ulcers is necessary, particularly
in cases of renal impairment. Pedal vascular exploration is aided by MR
angiography and the development of new surgical options.
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