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Atherosclerosis is a systemic vascular disease that often affects multiple vascular territories and leads to peripheral artery disease (PAD). The age-adjusted prevalence of peripheral atherosclerotic disease is approximately 12%.1 However, patients with established risk factors for this condition, such as diabetes mellitus, or patients with known coronary artery disease (CAD), have a much higher prevalence of peripheral athero-occlusive disease.2 Peripheral atherosclerotic disease remains poorly recognized, as recently demonstrated by the PARTNERS (Peripheral Arterial Disease Awareness, Risk and Treatment: New Resources for Survival) Investigators, a US national survey of almost 7000 patients seen in 320 primary care clinics. The survey showed that only 45% of the patients with peripheral vascular disease had been diagnosed with this condition prior to the PARTNERS Program.3

Consequently, clinicians must have a high grade of suspicion for detecting PAD in patients with known risk factors or with established CAD, and these patients must undergo a detailed history and physical examination as well as non-invasive tests such as ankle-brachial index and/or arterial duplex ultrasound to rule out the presence of peripheral vascular disease. In those with significant symptoms, assessment of the peripheral vascular anatomy is necessary if intervention is being considered.4

Despite major advances in noninvasive imaging techniques such as duplex ultrasonography, angiographic computerized tomography (CTA) (Fig. 23-1), and magnetic resonance angiography (MRA) (Fig. 23-2), contrast angiography remains the gold standard method for diagnosing peripheral arterial vascular disease, because it provides the anatomic details necessary to plan percutaneous or surgical revascularization. In the present chapter, we will address the basic anatomy and angiographic procedures for the vascular territories that more commonly undergo percutaneous or surgical intervention.


Digital subtraction angiography of a severely diseased superficial artery (right) compared with angiographic computerized tomography (CTA) (left).


Magnetic resonance angiography (MRA) of the aortic bifurcation, iliac, femoral, popliteal and infrapopliteal arteries.


The operator must be familiar with the techniques and equipment for different arterial vascular access sites (ie, common femoral artery [CFA], brachial artery, and radial artery). To obtain high quality angiographic images, it is essential to have a radiographic gantry with angulation capability in both the axial and sagittal planes as well as a large-field (14-16-in or 36-41-cm) image intensifier capable of capturing the larger regions of interest, such as the entire aortic arch, entire pelvic vasculature, and both legs.5

Digital angiography allows immediate monitor display of the acquired image, as well as electronic processing to enhance contrast, reduce noise, and subtract bony and soft-tissue density. Digital subtraction angiography (DSA) significantly enhances the angiographic anatomical detail and allows less contrast to be used, which shortens procedure time. A preliminary image (mask) is recorded ...

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