CT order location for lower extremity acute limb ischemia...?

[EMgordo]

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Do you all recommend CT angio lower extremity or CT angio abdomen pelvis with runoffs? I feel like in my ED its 50/50 split what I see ordered. And clearly if they're having very proximal symptoms you'd want the abdomen pelvis but I mean its 50/50 split for patients complaining of distal leg complaints. Thank you for your insight! (EM in training)

 

[sievert_fever]

In my opinion, any runoff should start from the aortic bifurcation. Even if there is only clinical concern for distal ischemia, the vascular surgeon (or equivalent) will want to know the extent of more proximal disease for procedure planning and access. How extensive is the steno-occlussive segment? Is it likely a thrombus or embolus? To what extent are the common femoral arteries calcified? At my institution, this is the default protocol for a CTA lower extremity with runoff. A full abdomen/pelvis is overkill.

Edit: Unfortunately, I wasn't able to find the guidelines on acute limb ischemia from the SVS. According to the ESVS (p. 181, section 2.2.3) they routinely scan from the level of the infrarenal abdominal aorta (essentially a full abdomen/pelvis). Seems excessive to me (namely due to the endless incidental findings) but I suppose the risk of concurrent aortic disease is sufficiently high (and would potentially change management) that they think it worthwhile. I personally would not advocate for it... but the customer is always right. 😉

 

[radsresident-US]

We usually do AP and legs manly to eval for AAA. Course you could extend tha logic to include chest but TAA much less likely. Most of the smokers with significant PAD have high risk for AAA

 

[qxrt]

My group does a lot of PAD work. I prefer CTA abdomen with run-off. Just the other night we had to repeat a CTA abdomen with run-off because the ED ordered a lower extremity angio, and there was partially visualized clot extending from the abdominal aorta into the common iliac, so a repeat was done to fully visualize the extent of the clot. We would also want to know about AAA if a patient had common iliac stenoses and potentially needed kissing stents, and I've also seen a case where the problem was bulky calcification causing narrowing of the abdominal aorta. Including the abdominal aorta doesn't add much scanning time, and excluding it can sometimes miss some critical findings.

Keep in mind that proximal stenoses can result in distal lower extremity symptoms.

 

[Dave1980]

CTA pelvis and lower extremities from the aortic bifurcation down