Optimized diagnostic angiography in high-risk patients with severe peripheral vascular disease.

Conventional arteriography remains the usual method for preoperative assessment of severe peripheral vascular disease (PVD). Unfortunately, many peripheral arteriograms are still performed with a suboptimal technique, which can cause significant diagnostic errors in patients with severe PVD. A suboptimal technique may be due to poor collimation (causing incorrect exposure and incorrect gray scale), excessive patient-film distance (magnification unsharpness), inadequate volume or density of contrast material, poor contrast resolution (screen-film arteriography), nonselective injection, patient movement, and pressure from restraints or incorrect patient position (failure to profile lesions, pseudo-occlusion from external pressure or plantar flexion). The technique of selective digital subtraction arteriography (DSA) allows one to avoid these errors. The superior contrast resolution of DSA allows use of lower concentrations of contrast material. Selective injection into the external iliac artery allows proper positioning and improves image quality. Demonstration of distal vessels is best achieved by using biplane arteriography. For patients with severe resting ischemia, especially those with diabetes, high-quality selective DSA is essential to ensure that all distal vessels suitable for distal bypass grafting are identified. When properly performed, selective DSA remains the investigation of choice for reliably demonstrating arterial anatomy in high-risk patients with severe PVD.