Diyabetik Ayak “Vasküler Görüntüleme”

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1 Diyabetik Ayak “Vasküler Görüntüleme”
Dr. Alaaddin NAYMAN

2 Genel Bilgiler Birçok komplikasyon, Bunların sonucunda, Mikrovasküler
Makrovasküler Metabolik Bunların sonucunda, Serebrovasküler, Kardiyovasküler ve Periferik Arter Hastalıkları, retinopati, nöropati ve nefropati. Harris MI. Diabetes in America: epidemiology and scope of the problem. Diabetes Care (Suppl)3:C11-C14, 1998. American Diabetes Association. Diabetes Facts and Figures, 2000, American Diabetes Association, Alexandria, VA, 2000.

3 Genel Bilgiler Kardiyovasküler komplikasyonlar erken ölüm nedeni,
Kalp hastalıkları ve inme diyabetiklerde diyabetik olmayanlara göre 2-4 kat daha fazla ve diyabetik hastaların %65’ inde ölüm sebebi, Harris MI. Diabetes in America: epidemiology and scope of the problem. Diabetes Care (Suppl)3:C11-C14, 1998. American Diabetes Association. Diabetes Facts and Figures, 2000, American Diabetes Association, Alexandria, VA, 2000.

4 Genel Bilgiler Diyabetik hastalarda çok sık diğer bir komplikasyon diyabetik ayak ülserleri, Hastalık sürecinde hastaların %15’inde alt ekstremite ülserlerinin gelişebileceği tahmin ediliyor, Nöropatik hastalar üzerinde yapılan geniş kapsamlı bir çalışmaya göre 1 yıllık süre içerisinde ülser başlama insidansı: %7 Frykberg RG, Habershaw GM, Chrzan JS. Epidemiology of the diabetic foot: ulcerations and amputations. In: Contemporary Endocrinology: Clinical Management of Diabetic Neuropathy, p 273, edited by A Veves, Humana Press, Totowa, NJ, 1998. Abbott CA, Vileikyte L, Williamson S, Carrington AL, Boulton AJ. Multicenter study of the incidence of and predictive risk factors for diabetic neuropathic foot ulceration. Diabetes Care 21: , 1998.

5 Genel Bilgiler Popülasyonlara göre farklılık göstermekle birlikte ülser prevalansı %2-10 arası, US ve Europe’ da alt ekstremite ampütasyonlarının en sık nedeni olmaya devam ediyor, Alt Ekstremite ampütasyon oranı: DM (X15-40)˃NonDM, E(X2)˃ K Walters DP, Gatling W, Mullee MA, Hill RD. The distribution and severity of diabetic foot disease: a community study with comparison to a non-diabetic group. Diabet Med 9: , 1992. Frykberg RG. Epidemiology of the diabetic foot: ulcerations and amputations. Adv Wound Care 12: , 1999.

6 Diabetik Ayak Problemleri
Nöropati İmmünopati (Enfeksiyon) Vaskülopati (İskemi) Diyabetik Triad

7 Diyabetik Vaskülopati
Diyab Ayak Problemleri mikroanjiopatiden ziyade periferik vasküler hastalıklar (PVH) şeklinde karşımıza çıkmakta, Bilateral büyük ve orta çaplı arterler (A,F,P,Dor Ped, Popl), DM’de PVH yanı sıra endotel kalınlaşması (Mikroanjiyopati),

8 Görüntüleme Doppler USG BT/MR Anjiografi
Konvansiyonel Anjiografi (DSA)

9 Doppler USG Öncelikli tercih Noninvaziv Pratik, kolay uygulanabilir
Real time görüntü Ara basamak ABI ve TCPO2 anormal→invaziv tetkik öncesi Rahman, Abdul, et al. "Vasculopathy in patients with diabetic foot using doppler ultrasound." Pak J Med Sci 25.3 (2009): Schaper, N. C., et al. "Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot." Diabetes/metabolism research and reviews 28.S1 (2012):

10 Doppler USG RDUS=Real Time B Mod+Pulsed Dp
Akım değişikllikeri, Spektral değ. RDUS Sensit (˃%50 sten lez.); %89 ilyak segm.→ % 68 popl. arter %90 ATA-PTA, %82 Peroneal A. (Patens.) Colour Doppler ultrasound (CDUS) combines real-time B-mode imaging and pulsed Doppler flow detection to provide both anatomic details and a physiologic assessment of blood flow at specific arterial sites. Moneta GL, Yeager RA, Antonovic R, et al. Accuracy of lower extremity arterial duplex mapping. J Vasc Surg 1992; 15: 275–284. Schaper, N. C., et al. "Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot." Diabetes/metabolism research and reviews 28.S1 (2012):

11 Doppler USG PAH lokalizasyon ve ciddiyeti, Girişimsel işlem gerekli?
Evet→Endovasküler ted için kılavuz Colour Doppler ultrasound (CDUS) combines real-time B-mode imaging and pulsed Doppler flow detection to provide both anatomic details and a physiologic assessment of blood flow at specific arterial sites. Schaper, N. C., et al. "Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot." Diabetes/metabolism research and reviews 28.S1 (2012):

12 Doppler USG Diyabetik Hastalık →→→Dizaltı arterler!!!!!
Diffüz multisegmenter tutulum Kalsifikasyon Ödem Colour Doppler ultrasound (CDUS) combines real-time B-mode imaging and pulsed Doppler flow detection to provide both anatomic details and a physiologic assessment of blood flow at specific arterial sites. Schaper, N. C., et al. "Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot." Diabetes/metabolism research and reviews 28.S1 (2012):

13 Doppler USG Popliteal arter, Posterior tibial arter*, Dorsalis Pedis Arter* Akım paternleri: Trifazik :Normal Bifazik :Orta derece vaskülopati Monofazik : Ciddi vaskülopati Akım yok : Ciddi vaskülopati Rahman, Abdul, et al. "Vasculopathy in patients with diabetic foot using doppler ultrasound." Pak J Med Sci 25.3 (2009):

14 Doppler USG

15 Doppler USG Popliteal arter, Posterior tibial arter*, Dorsalis Pedis Arter* Poststenotik normal laminer akım: Bifazik akım paterni

16 Doppler USG

17 Doppler USG

18 Doppler USG PRF değerleri çok düşük ayarlanmalı!!!!!

19 Doppler USG

20 BT Anjiografi En az 32 dedektörlü BT IV Noniyonik kontrast madde
Alt eks: Renal arterlerden başlanır! Row data→3D rekonstrüksiyon Güvenilir?? 2 meta analiz (sens. ve spes.) %92-95 ve %93-96 (%50↑ stenoz için) Colour Doppler ultrasound (CDUS) combines real-time B-mode imaging and pulsed Doppler flow detection to provide both anatomic details and a physiologic assessment of blood flow at specific arterial sites. Heijenbrok-Kal MH, Kock MC, Hunink MG. Lower extremity arterial disease: multidetector CT angiography metaanalysis. Radiology 2007; 245: 433–439. Met R, Bipat S, Legemate DA, Reekers JA, Koelemay MJ. Diagnostic performance of computed tomography angiography in peripheral arterial disease: a systematic review andmeta-analysis.JAMA2009;301:415–424.

21 BT Anjiografi Avantajları: Dezavantajları:
Yüksek rezolüsyon (Küçük kalf damarları) Dezavantajları: Ciddi kalsifikasyonlar Radyasyon Nefrotoksik kontrast madde Alerjik reaksiyon Colour Doppler ultrasound (CDUS) combines real-time B-mode imaging and pulsed Doppler flow detection to provide both anatomic details and a physiologic assessment of blood flow at specific arterial sites. Schaper, N. C., et al. "Diagnosis and treatment of peripheral arterial disease in diabetic patients with a foot ulcer. A progress report of the International Working Group on the Diabetic Foot." Diabetes/metabolism research and reviews 28.S1 (2012):

22 BT Anjiografi Colour Doppler ultrasound (CDUS) combines real-time B-mode imaging and pulsed Doppler flow detection to provide both anatomic details and a physiologic assessment of blood flow at specific arterial sites.

23 BT Anjiografi Colour Doppler ultrasound (CDUS) combines real-time B-mode imaging and pulsed Doppler flow detection to provide both anatomic details and a physiologic assessment of blood flow at specific arterial sites. Pomposelli, Frank. "Arterial imaging in patients with lower extremity ischemia and diabetes mellitus." Journal of vascular surgery 52.3 (2010): 81S-91S.

24 BT Anjiografi Koronal MIP Reformat Görüntü Curved Planar Reformat
Colour Doppler ultrasound (CDUS) combines real-time B-mode imaging and pulsed Doppler flow detection to provide both anatomic details and a physiologic assessment of blood flow at specific arterial sites. Koronal MIP Reformat Görüntü Curved Planar Reformat Görüntü Pomposelli, Frank. "Arterial imaging in patients with lower extremity ischemia and diabetes mellitus." Journal of vascular surgery 52.3 (2010): 81S-91S.

25 Kontratlı MR Anjiografi
Minimal invaziv IV Kontrast madde Kontrast öncesi ve sonrası Hibrit protokol (Tibial arter hst) 1) Kontrast + Kalf ve ayak, ↑ uzaysal rezolüsyon 2) 2. kontrast sonrası aortoilyak ve femoral Hibrit: Kalf arterleri için venöz kontaminasyon ↓ Colour Doppler ultrasound (CDUS) combines real-time B-mode imaging and pulsed Doppler flow detection to provide both anatomic details and a physiologic assessment of blood flow at specific arterial sites. DinterDJ,NeffKW,ViscianiG, etal.Peripheralbolus-chaseMRangiography:analysis of risk factors for nondiagnostic image quality of the calf vessels—a combined retrospective and prospective study. AJR AmJ Roentgenol 2009; 193: 234–240. Cornfeld D, Mojibian H. Clinical uses of time-resolved imaging in the body and peripheral vascular system. AJR Am J Roentgenol 2009; 193: W546–W557.

26 Kontratlı MR Anjiografi
Güvenilir?? 1 meta analiz (sens. ve spes.) %94-94 (Periferik arterler için) DM’de (ülser ve tibial arter hast +) hibrit ile yüksek doğruluk, Colour Doppler ultrasound (CDUS) combines real-time B-mode imaging and pulsed Doppler flow detection to provide both anatomic details and a physiologic assessment of blood flow at specific arterial sites. Koelemay MJ, Lijmer JG, Stoker J, Legemate DA, Bossuyt PM. Magnetic resonance angiography for the evaluation of lower extremity arterial disease: a metaanalysis. JAMA 2001; 285: 1338– Andreisek G, Pfammatter T, Goepfert K, Nanz D, Hervo P, Koppensteiner R, Weishaupt D. Peripheral arteries in diabetic patients: standard bolus-chase and time-resolved MR angiography. Radiology 2007; 242: 610–620.

27 Kontratlı MR Anjiografi
Avantajları: ↓Nefrotoksisite (Paramanyetik KM) Radyasyon Ø Dezavantajları: ↓ Rezolüsyon Artefaktlar (Akıma bağlı, Stent vs.) Klostrofobi (GFR˂30 ml/dk)→(Rölatif Kontrend.):NSF Colour Doppler ultrasound (CDUS) combines real-time B-mode imaging and pulsed Doppler flow detection to provide both anatomic details and a physiologic assessment of blood flow at specific arterial sites. Leiner T, Kucharczyk W. NSF prevention in clinical practice: summary of recommendations and guidelines in the United States, Canada, and Europe. J Magn Reson Imaging 2009; 30: 1357–1363.

28 Kontratlı MR Anjiografi
Colour Doppler ultrasound (CDUS) combines real-time B-mode imaging and pulsed Doppler flow detection to provide both anatomic details and a physiologic assessment of blood flow at specific arterial sites. MIP Sub Hıb.

29 Görüntüleme RDUS CEMRA BTA Sensitivite %90 %94 %97 Spesivite %99
%50 üzeri stenoz, dizaltı ve üstü stenozlar için. Collins R, Burch J, Cranny G, et al. Duplex ultrasonography, magnetic resonance angiography, and computed tomography angiography for diagnosis and assessment of symptomatic, lower limb peripheral arterial disease: systematic review. BMJ 2007; 334: 1257.

30 İntraarteryel DSA Yüksek uzaysal rezol.→Altın Std.
Aynı seans Endovask Tedavi Arteryel ponksiyon → Kanama (Hematom vs.), Alerjik reaks, Nefropati (İşlem öncesi hidrasyon faydalı) Colour Doppler ultrasound (CDUS) combines real-time B-mode imaging and pulsed Doppler flow detection to provide both anatomic details and a physiologic assessment of blood flow at specific arterial sites. Leiner T, Kucharczyk W. NSF prevention in clinical practice: summary of recommendations and guidelines in the United States, Canada, and Europe. J Magn Reson Imaging 2009; 30: 1357–1363. Pomposelli F. Arterial imaging in patients with lower extremity ischemia and diabetes mellitus. J Vasc Surg 2010; 52(3 Suppl): 81S–91S.

31 İntraarteryel DSA Colour Doppler ultrasound (CDUS) combines real-time B-mode imaging and pulsed Doppler flow detection to provide both anatomic details and a physiologic assessment of blood flow at specific arterial sites. Pomposelli F. Arterial imaging in patients with lower extremity ischemia and diabetes mellitus. J Vasc Surg 2010; 52(3 Suppl): 81S–91S.

32 Son Söz AVANTAJLAR DEZAVANTAJLAR BTA MRA DSA Noninvaziv
↑ Uzaysal Rezolüsyon Hızlı Multiple Rekonstrüksiyon İmkanı Yaygın kalsifiye aterom plaklar ↑ Miktar Kontrast Madde Kontrast Alerjisi Radyasyon Görüntü Artefaktları MRA Noninvaziv, Radyasyon Ø Yaygın Kalsifiye Aterom Plakları Problem Ø ↓ Uzaysal Rezolüsyon Yavaş Akım Artefaktları NSF DSA ↑↑↑ Uzaysal Rezolüsyon Tanı + Tedavi “Altın Std” İnvaziv (Kompl, kanama vs.) Kontrast Nefropatisi Colour Doppler ultrasound (CDUS) combines real-time B-mode imaging and pulsed Doppler flow detection to provide both anatomic details and a physiologic assessment of blood flow at specific arterial sites. Pomposelli, Frank. "Arterial imaging in patients with lower extremity ischemia and diabetes mellitus." Journal of vascular surgery 52.3 (2010): 81S-91S.

33 Sabrınız İçin Teşekkürler