The Use of Noninvasive Angiography for Digital Ischemia in Raynaud's Disease

Surgical intervention in Raynaud's disease can include interposition vein or arterial grafting, balloon angioplasty or open sympathectomy, with decision-making critical on individual angiographic features. Despite this, noninvasive angiographic techniques, particularly with advanced imaging technologies, have not been described. A recent article by Kim et al, “Classification of Raynaud's disease based on angiographic features,”[1] highlighted the necessity of angiography in this setting, with only catheter angiography used in each case, in which iodinated contrast is injected through the femoral artery. However, although catheter angiography may be sensitive in the imaging of hand ischemia, there exist distinct drawbacks to its use. We would like to offer our experience in the use of noninvasive, advanced imaging modalities for angiography.

Complications from catheter angiography are well established: first, arterial puncture is not without risk and diagnostic angiography performed via the femoral artery has been associated with air embolism, deep venous thrombosis, external iliac artery dissection, hematoma, and bleeding.[2] Any arterial access through the upper limbs in this cohort may further compromise perfusion to the distal extremities. Furthermore, conventional angiography provides limited information on bony and soft-tissue deformities that may contribute to the underlying pathology. Perhaps most importantly, iodinated contrast material has been shown to be associated with microvascular endothelial damage, which may further exacerbate the degree of tissue ischemia through microvascular spasm or thrombosis.[3]

Advanced imaging technologies have progressed such that high-resolution images can be produced of sufficient efficacy to match the benefits of conventional angiography. The use of computed tomographic angiography (CTA) and magnetic resonance angiography (MRA), though not described for imaging in Raynaud's disease, have been described in the imaging of other causes of hand ischemia, with results highlighting their efficacy when compared with catheter angiography.[4] Although CTA avoids most of the previously listed complications of conventional angiography, it still requires the use of iodinated contrast media, and thus is still of potential risk to the hand microvasculature.

MRA avoids all of the aforementioned complications, and offers high-resolution images for planning management in Raynaud's disease. [Fig. 1] highlights one such unique case, in which MRA was used in the imaging of a 28-year-old woman with severe Raynaud's disease who presented with ischemic ulceration of several fingertips. MRA mapping of the vasculature of the hand was able to demonstrate the absence of a superficial palmar arch, the presence of a deep palmar arch with no contribution to flow to the digital vessels, and a uniquely dominant dorsal metacarpal arterial system supplying the digital vessels. Although there have not been any acute risks to microvasculature described with gadolinium contrast, there is a theoretical risk of free radical production with continuous exposure to gadolinium contrast.[5] As such, MRA may be considered the preferred imaging modality in the setting of hand and peripheral ischemia.

Figure 1 Magnetic resonance angiogram performed for the mapping of the vasculature of the hand in Raynaud's disease. Imaging demonstrated the absence of a superficial palmar arch, the presence of a deep palmar arch with no contribution to flow to the digital vessels, and a uniquely dominant dorsal metacarpal arterial system supplying the digital vessels.

• References

• 1 Kim YH, Ng SW, Seo HS, Chang Ahn H. Classification of Raynaud's disease based on angiographic features. J Plast Reconstr Aesthet Surg 2011; 64: 1503-1511
• 2 Balduf LM, Langsfeld M, Marek JM, Tullis MJ, Kasirajan K, Matteson B. Complication rates of diagnostic angiography performed by vascular surgeons. Vasc Endovascular Surg 2002; 36: 439-445
• 3 Sumimura T, Sendo T, Itoh Y , et al. Calcium-dependent injury of human microvascular endothelial cells induced by a variety of iodinated radiographic contrast media. Invest Radiol 2003; 38: 366-374
• 4 Yuen JC, Wright E, Johnson LA, Culp WC. Hypothenar hammer syndrome: an update with algorithms for diagnosis and treatment. Ann Plast Surg 2011; 67: 429-438
• 5 Vassallo DV, Simões MR, Furieri LB , et al. Toxic effects of mercury, lead and gadolinium on vascular reactivity. Braz J Med Biol Res 2011; 44: 939-946