Four-dimensional CTA detects non-puncture hemorrhage after percutaneous transluminal angioplasty for peripheral arterial disease

Introduction

Peripheral arterial disease (PAD) is a common condition characterized by the narrowing or blockage of arteries that supply blood to the extremities; it often necessitates endovascular interventions, including percutaneous transluminal angioplasty (PTA) (1,2). However, postoperative bleeding remains one of the major complications of PTA (3), and the accurate detection and prompt management of this complication is crucial for optimizing patient outcomes. Computed tomography angiography (CTA) and ultrasound are commonly used methods for identifying hemorrhage sites, but they may be unable to find certain locations, such as those in the collateral branches of blood vessels or others distant from the puncture site. Under such conditions, digital subtraction angiography (DSA), an invasive method, may be the only means to identify the hemorrhage site. Four-dimensional CTA (4D-CTA), as a noninvasive method, may serve as a more favorable alternative.

Case presentation

A 62-year-old man presented to our institution with a three-month history of right leg intermittent claudication. CTA revealed occlusion of the right popliteal artery and severe stenosis of the bilateral femoral arteries, and thus PTA was performed. A retrograde left femoral access was established using palpation of the arterial pulse as guidance. After the right femoral artery was accessed, balloons were sequentially used to dilate the lesions in the anterior tibial artery, popliteal artery, and superficial femoral artery. A stent was implanted in the upper segment of the superficial femoral artery. The puncture site was closed with a vascular closure device and compressed dressing was applied. Before surgery, the patient was instructed to take 75 mg of aspirin once daily, and after surgery, the patient was additionally administered 75 mg of clopidogrel once daily. Preoperative (Figure 1A) and postoperative DSA (Figure 1B) showed that the patient’s occlusion had been successfully managed. All procedures performed in this study were in accordance with the ethical standards of the institutional or national research committees and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article and accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

Figure 1 Preoperative (A) and postoperative DSA (B) showed that the patient’s occlusion was addressed. DSA, digital subtraction angiography.

On postoperative day 2, the patient developed severe pain in his right thigh. Swelling occurred on the inner side of the right thigh without redness or local heat. Due to the lack of significant physical signs to aid in the localization of the bleeding point, the attending physician performed empirical compression bandaging at the puncture site. However, the patient’s pain and thigh swelling did not improve.

On postoperative day 3, the patient underwent a series of imaging examinations. Cinematic volume rendering technology (cVRT) revealed swelling of the right sartorius muscle (Figure 2A,2B), indicating that the site of bleeding was located beneath it. However, due to the limited width of the bandage, it remained necessary to identify the bleeding site with greater precision. Despite the use of CTA, the exact location of the hemorrhage site remained undetermined (Figure 2C).

Figure 2 Preoperative (A) and postoperative cVRT (B) revealed swelling of right sartorius muscle (white arrows), although the precise bleeding site was not determined. CTA also failed to locate the precise hemorrhage site (C). CTA, computed tomography angiography; cVRT, cinematic volume rendering technology.

During this period, multiple anemia-related indicators of the patient showed a progressive decline: the hemoglobin level had decreased to 65 g/L [red blood cell count (RBC): 1.8×10¹²/L] from a preoperative level of 95 g/L (RBC: 2.71×10¹²/L), and blood pressure had decreased to 98/61 mmHg from a preoperative blood pressure of 118/76 mmHg.

Using a third-generation dual-source CT scanner in 4D-CTA mode (80 kVp and 40 mA) with the shuttle bed technique, we injected 40 mL of iodine contrast via the median cubital vein at 4 mL/s. The subsequent imaging scan included a 63-cm range from the hip to upper leg with a duration of 45 seconds and 15 acquisitions (Figure 3). The 4D-CTA approach successfully identified a non-puncture hemorrhagic site within the sartorius muscle, about 22 cm from the anterior superior iliac spine (Video 1).

Figure 3 4D-CTA revealed a minor contrast leakage in the mid-right thigh region (black dashed lines). The affected vessel was a branch of the superficial femoral artery. CTA, computed tomography angiography.

After the application of local pressure and compression bandage, the patient’s blood pressure stabilized at 118/78 mmHg. After one unit of packed red blood cells was administered, the patient’s hemoglobin level increased to 81 g/L (RBC: 2.28×10¹²/L) on postoperative day 4 and remained stable in the following days. Subsequent magnetic resonance imaging corroborated the hemorrhagic signal in the mid-right sartorius muscle, which confirmed the location of the hemorrhage point (Figure 4A,4B).

Figure 4 Magnetic resonance imaging corroborated a hemorrhagic signal in the mid-right sartorius muscle (A,B; white arrows).

Discussion

To our knowledge, this case marks the first instance in which 4D-CTA was used to identify a bleeding site following PTA. Our findings highlight the value of 4D-CTA in detecting bleeding at nonpenetrating sites. By employing dynamic CTA software, we can obtain dynamic 4D-CTA images across all time phases, and this provides a noninvasive alternative to traditional DSA.

Postoperative bleeding is a common complication of peripheral endovascular surgeries, and 16.6% of peripheral endovascular surgeries result in acute access-site complications, including hematomas in 78.6% of cases and significant bleeding in 1.1% (3). These cases of postoperative bleeding primarily occur at the puncture site, while bleeding at non-puncture sites is relatively rare. Non-puncture point bleeding may be caused by intraoperative vascular injury of the sheath or by reperfusion injury after vascular intervention (4). Considering that the position of the guide wire passing through is very close to the bleeding point, we believe that intraoperative vascular injury was the cause of the bleeding in this case.

Accurate hemorrhage localization is critical for optimizing patient outcomes and is primarily achieved via CTA and ultrasound. DSA, the gold standard for this purpose, serves as the preferred alternative when CTA and ultrasound are inadequate, but it is associated with an elevated risk of adverse events due to its invasiveness. Meanwhile, ultrasound enables real-time monitoring of the bleeding site but requires a preliminary identification of the approximate hemorrhagic focus location and tissue depth due to its limited detection range. Multiphase CTA (mCTA), with scanning at 0 s, 5 s, and 10 s after intravenous iodinated contrast administration, is used for collateral circulation assessment in patients with acute ischemic stroke and has been confirmed to be superior to single-phase CTA (sCTA) in collateral evaluation (5). In circumventing the inherent limitations of sCTA and mCTA, Denby et al. demonstrated the ability of 4D-CTA to diagnose spontaneous intracerebral hemorrhage (6). Notably, in the lower extremities characterized by long cardiac distance, sCTA and mCTA, when used at a relatively low temporal resolution, may be unable to detect subtle transient arterial-phase bleeding, especially at non-puncture sites. In contrast, 4D-CTA allows for the dynamic real-time visualization of contrast extravasation, facilitating detection of the transient bleeding foci overlooked by conventional CTA.

The third-generation dual-source CT scanner from Siemens Healthineers enhances this capability with a dynamic acquisition range of up to 63 cm, a gantry rotation time of 250 ms, and a high temporal resolution of 66 ms. Furthermore, the use of low-dose technology significantly reduces the cumulative radiation dose associated with multiphase imaging. The combination of a wide detector, Bv40 convolution, and the full-mode, advanced modeled iterative reconstruction (ADMIRE) algorithm ensures high-quality 4D-CTA images, thereby enhancing the visualization of vascular flow and active bleeding lesions (7-9).

Integrating body surface projection technology with 4D-CTA allows for the accurate localization of externally compressible hemorrhagic sites. One advantage of 4D-CTA lies in its ability to demonstrate tissue-level development alongside specific body surface projection positions, effectively addressing the limitations associated with a narrow field of view inherent to ultrasound. Another advantage is its ability to provide dynamic blood flow signals, which enhances treatment efficacy when compared to conventional CTA.

It is important to acknowledge various limitations associated with 4D-CTA. Notably, 4D-CTA exposes patients to a higher level of radiation than does conventional CTA (10). Post-PTA bleeding typically occurs within thigh blood vessels that are situated closer to sensitive organs such as testes or ovaries, thus increasing their susceptibility to radiation exposure. Advancements in iterative reconstruction techniques and improvements in temporal resolution have allowed clinicians to reduce the cumulative radiation doses involved in multiphase imaging while maintaining spatial resolution (11).

At present, there is a lack of reports on the use of 4D-CTA technology for examining bleeding lesions in the limbs. Previous studies on this subject have primarily focused on the use of 4D-CTA in cerebrovascular diseases, such as stroke, cerebral hemorrhage, and aneurysms (8,9,12). The use of 4D-CTA in lower-limb bleeding lesions remains in its early stages. Future research and clinical practice should examine the potential of 4D-CTA technology to diagnose bleeding lesions of the lower limbs, which may facilitate greater precision and effectiveness in the care of patients.

Conclusions

This report supports the utility of 4D-CTA in effectively diagnosing and managing bleeding sites with a complex location after PTA.

Acknowledgments

None.

Footnote

Funding: This work was supported by the National Natural Science Foundation of China (Nos. 82174382, 12505377).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-aw-2285/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional or national research committees and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article and accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Aboyans V, Ricco JB, Bartelink MEL, Björck M, Brodmann M, Cohnert T, et al. 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteriesEndorsed by: the European Stroke Organization (ESO)The Task Force for the Diagnosis and Treatment of Peripheral Arterial Diseases of the European Society of Cardiology (ESC) and of the European Society for Vascular Surgery (ESVS). Eur Heart J 2018;39:763-816. [Crossref] [PubMed]
2. Patel RAG, White CJ. Progress in peripheral arterial disease. Prog Cardiovasc Dis 2021;65:1. [Crossref] [PubMed]
3. Ciprian Cacuci A, Krankenberg H, Ingwersen M, Gayed M, Stein SD, Kretzschmar D, Schulze PC, Thieme M. Access Site Complications of Peripheral Endovascular Procedures: A Large, Prospective Registry on Predictors and Consequences. J Endovasc Ther 2021;28:746-54. [Crossref] [PubMed]
4. Masuo O, Terada T, Matsumoto H, Tsuura M, Itakura T, Yamaga H, Ozaki F, Moriwaki H, Nakamura Y, Kido T. Haemorrhagic complication following percutaneous transluminal angioplasty for carotid stenosis. Acta Neurochir (Wien) 2000;142:1365-8. [Crossref] [PubMed]
5. Busto G, Morotti A, Carlesi E, Fiorenza A, Di Pasquale F, Mancini S, Lombardo I, Scola E, Gadda D, Moretti M, Miele V, Fainardi E. Pivotal role of multiphase computed tomography angiography for collateral assessment in patients with acute ischemic stroke. Radiol Med 2023;128:944-59. [Crossref] [PubMed]
6. Denby CE, Chatterjee K, Pullicino R, Lane S, Radon MR, Das KV. Is four-dimensional CT angiography as effective as digital subtraction angiography in the detection of the underlying causes of intracerebral haemorrhage: a systematic review. Neuroradiology 2020;62:273-81. [Crossref] [PubMed]
7. Boonen PT, Aerden D. Intraarterial Four-dimensional CT Angiography with Soft Tissue Perfusion Evaluation in Diabetic Feet. Radiology 2023;307:e222663. [Crossref] [PubMed]
8. Kaschka IN, Kloska SP, Struffert T, Engelhorn T, Gölitz P, Kurka N, Köhrmann M, Schwab S, Doerfler A. Clot Burden and Collaterals in Anterior Circulation Stroke: Differences Between Single-Phase CTA and Multi-phase 4D-CTA. Clin Neuroradiol 2016;26:309-15. [Crossref] [PubMed]
9. Cao R, Ye G, Wang R, Xu L, Jiang Y, Wang G, Wang D, Chen J. Collateral Vessels on 4D CTA as a Predictor of Hemorrhage Transformation After Endovascular Treatments in Patients With Acute Ischemic Stroke: A Single-Center Study. Front Neurol 2020;11:60. [Crossref] [PubMed]
10. Denby CE, Chatterjee K, Pullicino R, Lane S, Radon MR, Das KV. Is four-dimensional CT angiography as effective as digital subtraction angiography in the detection of the underlying causes of intracerebral haemorrhage: a systematic review. Neuroradiology 2020;62:273-81. [Crossref] [PubMed]
11. Haubenreisser H, Bigdeli A, Meyer M, Kremer T, Riester T, Kneser U, Schoenberg SO, Henzler T. From 3D to 4D: Integration of temporal information into CT angiography studies. Eur J Radiol 2015;84:2421-4. [Crossref] [PubMed]
12. Cui Y, Xing H, Zhou J, Chen Y, Lin B, Ding S, Zhao H, Pan Y, Wan J, Zhang X, Zhao B. Aneurysm morphological prediction of intracranial aneurysm rupture in elderly patients using four-dimensional CT angiography. Clin Neurol Neurosurg 2021;208:106877. [Crossref] [PubMed]