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The British Journal of Radiology logoLink to The British Journal of Radiology
. 2020 May 6;93(1113):20200103. doi: 10.1259/bjr.20200103

Vascular findings on FDG PET/CT

Stephen Liddy 1,2,1,2, Andrew Mallia 3, Conor D Collins 1,2,1,2, Ronan P Killeen 1,2,1,2, Stephen Skehan 1,2,1,2, Jonathan D Dodd 1, Manil Subesinghe 4,5,4,5, David J Murphy 1,2,1,2,✉
PMCID: PMC7465845  PMID: 32356457

Abstract

Since its introduction into clinical practice, 2-deoxy-2-[18F]flu-D-glucose (FDG) positron emission tomography/computed tomography (PET/CT) has become firmly established in the field of oncological imaging, with a growing body of evidence demonstrating its use in infectious and inflammatory vascular pathologies. This pictorial review illustrates the utility of FDG PET/CT as a diagnostic tool in the investigation of vascular disease and highlights some of the more common incidental vascular findings that PET reporters may encounter on standard oncology FDG PET/CTs, including atherosclerosis, large vessel vasculitis, complications of vascular grafts, infectious aortitis and acute aortic syndromes.

Introduction

Since its introduction into clinical practice, 2-deoxy-2-[18F]flu-D-glucose (FDG) positron emission tomography/computed tomography (PET/CT) has become firmly established in the field of oncological imaging, with a growing body of evidence demonstrating its use in infectious and inflammatory vascular pathologies, particularly large vessel vasculitis.1 This pictorial review illustrates the utility of FDG PET/CT as a diagnostic tool in the investigation of vascular disease and highlights some of the more common incidental vascular findings that PET reporters may encounter on standard oncology FDG PET/CTs.

Atherosclerosis

It is recognised that atherosclerosis is more than simply a flow limiting process and that atheromatous plaque represents a nidus for inflammation.2 Management of vascular disease is often determined by the degree of luminal stenosis, however this simple anatomical quantification fails to consider the degree of inflammation and its associated risk of plaque rupture. The limitations of conventional anatomical imaging in the assessment of atherosclerosis have led to increased interest in non-invasive functional imaging which can identify features of plaque vulnerability and disease activity.3

Atherosclerotic plaque often manifests as focal, usually low-grade, patchy FDG uptake along the aortic wall, which frequently corresponds with atheromatous plaque on the CT component (Figure 1). The ability to measure plaque inflammation was described in early work by Rudd et al where FDG uptake successfully differentiated between symptomatic and asymptomatic carotid atheroma, a finding which has since been confirmed in larger studies.4 In addition, higher FDG uptake in carotid atheroma has also been shown to be associated with a high risk of stroke, independent of the severity of luminal stenosis.5

Figure 1.

Figure 1.

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A 55-year-old male underwent FDG PET/CT for investigation of suspected lymphoma. Axial non-contrast CT (A) and FDG PET (B) show low-grade focal FDG uptake (black arrow) in non-calcified atherosclerotic plaque of the descending thoracic aorta (solid white arrow) as well as an adjacent inactive calcified plaque (dashed white arrow). FDG,[18F]flu-D-glucose; PET, positronemission tomography.

FDG uptake correlates closely between different arterial territories, suggesting a systemic upregulation of inflammation rather than a localised phenomenon6; FDG uptake in the aorta has been shown to reflect the clinical severity of coronary syndromes, with greater aortic uptake in patients with recent myocardial infarction compared with those with stable angina.7 Similarly, carotid uptake is significantly higher in patients with acute coronary syndromes than those with chronic stable angina.8

Broad adoption of FDG PET/CT in the evaluation of atherosclerosis is limited by availability, cost and radiation exposure, and it remains mainly in the research setting. Nevertheless, PET reporters should consider including incidental atherosclerotic plaque in the PET/CT report in appropriate patients, particularly the presence of coronary artery calcification, given the significant morbidity and mortality associated with cardiovascular disease among cancer survivors.9–11

Vasculitis

Primary vasculitides are a group of relatively rare inflammatory diseases characterised by inflammation of the wall of blood vessels. Categorisation is based on the size of the vessel affected into small-, medium- or large vessel vasculitis (LVV). LVV primarily affects the aorta and its major branches and is classically divided into two distinct entities—giant cell arteritis (GCA) and Takayasu arteritis (TAK). The two conditions share many similarities: both are chronic idiopathic granulomatous autoimmune vasculitides which show a dramatic response to steroid therapy. However, GCA tends to affect patients > 50 years of age, whereas TAK typically affects females of childbearing age and has a higher incidence among Asian populations.12

Establishing a diagnosis of LVV is challenging. The diagnostic criteria of the American College of Rheumatology are the most widely used, however such criteria rely heavily on signs and symptoms of arterial stenosis.13 By the time morphological changes in the vessel calibre have developed, the disease is already in a late stage.

The primary advantage of FDG PET/CT in the setting of LVV lies in its ability to detect vascular inflammation early in the disease process before morphological changes have taken hold. LVV classically appears as smooth, circumferential, increased FDG uptake involving the aorta and great vessels (Figures 2–5), in distinction to atheromatous plaque which has low-grade, patchy, discontinuous uptake. Superficial temporal artery involvement may be identified in patients with GCA.14 PET/CT can also help identify atypical sites of disease involvement which may go undetected on conventional imaging, such as the coronary arteries (Figure 6). A standardised 4-point scale qualitatively comparing vascular uptake to liver uptake has been recommended in the investigation of LVV.15 Vascular wall uptake greater than liver (Grade 3) is considered positive for LVV, with uptake equal to liver (Grade 2) indicating possible LVV. Uptake less than liver (Grade 1) or completely absent (Grade 0) is considered negative for LVV. In our experience, use of the rotating maximum intensity projection (MIP) images is very useful in the detection of LVV.

Figure 2.

Figure 2.

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A 72-year-old male with giant cell arteritis underwent PET/CT for staging of synchronous colon and lung cancers. MIP (A) shows increased FDG uptake in the subclavian, carotid and femoral arteries (solid arrows) consistent with active vasculitis. Focal FDG uptake secondary to a right lung cancer (dashed arrow) and two synchronous colonic tumours of the caecum and splenic flexure (arrowheads) are also shown. Axial PET (B) and fused PET/CT (C) show increased FDG uptake in the wall of the ascending and descending thoracic aorta (arrows). Axial fused PET/CT (D) shows focal FDG uptake centred on the wall of the splenic flexure (arrowhead). FDG,[18F]flu-D-glucose; MIP, maximumintensity projection; PET, positron emission tomography.

Figure 3.

Figure 3.

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A 68-year-old male underwent FDG PET/CT for staging of lung cancer. MIP (A), axial non-contrast CT (B) and fused FDG PET/CT (C) show aortic wall thickening and periaortic soft tissue (white arrow) with increased FDG uptake (curved black arrow), which was an incidental finding. The subclavian artery uptake is within normal limits. Retroperitoneal fibrosis was considered but further areas of non-FDG avid arterial wall thickening (not shown) were more suggestive of a systemic vasculitis. Giant cell arteritis was confirmed on temporal artery biopsy. An FDG avid pulmonary mass at the left lung base (straight black arrow) and mediastinal lymphadenopathy (black arrowhead) are also shown. FDG,[18F]flu-D-glucose; MIP, maximumintensity projection; PET, positron emission tomography.

Figure 4.

Figure 4.

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A 60-year-old male with recently diagnosed IgG4 disease of the orbit underwent FDG PET/CT to assess for extra orbital disease. Fused coronal FDG PET/CT shows smooth circumferential FDG uptake within the wall of the aortic root (arrow) consistent with IgG4-related large vessel vasculitis. The patient had no history of aortic surgery. FDG,[18F]flu-D-glucose; PET, positronemission tomography.

Figure 5.

Figure 5.

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A 62-year-old male with giant cell arteritis and polymyalgia rheumatica underwent FDG PET/CT to assess disease activity. MIP image from an FDG PET/CT shows increased FDG uptake in the aorta, carotid and subclavian arteries (arrows) consistent with active large vessel vasculitis. FDG,[18F]flu-D-glucose; MIP, maximumintensity projection; PET, positron emission tomography.

Figure 6.

Figure 6.

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A 42-year-old male with IgG4-related retroperitoneal fibrosis underwent FDG PET/CT for surveillance of disease activity while on therapy. Axial non-contrast CT (A), FDG PET (B) and repeat examination performed 3 years later (C, D) show interval development of soft tissue thickening (white arrow) surrounding the LAD coronary artery with focal FDG uptake (black arrow), consistent with IgG4-related vasculitis. The patient had an LAD territory myocardial infarction 6 weeks following the second study. MIP (E) shows diffusely increased FDG uptake around the wall of the abdominal aorta and proximal common iliac arteries (arrowhead). FDG,[18F]flu-D-glucose; LAD, leftanterior descending; MIP, maximum intensity projection; PET, positron emissiontomography.

A meta-analysis of 21 studies showed that FDG PET/CT accurately detected LVV (GCA and TAK), with a sensitivity and specificity of 0.9 and 0.98 for GCA, and 0.84 and 0.84 for TAK respectively.16 FDG PET/CT is also of value in assessing disease activity and monitoring response to therapy. Several studies have demonstrated reduced FDG uptake following successful immunosuppressive therapy, although faint uptake is often seen several months following treatment, and complete normalisation of uptake is seen in less than 20% of patients.17 FDG uptake can be expected to decrease in response to successful therapy within 4–12 weeks of initiating treatment.

Complications of vascular grafts

Vascular prosthetic graft infection (VPGI) is a rare but severe complication of prosthetic graft replacement occurring in 0.5–5% of cases.18 Axillofemoral grafts are most commonly affected, with intra-abdominal grafts having the lowest incidence of graft infection. Reported risk factors include prolonged pre-operative stay, post-operative bacteraemia, end-stage renal disease, obesity, malnutrition/older age, low serum albumin, smoking, diabetes mellitus, prior irradiation, autoimmune disease/corticosteroid therapy, malignancy and chemotherapy.18

Diagnosis of VGPI can be challenging, particularly in cases of low-grade infection. FDG PET/CT is a useful imaging modality in the investigation of VPGI. A recent meta-analysis reported high sensitivity and moderate specificity of 0.96 and 0.74, respectively of FDG PET for the detection of VPGI.19 Most studies evaluating its accuracy have relied on a visual assessment. Mild linear uptake along the graft usually represents inflammation following surgery, particularly in the first 3 months, although this can persist for years due to a foreign body reaction20 (Figure 7). Infected grafts typically demonstrate intense focal FDG uptake or focal-on-diffuse FDG uptake (Figures 8–11), with intense focal uptake the most accurate PET sign.19 A maximum standardised uptake value (SUVmax) >8 in the perigraft area has been proposed as the optimal cut-off value for distinguishing infected from non-infected grafts.19

Figure 7.

Figure 7.

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A 72-year-old female underwent FDG PET/CT for staging of colonic carcinoma. The patient had undergone aorto-bi-iliac bypass surgery 5 years previously for lower limb claudication and was well at the time of PET/CT. Inflammatory markers were normal. MIP (A), axial FDG PET (B) and axial non-contrast CT (C) show low-grade FDG uptake along the length of an aorto-bi-iliac graft (black arrows). Diffuse low-grade activity associated with vascular prostheses may persist for years following surgery. Note, the heavily calcified native aorta (white arrow) medial to the aortic prosthesis. FDG,[18F]flu-D-glucose; MIP, maximumintensity projection; PET, positron emission tomography.

Figure 8.

Figure 8.

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A 64-year-old male presented with fever 2 months post open repair of an abdominal aortic aneurysm. FDG PET/CT was performed to assess for graft infection. MIP (A) and axial fused FDG PET/CT (B) show intense focal-on-diffuse FDG uptake along the length of the abdominal aorta (solid arrows) consistent with graft infection. Axial CT (C) shows periaortic soft tissue thickening and gas within the aortic wall (dashed arrow) . Blood cultures grew Staphylococcus aureus. MIP image from a repeat FDG PET/CT (D) following 3 months of antibiotic therapy shows an interval reduction in FDG uptake. Reactive FDG avid hilar lymphadenopathy had also developed in the interim (arrowheads). FDG,[18F]flu-D-glucose; MIP, maximumintensity projection; PET, positron emission tomography.

Figure 9.

Figure 9.

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A 50-year-old male with a background of Marfan’s syndrome presented with fever and abdominal pain. He had undergone repair of an abdominal aortic aneurysm 5 months previously. FGD PET/CT was performed to assess for graft infection and determine its extent. MIP (A), axial FDG PET (B) and axial fused FDG PET/CT (C) showing focal-on-diffuse FDG uptake along an infrarenal aorto-bi-iliac graft (arrows) consistent with graft infection. FDG, [18F]flu-D-glucose; MIP, maximumintensity projection; PET, positron emission tomography.

Figure 10.

Figure 10.

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A 64-year-old male who had undergone femoral bypass surgery 6 weeks previously presented with fever and left groin pain. FDG PET/CT was performed to evaluate for graft infection and to assess its extent. MIP (A), axial fused FDG PET/CT (B) and axial non-contrast CT (C) showing focal-on-diffuse FDG uptake along a femoral–femoral crossover graft (arrows) consistent with graft infection. Blood cultures grew Staphylococcus aureus. FDG,[18F]flu-D-glucose; MIP, maximumintensity projection; PET, positron emission tomography.

Figure 11.

Figure 11.

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A 70-year-old male who had undergone endovascular aortic aneurysm repair eight years previously underwent FDG PET/CT for pyrexia of unknown origin. Axial PET (A), non-contrast CT (B) and fused FDG PET/CT (C) show increased FDG uptake within paravertebral and para-aortic soft tissue (solid arrows) consistent with discitis complicated by aortic endograft infection. Note, the aortic bifurcation graft (curved arrows) and the surrounding gas within the excluded aneurysm sac (dashed arrows). Blood cultures grew Staphylococcus aureus. FDG,[18F]flu-D-glucose; MIP, maximumintensity projection; PET, positron emission tomography.

Endovascular aneurysm repair is the treatment of choice in a majority of patients with an abdominal aortic aneurysm. Up to 20% of patients will experience some form of stent graft complication with 5 years of endovascular aneurysm repair.21 Endoleaks are the most common complication and may lead to sac expansion and contribute to sac rupture, and are usually detected with duplex ultrasonography or CT angiography. Although not used in the investigation of endoleaks, FDG PET/CT may incidentally detect endoleaks by the presence of blood pool activity within the excluded aneurysm sac in patients undergoing imaging for other indications (Figure 12).22 In addition to graft infection and endoleaks, complications related to the arterial access site may also be detected, such as arterial pseudoaneurysms (Figure 13).

Figure 12.

Figure 12.

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An 84-year-old female who had recently undergone endovascular repair of an aortic abdominal aneurysm. FDG PET/CT was performed for investigation of aortic graft infection due to low grade fever and raised inflammatory markers. Axial fused FDG PET/CT (A) shows faint activity (arrow) in the excluded aneurysm sac. Axial contrast-enhanced CT angiogram (B) performed subsequently confirms an endoleak, likely arising from a lumbar branch (arrowheads). FDG,[18F]flu-D-glucose; PET, positronemission tomography.

Figure 13.

Figure 13.

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A 68-year-old male underwent FDG PET/CT for investigation of recurrent lung cancer. He had a coronary angiogram via right common femoral artery access for stable angina the day before. MIP (A) and axial fused FDG PET/CT (B) show low-grade activity in the right groin (solid arrows). Doppler ultrasound (C) shows turbulent swirling blood flow consistent with a pseudoaneurysm. The pulmonary lobe (arrow head) and linear uptake related to previous sternotomy (dashed arrows) are also evident. FDG, [18F]flu-D-glucose; MIP, maximum intensity projection; PET, positron emission tomography.

Infectious aortitis

While CT is the primary modality for the investigation on infectious aortitis, FDG PET/CT may be of value in more challenging cases. Murukami et al looked at 11 cases in which infected aortic aneurysms were suspected based on clinical symptoms and raised inflammatory markers. All 11 patients underwent pre-operative FDG PET/CT and post-operative pathological examination of the aortic wall. FDG PET/CT reliably distinguished between infected and non-infected cases, with infection showed an SUVmax >4.46 compared with SUVmax <2.59 in non-infected aneurysms.23 Moreover, FDG PET/CT may also be of value in monitoring a response to therapy. A 2008 report described a case of infectious aortitis secondary to Salmonella enteritides in which a reduction in FGD uptake following successful therapy was observed before the morphological changes on CT had resolved.24 Several further reports also describe cases in which FGD PET/CT provided valuable additional information.25–27

Acute aortic syndrome

Acute aortic syndrome is a spectrum of emergency conditions, encompassing penetrating atherosclerotic ulcer, intramural haematoma and aortic dissection. They are life-threatening conditions that require prompt diagnosis and treatment. FDG PET/CT is unsuited to the emergency setting due to its limited availability and long acquisition times, but may incidentally detect cases of chronic dissection and chronic intramural haematoma in patients undergoing imaging for other indications (Figure 14). Moreover, there is some evidence to suggest that PET/CT may be of value in discriminating acute from chronic aortic dissection, and in identifying patients with acute aortic syndromes who are at increased risk of disease progression. Reeps et al reported on 18 patients with acute, symptomatic progressive or stable chronic aortic dissection and found the SUVmax of the dissection membrane or aortic wall was significantly higher in acute dissections than in chronic stable dissections.28 In addition, Sakalihasan looked at 23 patients with acute descending aortic dissections and found that elevated FDG uptake was associated with an increased risk of secondary complications.29

Figure 14.

Figure 14.

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An 82-year-old male with a history of melanoma underwent FDG PET/CT for staging of recurrent disease of the left lower limb. Axial (A) and sagittal (B) fused FDG PET/CT images show unexpected crescentic photopenia inseparable from the anterior aspect of the ascending thoracic aorta (solid arrows); the patient reported a prior history of acute chest discomfort but had not sought medical attention at that time. Axial (C) and sagittal (D) contrast-enhanced CT angiogram images performed shortly afterwards confirm the presence of a type A IMH (dashed arrows) with likely culprit penetrating atherosclerotic ulcer (*) arising anteriorly from the distal ascending thoracic aorta. FDG,[18F]flu-D-glucose; IMH, intramuralhaematoma; PET, positron emission tomography.

Conclusion

Incidental vascular findings on FDG PET/CT can be highly clinically significant, and PET/CT reporters should be familiar with their appearances and the additional value FDG PET/CT can offer in such cases.

Contributor Information

Stephen Liddy, Email: stephenliddy@gmail.com.

Andrew Mallia, Email: mallia.and@gmail.com.

Conor D Collins, Email: ccollins@svhg.ie.

Ronan P Killeen, Email: RP.Killeen@st-vincents.ie.

Stephen Skehan, Email: stephenskehan@me.com.

Jonathan D Dodd, Email: jonniedodd@gmail.com.

Manil Subesinghe, Email: manil.subesinghe@kcl.ac.uk.

David J Murphy, Email: david.murphy@st-vincents.ie.

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