HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Rofsky, N. M. Articles by Adelman, M. A. Search for Related Content PubMed PubMed Citation Articles by Rofsky, N. M. Articles by Adelman, M. A.

MR Angiography in the Evaluation of Atherosclerotic Peripheral Vascular Disease¹

¹ From the Departments of Radiology (N.M.R.) and Surgery (M.A.A.), New York University Medical Center, MRI-Basement, Schwartz Bldg, 530 First Ave, New York, NY 10016. Received November 9, 1998; revision requested January 5, 1999; revision received July 30; accepted August 11. Address reprint requests to N.M.R. (e-mail: rofsky @mri.med.nyu.edu).   N.M.R. receives research support from Berlex Laboratories and is a member of the Speaker's Bureau for Berlex Laboratories.

View larger version (106K): [in a new window]   Figure 1a. Symptomatic iliac artery occlusive disease, diagnosed with gadolinium-enhanced MR angiography and treated with angiographically guided stent placement. (a) Coronal MIP image from a gadolinium-enhanced 3D MR angiographic study (5/2 [repetition time msec/echo time msec], 25° flip angle) performed with administration of gadopentetate dimeglumine at 0.1 mmol/kg demonstrates bilateral severe proximal iliac artery stenoses, with the right greater than the left (arrows). (Reprinted, with permission, from reference 37.) (b) The next anatomic station was imaged 10 minutes after the preceding study with a second dose of gadopentetate dimeglumine (0.1 mmol/kg) by using a slightly faster sequence (3.2/1.2, 20° flip angle). There is no occlusive disease. (c) Preangioplasty digital subtraction angiogram confirms the bilateral high-grade proximal common iliac artery stenoses. (Reprinted, with permission, from reference 37.) (d) Digital subtraction angiogram following angioplasty and stent placement demonstrates markedly improved inflow. This patient remains free of symptoms 2 years after treatment, at the time of this writing. (Reprinted, with permission, from reference 37.)

View larger version (98K): [in a new window]   Figure 1b. Symptomatic iliac artery occlusive disease, diagnosed with gadolinium-enhanced MR angiography and treated with angiographically guided stent placement. (a) Coronal MIP image from a gadolinium-enhanced 3D MR angiographic study (5/2 [repetition time msec/echo time msec], 25° flip angle) performed with administration of gadopentetate dimeglumine at 0.1 mmol/kg demonstrates bilateral severe proximal iliac artery stenoses, with the right greater than the left (arrows). (Reprinted, with permission, from reference 37.) (b) The next anatomic station was imaged 10 minutes after the preceding study with a second dose of gadopentetate dimeglumine (0.1 mmol/kg) by using a slightly faster sequence (3.2/1.2, 20° flip angle). There is no occlusive disease. (c) Preangioplasty digital subtraction angiogram confirms the bilateral high-grade proximal common iliac artery stenoses. (Reprinted, with permission, from reference 37.) (d) Digital subtraction angiogram following angioplasty and stent placement demonstrates markedly improved inflow. This patient remains free of symptoms 2 years after treatment, at the time of this writing. (Reprinted, with permission, from reference 37.)

View larger version (111K): [in a new window]   Figure 1c. Symptomatic iliac artery occlusive disease, diagnosed with gadolinium-enhanced MR angiography and treated with angiographically guided stent placement. (a) Coronal MIP image from a gadolinium-enhanced 3D MR angiographic study (5/2 [repetition time msec/echo time msec], 25° flip angle) performed with administration of gadopentetate dimeglumine at 0.1 mmol/kg demonstrates bilateral severe proximal iliac artery stenoses, with the right greater than the left (arrows). (Reprinted, with permission, from reference 37.) (b) The next anatomic station was imaged 10 minutes after the preceding study with a second dose of gadopentetate dimeglumine (0.1 mmol/kg) by using a slightly faster sequence (3.2/1.2, 20° flip angle). There is no occlusive disease. (c) Preangioplasty digital subtraction angiogram confirms the bilateral high-grade proximal common iliac artery stenoses. (Reprinted, with permission, from reference 37.) (d) Digital subtraction angiogram following angioplasty and stent placement demonstrates markedly improved inflow. This patient remains free of symptoms 2 years after treatment, at the time of this writing. (Reprinted, with permission, from reference 37.)

View larger version (116K): [in a new window]   Figure 1d. Symptomatic iliac artery occlusive disease, diagnosed with gadolinium-enhanced MR angiography and treated with angiographically guided stent placement. (a) Coronal MIP image from a gadolinium-enhanced 3D MR angiographic study (5/2 [repetition time msec/echo time msec], 25° flip angle) performed with administration of gadopentetate dimeglumine at 0.1 mmol/kg demonstrates bilateral severe proximal iliac artery stenoses, with the right greater than the left (arrows). (Reprinted, with permission, from reference 37.) (b) The next anatomic station was imaged 10 minutes after the preceding study with a second dose of gadopentetate dimeglumine (0.1 mmol/kg) by using a slightly faster sequence (3.2/1.2, 20° flip angle). There is no occlusive disease. (c) Preangioplasty digital subtraction angiogram confirms the bilateral high-grade proximal common iliac artery stenoses. (Reprinted, with permission, from reference 37.) (d) Digital subtraction angiogram following angioplasty and stent placement demonstrates markedly improved inflow. This patient remains free of symptoms 2 years after treatment, at the time of this writing. (Reprinted, with permission, from reference 37.)

View larger version (102K): [in a new window]   Figure 2a. Improved imaging of disease with an oblique view. (a) Frontal MIP image from a gadolinium-enhanced MR angiographic study (3.8/1.3, 30° flip angle) acquired in 23 seconds appears normal. (b) Oblique projection offers a different perspective, from which the presence of a high-grade, short-segment stenosis (arrow) in the proximal right superficial femoral artery can be realized. For treatment, it is essential to improve flow at this most proximal lesion.

View larger version (101K): [in a new window]   Figure 2b. Improved imaging of disease with an oblique view. (a) Frontal MIP image from a gadolinium-enhanced MR angiographic study (3.8/1.3, 30° flip angle) acquired in 23 seconds appears normal. (b) Oblique projection offers a different perspective, from which the presence of a high-grade, short-segment stenosis (arrow) in the proximal right superficial femoral artery can be realized. For treatment, it is essential to improve flow at this most proximal lesion.

View larger version (115K): [in a new window]   Figure 3a. Use of transverse reformation to diagnosis an occult aneurysm. (a) Frontal oblique MIP image from a gadolinium-enhanced MR angiographic study (4.0/1.6, 30° flip angle) acquired in 23 seconds shows aneurysmal disease in the femoral arteries bilaterally (arrows). Note slight prominence of the right hypogastric artery (arrowhead). (b) Transverse reformation obtained from the same data set used to generate the MIP image reveals a right hypogastric artery aneurysm with peripherally based thrombus (arrows). The thrombotic material does not enhance and therefore is not depicted with the MIP image. This is a clinically relevant lesion that requires treatment to eliminate the risk of rupture.

View larger version (96K): [in a new window]   Figure 3b. Use of transverse reformation to diagnosis an occult aneurysm. (a) Frontal oblique MIP image from a gadolinium-enhanced MR angiographic study (4.0/1.6, 30° flip angle) acquired in 23 seconds shows aneurysmal disease in the femoral arteries bilaterally (arrows). Note slight prominence of the right hypogastric artery (arrowhead). (b) Transverse reformation obtained from the same data set used to generate the MIP image reveals a right hypogastric artery aneurysm with peripherally based thrombus (arrows). The thrombotic material does not enhance and therefore is not depicted with the MIP image. This is a clinically relevant lesion that requires treatment to eliminate the risk of rupture.

View larger version (139K): [in a new window]   Figure 4a. Overestimation of segmental occlusions with TOF imaging. (a) Coronal MIP image obtained with TOF imaging (repetition time [TR] = triggered; echo time [TE] = 7 msec; 70° flip angle) demonstrates bilateral iliac artery occlusions, with right greater than left. The occlusive segments are depicted between the thick arrows for the right side and between the thin arrows for the left side. Note numerous collateral vessels (open arrow). (Reprinted, with permission, from reference 46.) (b) MIP image from a gadolinium-enhanced 3D MR angiogram obtained after administration of gadopentetate dimeglumine. MIP image was obtained just minutes prior to the TOF data and shows a shorter length of each occlusion compared with a. Also note the depiction of the right hypogastric artery (arrow), which was not seen with TOF imaging. Suppression of the signal from retrograde flow is a major limitation of TOF strategies designed to eliminate venous signal. H = direction of head. (Reprinted, with permission, from reference 46.)

View larger version (135K): [in a new window]   Figure 4b. Overestimation of segmental occlusions with TOF imaging. (a) Coronal MIP image obtained with TOF imaging (repetition time [TR] = triggered; echo time [TE] = 7 msec; 70° flip angle) demonstrates bilateral iliac artery occlusions, with right greater than left. The occlusive segments are depicted between the thick arrows for the right side and between the thin arrows for the left side. Note numerous collateral vessels (open arrow). (Reprinted, with permission, from reference 46.) (b) MIP image from a gadolinium-enhanced 3D MR angiogram obtained after administration of gadopentetate dimeglumine. MIP image was obtained just minutes prior to the TOF data and shows a shorter length of each occlusion compared with a. Also note the depiction of the right hypogastric artery (arrow), which was not seen with TOF imaging. Suppression of the signal from retrograde flow is a major limitation of TOF strategies designed to eliminate venous signal. H = direction of head. (Reprinted, with permission, from reference 46.)

View larger version (38K): [in a new window]   Figure 5. Illustrations of hypothetical distributions of atherosclerotic occlusive peripheral vascular disease, including surgical incisions for routing of bypass grafts. Occluded segments are indicated in black. Graft segments are indicated by arrows.A, This femoral artery-distal posterior tibial artery bypass graft originates from an area of normal inflow to an area with normal outflow around the levels of occlusive disease. B, Femoral-proximal anterior tibial artery bypass graft procedure is best performed with a lateral infrageniculate exposure of the recipient vessel. If the proximal peroneal artery were chosen as a graft insertion site, a medial approach would be preferred. C, Femoral-distal anterior tibial artery bypass graft procedure is performed through a distal lateral exposure. That exposure also is sufficient for a distal peroneal artery bypass. The osseous landmarks can be used to help identify the outflow vessel and thus guide the surgical approach. (Reprinted, with permission, from reference 37.)

View larger version (79K): [in a new window]   Figure 6. A "blind" popliteal segment. This frontal MIP image from a 2D TOF MR angiogram (TR = triggered; TE = 7 msec; 70° flip angle) shows a popliteal artery (long arrow) that is isolated from the circulation. Note the relatively long length of that segment, as well as the numerous collateral vessels (short arrows). In this case, a bypass to that popliteal segment would be preferred over a longer bypass to an infrageniculate segment. (Reprinted, with permission, from reference 37.)

View larger version (80K): [in a new window]   Figure 7a. Evaluations of the pedal arteries with conventional digital subtraction angiography, TOF MR angiography, and intraoperative angiography. (a) Sagittal MIP image from a 2D TOF MR angiogram of the foot (TR = triggered; TE = 7 msec; 70° flip angle) demonstrates an isolated segment of dorsalis pedis artery (solid arrow), as well as incomplete posterior tibial artery segments (open arrows). (b) Conventional digital subtraction angiogram obtained prior to MR angiography does not depict any outflow vessel in the foot because of multiple-level occlusive disease and a limited delivery of contrast medium to the foot. (c) After depicting the occult pedal artery with MR angiography, an anterior tibial-dorsalis pedis bypass procedure was performed. This intraoperative angiogram shows outflow through the dorsalis pedis artery (long arrow), as well as plantar collateral vessels (short arrow).

View larger version (110K): [in a new window]   Figure 7b. Evaluations of the pedal arteries with conventional digital subtraction angiography, TOF MR angiography, and intraoperative angiography. (a) Sagittal MIP image from a 2D TOF MR angiogram of the foot (TR = triggered; TE = 7 msec; 70° flip angle) demonstrates an isolated segment of dorsalis pedis artery (solid arrow), as well as incomplete posterior tibial artery segments (open arrows). (b) Conventional digital subtraction angiogram obtained prior to MR angiography does not depict any outflow vessel in the foot because of multiple-level occlusive disease and a limited delivery of contrast medium to the foot. (c) After depicting the occult pedal artery with MR angiography, an anterior tibial-dorsalis pedis bypass procedure was performed. This intraoperative angiogram shows outflow through the dorsalis pedis artery (long arrow), as well as plantar collateral vessels (short arrow).

View larger version (98K): [in a new window]   Figure 7c. Evaluations of the pedal arteries with conventional digital subtraction angiography, TOF MR angiography, and intraoperative angiography. (a) Sagittal MIP image from a 2D TOF MR angiogram of the foot (TR = triggered; TE = 7 msec; 70° flip angle) demonstrates an isolated segment of dorsalis pedis artery (solid arrow), as well as incomplete posterior tibial artery segments (open arrows). (b) Conventional digital subtraction angiogram obtained prior to MR angiography does not depict any outflow vessel in the foot because of multiple-level occlusive disease and a limited delivery of contrast medium to the foot. (c) After depicting the occult pedal artery with MR angiography, an anterior tibial-dorsalis pedis bypass procedure was performed. This intraoperative angiogram shows outflow through the dorsalis pedis artery (long arrow), as well as plantar collateral vessels (short arrow).

View larger version (124K): [in a new window]   Figure 8a. Improved TOF MIP images with use of a restricted volume of interest. (a) Vascular anatomy of popliteal and tibial artery segments was obtained with electrocardiographically triggered 2D TOF imaging (TR = triggered; TE = 10 msec; 70° flip angle) by using spine phased-array coil. This coronal MIP image was generated from transverse source images by using the full volume of interest. The MIP algorithm incorporates relatively bright pixels from posterior soft tissues that are close to the coil. (b) Collapsed view of transverse source image data depicts the anterior and posterior extent of the vessels. This view allows the operator to exclude bright nonvascular soft tissues by restricting the volume of interest (box). Circle indicates the center about which MIP images would be generated. (c) Restrictedvolume-of-interest coronal MIP image yields a better demonstration of the vascular anatomic structures. The right posterior tibial artery (long arrow) is now depicted, as are the midtibial vessels on the left (short arrows). Spine phased-array coil allows longer segments of anatomic structure to appear on the MIP image compared with head or conventional extremity coils.

View larger version (74K): [in a new window]   Figure 8b. Improved TOF MIP images with use of a restricted volume of interest. (a) Vascular anatomy of popliteal and tibial artery segments was obtained with electrocardiographically triggered 2D TOF imaging (TR = triggered; TE = 10 msec; 70° flip angle) by using spine phased-array coil. This coronal MIP image was generated from transverse source images by using the full volume of interest. The MIP algorithm incorporates relatively bright pixels from posterior soft tissues that are close to the coil. (b) Collapsed view of transverse source image data depicts the anterior and posterior extent of the vessels. This view allows the operator to exclude bright nonvascular soft tissues by restricting the volume of interest (box). Circle indicates the center about which MIP images would be generated. (c) Restrictedvolume-of-interest coronal MIP image yields a better demonstration of the vascular anatomic structures. The right posterior tibial artery (long arrow) is now depicted, as are the midtibial vessels on the left (short arrows). Spine phased-array coil allows longer segments of anatomic structure to appear on the MIP image compared with head or conventional extremity coils.

View larger version (125K): [in a new window]   Figure 8c. Improved TOF MIP images with use of a restricted volume of interest. (a) Vascular anatomy of popliteal and tibial artery segments was obtained with electrocardiographically triggered 2D TOF imaging (TR = triggered; TE = 10 msec; 70° flip angle) by using spine phased-array coil. This coronal MIP image was generated from transverse source images by using the full volume of interest. The MIP algorithm incorporates relatively bright pixels from posterior soft tissues that are close to the coil. (b) Collapsed view of transverse source image data depicts the anterior and posterior extent of the vessels. This view allows the operator to exclude bright nonvascular soft tissues by restricting the volume of interest (box). Circle indicates the center about which MIP images would be generated. (c) Restrictedvolume-of-interest coronal MIP image yields a better demonstration of the vascular anatomic structures. The right posterior tibial artery (long arrow) is now depicted, as are the midtibial vessels on the left (short arrows). Spine phased-array coil allows longer segments of anatomic structure to appear on the MIP image compared with head or conventional extremity coils.

View larger version (95K): [in a new window]   Figure 9a. Bolus chase technique with manual patient movement performed following the insertion of an axillofemoral and femorofemoral graft. (a) Oblique coronal MIP image of the first anatomic region obtained during the infusion of gadolinium chelate with a 3D gradient-echo sequence (4.0/1.6, 30° flip angle) acquired in 22 seconds. The distal right axillary graft component (long arrow) is depicted, as is the crossover (femorofemoral) graft (arrowheads), in this patient who had achieved only a partial result following thrombolytic therapy for infrarenal aortoiliac occlusive disease (short arrows). Contrast-enhanced MR angiography is useful for demonstrating both graft segments in a short acquisition time. (b) The next anatomic segment was obtained immediately after a by manually moving the patient with the use of a plastic board. This coronal MIP image shows a good depiction of the left trifurcation, and a high-grade stenosis (arrow) is noted at the origin of the right tibial-peroneal trunk. There is an occlusion of the right anterior tibial artery.

View larger version (89K): [in a new window]   Figure 9b. Bolus chase technique with manual patient movement performed following the insertion of an axillofemoral and femorofemoral graft. (a) Oblique coronal MIP image of the first anatomic region obtained during the infusion of gadolinium chelate with a 3D gradient-echo sequence (4.0/1.6, 30° flip angle) acquired in 22 seconds. The distal right axillary graft component (long arrow) is depicted, as is the crossover (femorofemoral) graft (arrowheads), in this patient who had achieved only a partial result following thrombolytic therapy for infrarenal aortoiliac occlusive disease (short arrows). Contrast-enhanced MR angiography is useful for demonstrating both graft segments in a short acquisition time. (b) The next anatomic segment was obtained immediately after a by manually moving the patient with the use of a plastic board. This coronal MIP image shows a good depiction of the left trifurcation, and a high-grade stenosis (arrow) is noted at the origin of the right tibial-peroneal trunk. There is an occlusion of the right anterior tibial artery.

View larger version (45K): [in a new window]   Figure 10. Bolus chase technique with 3D gradient-echo technique (6.0/2.2, 30° flip angle) and automated table movement in a patient with claudication. Three separate coronal MIP images of overlapping regions of vascular anatomic structures are presented in continuous display. A, The aortoiliac segment shows occlusion of the infrarenal abdominal aorta and the common iliac arteries (long arrows), with reconstitution of the distal external iliac arteries. B, There are bilateral segmental occlusions of the superficial femoral arteries (short arrows) with reconstitution of the popliteal arteries via profunda collateral vessels. C, Disease at the popliteal arteries is seen bilaterally with geniculate collateral vessels (arrowheads) reconstituting three-vessel runoff in both legs. The pre- and postcontrast data sets were obtained with only 200 seconds of examination time for both. However, procedural setup and proper positioning require a greater overall table time.