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Leg Ischemia: Assessment with MR Angiography and Spectroscopy¹

¹ From the Swiss Cardiovascular Center, Division of Angiology (I.B., O.K., C.S.) and Departments of Diagnostic, Interventional, and Pediatric Radiology (H.C.T., C.R.), University Hospital Bern, Freiburgstrasse 10, 3010 Bern, Switzerland; and Department for Clinical Research (MR Spectroscopy and Methodology), University of Bern, Bern, Switzerland (C.B., R.K.). Received September 8, 2003; revision requested November 20; final revision received June 23, 2004; accepted June 29. Supported by the Swiss National Science Foundation (4037–055161, 3100–065315, 3100059082). Address correspondence to H.C.T. (e-mail: harriet.thoeny@insel.ch).

View larger version (82K): [in a new window]   Figure 1. Patient 2. Coronal maximum intensity projection from contrast-enhanced three-dimensional gradient-echo MR angiography (4.6/1.8) at calf level in a 47-year-old man (reliability study) shows large collateral vessels (arrowhead), small collateral vessels (arrow), and occlusion of anterior tibial artery (*).

View larger version (16K): [in a new window]   Figure 2. Graph depicts recovery times (reoxygenation) of ischemia-induced deoxymyoglobin at 1H MR spectroscopy at proximal and distal calf correlated with anatomic extent and level of arterial occlusive disease, as graded with the six-point anatomic score.

View larger version (94K): [in a new window]   Figure 3a. Patient 3. Coronal maximum intensity projections from contrast-enhanced three-dimensional gradient-echo MR angiography (4.6/1.8) at the level of calf in an 84-year-old man show increased visualization of collateral vessels after pVEGF-C gene therapy. (a) Baseline, (b) 3 months after single-dose gene therapy, and (c) 9 months after multiple-dose gene therapy.

View larger version (86K): [in a new window]   Figure 3b. Patient 3. Coronal maximum intensity projections from contrast-enhanced three-dimensional gradient-echo MR angiography (4.6/1.8) at the level of calf in an 84-year-old man show increased visualization of collateral vessels after pVEGF-C gene therapy. (a) Baseline, (b) 3 months after single-dose gene therapy, and (c) 9 months after multiple-dose gene therapy.

View larger version (90K): [in a new window]   Figure 3c. Patient 3. Coronal maximum intensity projections from contrast-enhanced three-dimensional gradient-echo MR angiography (4.6/1.8) at the level of calf in an 84-year-old man show increased visualization of collateral vessels after pVEGF-C gene therapy. (a) Baseline, (b) 3 months after single-dose gene therapy, and (c) 9 months after multiple-dose gene therapy.

View larger version (45K): [in a new window]   Figure 4. Patient 3. Graphs in a patient who underwent 1H MR spectroscopy of deoxymyoglobin and pVEGF-C gene therapy. Data points for the second examination (top row) were recorded 4 months after single-dose pVEGF-C gene therapy, with clinical deterioration and development of new ischemic lesions. Data points for the third examination (bottom row) were recorded after additional multiple-dose pVEGF-C gene therapy, with complete healing of lesions. In distal and proximal locations, third examination revealed clear shortening of the recovery time due to improved perfusion compared with that in second examination. Mb = myoglobin.

View larger version (6K): [in a new window]   Figure 5a. Patient 3. (a) Summed 1H MR spectrum (2.2-7.6 minutes after application of the cuff) and (b) 1H MR spectra of deoxymyoglobin as function of time demonstrate the spectral quality of the deoxymyoglobin signal at 78 ppm and its temporal course. The deoxymyoglobin signal arises during application of the pressure cuff for the first 7 minutes. Each spectrum corresponds to the average of 128 acquisitions, while each data point in Figure 4 represents the average of 64 acquisitions. The spectra correspond to baseline measurements in the proximal location (recovery time, 2.4 minutes). The small signals near 120 ppm are the infolded residual peaks of water and fat.

View larger version (110K): [in a new window]   Figure 5b. Patient 3. (a) Summed 1H MR spectrum (2.2-7.6 minutes after application of the cuff) and (b) 1H MR spectra of deoxymyoglobin as function of time demonstrate the spectral quality of the deoxymyoglobin signal at 78 ppm and its temporal course. The deoxymyoglobin signal arises during application of the pressure cuff for the first 7 minutes. Each spectrum corresponds to the average of 128 acquisitions, while each data point in Figure 4 represents the average of 64 acquisitions. The spectra correspond to baseline measurements in the proximal location (recovery time, 2.4 minutes). The small signals near 120 ppm are the infolded residual peaks of water and fat.