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Stepping-Table Gadolinium- enhanced Digital Subtraction MR Angiography of the Aorta and Lower Extremity Arteries: Preliminary Experience¹

¹ From the Depts of Magnetic Resonance Imaging (J.F.M.M., A.R.) and Medical Physics (J.P.R., A.R., M.A.S.), Leeds General Infirmary, United Kingdom; Dept of Radiology, Bradford Royal Infirmary, Leeds (S.C.); Dept of Radiology, St James University Hospital, Leeds (I.R., D.K.); and Philips Medical Systems, Best, the Netherlands (M.K., A.K.). Received Oct 8, 1997; revision requested Nov 24; final revision received Aug 19, 1998; accepted Nov 5. Supported by Northern and Yorkshire Research and Development Directorate. Address reprint requests to J.F.M.M., CT Department, Jubillee Wing, Leeds General Infirmary, Leeds LS2 1EX, United Kingdom.

View larger version (33K): [in a new window]   Figure 1. The two components of the Glide `n' Go are slid onto the rail running up the center of the table support. A–C, Masks for image subtraction in the precontrast image acquisition phase. A, Imaging position for acquisition of the first precontrast image, which is obtained in the legs. The table top is pulled back until the ankles lie within the lower part of the imaging field. The two pieces of the Glide `n' Go device are fixed to the rail on the table by tightening the brass thumb screws. The two pieces lie in contact with one another, with the "glider" lying firmly in contact with the back of the table. B, For acquisition of the second precontrast image, the table is moved to the position that is midway between the imaging position for the legs and the thighs to ensure equal overlap of the imaging volumes at the cranial and caudal aspects. The glider is moved from its earlier position to lie against the back of the table top and fixed firmly in this position; the "stopper" remains in position. The second precontrast image (mask for the thighs) is acquired in this position. C, Acquisition of the third precontrast image. Without moving the parts of the Glide `n' Go device, the table is moved to the imaging position for the aortoiliac segments, and the third mask is acquired in this position. D–F, Postcontrast image acquisition. D, After a 30-second delay from the start of the contrast material infusion, the first gadolinium-enhanced images are acquired in the same position as that in C. Therefore, no further registration of pre- and postcontrast images is required. E, On completion of imaging, the table is pulled back until it lies in contact with the glider. The postcontrast image set for the thighs is acquired in this position. During image acquisition, the glider is moved back to its original position in contact with the stopper and fixed at this location. F, For the final data set (ie, postcontrast images of the legs) the table is pulled back until it comes to lie in contact with the glider, and image acquisition is commenced. 3&4, 2&5, and 1&6 refer to the pairs of pre- and postcontrast images acquired at the same location in the order in which they were obtained.

View larger version (55K): [in a new window]   Figure 2. Subtracted MIP image of the legs in the anteroposterior position. There is good depiction of the entire vasculature of the lower extremities. There is widespread atheroma affecting the distal aorta in addition to significant stenoses affecting the right common iliac artery at its origin (1), the right common femoral artery (2), and the right superficial femoral artery (3). There is a short occlusion of the middle superficial femoral artery (4) but good runoff into the calf vessels. On the left, there is stenosis of the common femoral artery (5) and mild stenosis of the horizontal portion of the left anterior tibial artery (6).

View larger version (54K): [in a new window]   Figure 3a. Comparison of (a) MR angiography and (b) DSA (anteroposterior projection). There is occlusion of the left external iliac artery (curved arrow) beyond its origin, with reconstitution of flow at the level of the common femoral artery from the collateral arteries. Note the enlarged left lumbar collateral artery (arrowheads), which is seen equally well on the MR angiogram and digital subtraction angiogram. There is occlusion of both superficial femoral arteries at their origins (straight solid arrows), with reconstitution of distal flow on both sides at the level of the adductor canal (open arrows) by the marked collateral vessels (C) from the profunda femoral arteries. There is better demonstration of the below-the-knee arteries (B) on the MR angiogram (a), especially on the left.

View larger version (51K): [in a new window]   Figure 3b. Comparison of (a) MR angiography and (b) DSA (anteroposterior projection). There is occlusion of the left external iliac artery (curved arrow) beyond its origin, with reconstitution of flow at the level of the common femoral artery from the collateral arteries. Note the enlarged left lumbar collateral artery (arrowheads), which is seen equally well on the MR angiogram and digital subtraction angiogram. There is occlusion of both superficial femoral arteries at their origins (straight solid arrows), with reconstitution of distal flow on both sides at the level of the adductor canal (open arrows) by the marked collateral vessels (C) from the profunda femoral arteries. There is better demonstration of the below-the-knee arteries (B) on the MR angiogram (a), especially on the left.

View larger version (52K): [in a new window]   Figure 4a. Comparison of (a) MR angiography and (b) DSA (anteroposterior projection). There is occlusion of the left common and external iliac arteries. Note the large lumbar collateral artery (large solid arrow) that arises from the right common iliac artery just beyond its origin. On the MR angiogram, there is reconstitution of flow in the left common femoral artery (curved solid arrow in a) from the collateral vessels (large arrowheads); however, the left common femoral artery is not demonstrated on the digital subtraction angiogram and appears to be occluded. On the right side, there is a tight stenosis (curved open arrow) of the common iliac artery at its origin and diffuse atheroma throughout the remainder of its length. There is occlusion of both superficial femoral arteries from their origins and reconstitution of flow from the marked collateral vessels (C) to the middle distal superficial femoral arteries on both sides (short open arrows), with normal popliteal arteries bilaterally. Note the slight misregistration in the legs due to slight movement between the pre- and postcontrast image acquisitions. The infrapopliteal vessels (three small solid arrows in a) were not demonstrated on the initial DSA image; therefore, delayed imaging was necessary to demonstrate the runoff vessels on both sides. The catheter was pulled back into the right external iliac artery, and selective contrast material injection was performed on this side; selective contrast material injection in the left iliac artery was impossible because of the left common iliac arterial occlusion. Note the severe disease affecting the right anterior tibial artery (short solid arrow), which is occluded just beyond its origin. The tibioperoneal trunk and peroneal artery are normal, but the posterior tibial artery is occluded. On the left, there is diffuse disease affecting all three runoff vessels, but the left anterior tibial artery (small arrowheads) is seen better on the MR angiogram than on the digital subtraction angiogram. Small left posterior tibial and peroneal arteries are seen on both the MR angiogram and digital subtraction angiogram.

View larger version (49K): [in a new window]   Figure 4b. Comparison of (a) MR angiography and (b) DSA (anteroposterior projection). There is occlusion of the left common and external iliac arteries. Note the large lumbar collateral artery (large solid arrow) that arises from the right common iliac artery just beyond its origin. On the MR angiogram, there is reconstitution of flow in the left common femoral artery (curved solid arrow in a) from the collateral vessels (large arrowheads); however, the left common femoral artery is not demonstrated on the digital subtraction angiogram and appears to be occluded. On the right side, there is a tight stenosis (curved open arrow) of the common iliac artery at its origin and diffuse atheroma throughout the remainder of its length. There is occlusion of both superficial femoral arteries from their origins and reconstitution of flow from the marked collateral vessels (C) to the middle distal superficial femoral arteries on both sides (short open arrows), with normal popliteal arteries bilaterally. Note the slight misregistration in the legs due to slight movement between the pre- and postcontrast image acquisitions. The infrapopliteal vessels (three small solid arrows in a) were not demonstrated on the initial DSA image; therefore, delayed imaging was necessary to demonstrate the runoff vessels on both sides. The catheter was pulled back into the right external iliac artery, and selective contrast material injection was performed on this side; selective contrast material injection in the left iliac artery was impossible because of the left common iliac arterial occlusion. Note the severe disease affecting the right anterior tibial artery (short solid arrow), which is occluded just beyond its origin. The tibioperoneal trunk and peroneal artery are normal, but the posterior tibial artery is occluded. On the left, there is diffuse disease affecting all three runoff vessels, but the left anterior tibial artery (small arrowheads) is seen better on the MR angiogram than on the digital subtraction angiogram. Small left posterior tibial and peroneal arteries are seen on both the MR angiogram and digital subtraction angiogram.

View larger version (58K): [in a new window]   Figure 5a. Comparison of (a) MR angiography and (b) DSA (anteroposterior projection). The aortoiliac system is normal bilaterally. There is occlusion of the right superficial femoral artery at its origin (large straight arrow), with reconstitution of flow into a normal distal superficial femoral artery (curved arrow). The normal popliteal artery and runoff arteries on the right are seen equally well on the MR angiogram and digital subtraction angiogram. On the left, the normal common and external iliac arteries are seen. The proximal and middle superficial femoral arteries appear to be normal, but there is occlusion of the distal superficial femoral artery (open arrow), which is seen equally well on the MR angiogram and digital subtraction angiogram. In both a and b, the popliteal, tibial peroneal, and proximal anterior tibial arteries are occluded, but there is good depiction of the left anterior artery (arrowheads) and posterior tibial artery, and diffuse atheroma throughout the peroneal artery (small arrows) on the MR angiogram (a). DSA failed to demonstrate the anterior tibial artery; there is only faint opacification of the posterior tibial and peroneal arteries.

View larger version (48K): [in a new window]   Figure 5b. Comparison of (a) MR angiography and (b) DSA (anteroposterior projection). The aortoiliac system is normal bilaterally. There is occlusion of the right superficial femoral artery at its origin (large straight arrow), with reconstitution of flow into a normal distal superficial femoral artery (curved arrow). The normal popliteal artery and runoff arteries on the right are seen equally well on the MR angiogram and digital subtraction angiogram. On the left, the normal common and external iliac arteries are seen. The proximal and middle superficial femoral arteries appear to be normal, but there is occlusion of the distal superficial femoral artery (open arrow), which is seen equally well on the MR angiogram and digital subtraction angiogram. In both a and b, the popliteal, tibial peroneal, and proximal anterior tibial arteries are occluded, but there is good depiction of the left anterior artery (arrowheads) and posterior tibial artery, and diffuse atheroma throughout the peroneal artery (small arrows) on the MR angiogram (a). DSA failed to demonstrate the anterior tibial artery; there is only faint opacification of the posterior tibial and peroneal arteries.