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Technical Developments |
1 From the Department of Diagnostic and Interventional Radiology, University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany (M.G., H.H.Q., J.F.D., M.E.L., J.B., C.U.H., S.B., H.K., S.G.R.); and Siemens Medical Systems, Erlangen, Germany (M.S.). Received August 8, 2001; revision requested September 28; revision received November 5; accepted January 7, 2002. Address correspondence to M.G. (e-mail: mathias.goyen@uni-essen.de).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMaterials and MethodsResultsDiscussionREFERENCES |
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© RSNA, 2002
Index terms: Angiography, technology, 928.122 • Arteries, extremities • Arteries, MR, 92.129412, 928.12942, 928.12943 • Arteries, stenosis or obstruction, 928.721 • Magnetic resonance (MR), vascular studies, 928.121412, 928.12942, 928.12943
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMaterials and MethodsResultsDiscussionREFERENCES |
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Contrast agent dose limitations had initially restricted 3D MR angiography to the display of arteries contained in a single 40–48-cm field of view. Before bolus-chase MR imaging, extended coverage could be achieved with separate injections in one examination: Two contiguous areas were studied with separate doses of gadolinium-based contrast agent (7,8).
Implementation of bolus-chase techniques extended coverage to two or three territories with a single administration of contrast agent, which permitted assessment of runoff arteries with high sensitivity and specificity in a single sitting (9–12). Implementation of stronger faster gradient systems has laid the foundation for faster MR imaging. Thus, five-station 3D MR angiography that covers the arterial system from head to ankle and excludes the coronary and intracerebral arteries has recently become possible (13). Requiring the body coil for signal transmission and reception, this type of whole-body MR angiography was characterized by suboptimal signal-to-noise ratio (SNR) and, hence, limited spatial resolution (13).
The purpose of this study was to develop and evaluate a self-developed rolling table platform at whole-body 3D MR angiography.
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Materials and Methods |
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TOPABSTRACTINTRODUCTIONMaterials and MethodsResultsDiscussionREFERENCES |
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Whole-body MR angiography is based on the acquisition of five slightly overlapping 3D data sets in immediate succession. The first data set covers the aortic arch, supraaortic branch arteries, and thoracic aorta; second data set, the abdominal aorta with its major branches, including the renal arteries; third data set, the pelvic arteries; fourth data set, the arteries of the thighs; fifth data set, the arteries of the calves.
To plan the five-station 3D data acquisitions, the following protocol for moving-vessel scout imaging was used. For every region, six transverse images (obtained every 7.5 cm) were acquired (repetition time msec/echo time msec/inversion time msec = 539/10/300; flip angle, 50°; section thickness, 8 mm; matrix, 114 x 256; field of view, 400 mm; acquisition time, 20 seconds). The imaging delay for the first 3D data set was calculated on the basis of the travel time of a test bolus of contrast agent from the injection site (antecubital vein) to the proximal third of the descending aorta. After intravenous injection of a 2-mL test bolus (flow rate, 1.3 mL/sec) of gadobenate dimeglumine flushed with 20 mL of saline at a rate of 1.3 mL/sec, transverse single-section multiphase turbo fast low-angle shot, or FLASH, images (1,000/3.2/8; flip angle, 10°; section thickness, 10 mm; matrix, 128 x 256; field of view, 400 x 400 mm) were acquired every second.
For the five-station MR angiographic protocol, a commercially available turbo fast low-angle shot 3D sequence was used (2.1/0.7; flip angle, 25°; 40 partitions interpolated by means of zero filling to 64; slab thickness, 120 mm; section thickness, 3.0 mm interpolated to 1.9 mm; field of view, 390 x 390 mm; matrix, 256 x 225 interpolated by means of zero filling to 512 x 512 readout bandwidth, 863 Hz/pixel). Eighty percent partial Fourier was applied in both phase-encoding directions to reduce the acquisition time to 12 seconds (2.12 msec x 225 x 0.8 x 40 x 0.8 = 12.2 seconds). The k-space sampling was performed linearly and sequentially, starting on the shorter side of k space, to allow the central lines of k space to be sampled after 38% (4.5 of 12.0 msec) of the acquisition time. To avoid any gaps, the 3D data sets were overlapped by 3 cm, which resulted in a craniocaudal coverage of 176 cm. Each 3D data set was collected during 12 seconds. Manual repositioning of the rolling table platform to the next station was accomplished in 3 seconds, which resulted in a cumulative acquisition time of 72 seconds. Gadobenate dimeglumine was automatically injected (MR Spectris; Medrad, Pittsburgh, Pa) at a dose of 0.2 mmol per kilogram of body weight (always diluted with normal saline to a total volume of 60 mL) by using the following biphasic protocol. The first half of the contrast agent volume was injected at a rate of 1.3 mL/sec, and the second half was administered at a rate of 0.7 mL/sec. The contrast agent was flushed with 30 mL of normal saline injected at a flow rate of 1.3 mL/sec.
Subjects
Between March and May 2001, whole-body MR angiography with the rolling table platform was performed with three volunteers (two men and one woman; age range, 28–31 years; mean age, 29 years) without any history of peripheral vascular disease and 10 consecutive patients (eight men and two women; age range, 49–78 years; mean age, 62.3 years) with angiographically documented vascular disease (Fontaine grade IIb, eight patients; grade III, one patient; grade IV, one patient). The patients had been referred for an MR angiographic examination of the peripheral vasculature; digital subtraction angiography (DSA) was performed within 72 hours before MR angiography in all cases. The study protocol was approved by the institutional review board, and informed consent was obtained from all subjects. To determine the effect of the integrated surface coil, the volunteers were examined twice: once without the rolling table platform, with use of the body coil for signal reception, and a second time with the rolling table platform, with use of the integrated torso phased-array surface coil for signal reception.
Rolling Table Platform
For easy movement in the z direction, the rolling table platform was placed on seven pairs of roller bearings, which were anchored within the existing table. The roller bearings were made of polyethylene. The rolling table platform enabled acquisition of as many as six 3D data sets in immediate succession, with a field of view of 400 mm. The platform was used to move a subject over the stationary table. Markers permitted adjustment of the desired field of view.
Signal reception was accomplished by using posteriorly located spine coils and an anteriorly located body phased-array coil, which remained stationary within the bore. The two elements of the spine coil were integrated in the table, and the standard body phased-array coil was anchored in a height-adjustable holder that remained fixed to the stationary table. Thus, data for all five stations were collected with the same stationary coil set positioned in the isocenter of the magnet. By sliding over the subject, the coil holder adapted to the contours of the patient.
The rolling table platform functioned well for all MR examinations. The platform was easily moved and positioned by one person. All examinations were performed without complications, and no adverse events were reported by any of the subjects. No technical failures occurred during injection of the contrast material or during data acquisition. Including patient positioning, all examinations were concluded within 25 minutes. Owing to the interpolation used, substantial reconstruction time was needed because of the software (Numaris, version 3.5; Siemens Medical Systems) in our MR system. With newer software (MR Ease; Siemens Medical Systems), reconstruction time is no longer an issue because imaging and reconstruction can be performed simultaneously.
Conventional DSA
DSA of the pelvic and lower extremity vessels was performed with a standard angiographic unit (Integris; Philips Medical Systems, Best, the Netherlands). All 10 patients underwent angiography, with a transfemorally inserted 5-F pigtail catheter, from the distal aorta (including the renal arteries) to the proximal pedal vessels. At DSA, the catheter tip was positioned just above the branching of the renal arteries to depict the distal aorta. Then, the catheter tip was pulled back to a position just proximal to the aortic bifurcation to assess the pelvic arteries. Finally, multiple images were acquired to encompass the thigh and lower limbs. At each station, 20 mL of contrast material (iobitridole, Xenetix; Guerbet, Aulnay-sous Bois, France) was administered. As required, examinations were supplemented by acquiring one or more oblique views of the pelvic arteries with 20 mL of contrast material. Select catheterization of individual extremities was not necessary in any case.
Image Analyses
For both quantitative and qualitative analyses of the DSA and MR angiographic data sets, the arterial tree was divided into 30 segments: segments 1 and 2, bilateral internal carotid arteries; segments 3 and 4, bilateral common carotid arteries; segment 5, brachiocephalic trunk; segment 6, thoracic aorta; segment 7, suprarenal abdominal aorta; segment 8, infrarenal abdominal aorta; segments 9 and 10, bilateral renal arteries; segments 11 and 12, bilateral common iliac arteries; segments 13 and 14, bilateral external iliac arteries; segments 15 and 16, bilateral common femoral arteries; segments 17 and 18, proximal half of bilateral superficial femoral arteries; segments 19 and 20, distal half of bilateral superficial femoral arteries; segments 21 and 22, bilateral popliteal arteries; segments 23 and 24, bilateral tibioperoneal trunk; segments 25 and 26, bilateral anterior tibial arteries; segments 27 and 28, bilateral peroneal arteries; and segments 29 and 30, bilateral posterior tibial arteries.
For an intraindividual quantitative comparison of the two MR examinations performed with each of the three volunteers, SNRs and contrast-to-noise ratios (CNRs) were calculated on the basis of signal intensity measurements in regions of interest (size range, 4–6 mm) placed (M.G.) in the center of all 30 arterial segments in each subject. SNRs and CNRs were calculated in the usual manner.
Patient DSA and 3D MR angiographic images were evaluated with a prospective qualitative analysis based on a segment-by-segment review. All DSA images were interpreted by a board-certified radiologist (H.K.) who specializes in vascular interventions; he was unaware of the MR angiographic data. The MR angiographic images were reviewed by a board-certified radiologist (S.G.R.) with special training in MR angiography; he was unaware of the DSA results. Analysis of both examinations was based on all images. DSA images and the maximum intensity projection displays were printed on film, with similar magnification factors. Furthermore, both DSA and MR angiographic data sets were available on a workstation that permitted review of the source images and interactive reformatting at the time of interpretation. DSA was used as the standard of reference.
All MR angiographic data sets were first assessed regarding image quality. For this purpose, each arterial segment was characterized as being displayed with either diagnostic or nondiagnostic quality. A vascular segment was regarded as diagnostic when the image quality allowed reliable detection or exclusion of relevant vascular disease. DSA and MR angiographic image sets were further analyzed regarding the presence of vascular disease. Thus, each vascular segment was assessed for the presence of stenoses with (a) luminal narrowing that exceeded 50%, on the basis of the most severe reduction of the arterial diameter compared with the most normal appearing segment proximal or distal to the area of arterial compromise; (b) vessel occlusion; or (c) aneurysmal disease.
Statistical Analysis
Intraindividual quantitative comparison was performed of the two MR examinations for each of the three volunteers. Student t test analysis was used to determine the effect on image quality of the rolling table platform with integrated surface coils.
For all vessel segments with DSA correlation in the 10 patients, overall sensitivities and specificities were calculated for the detection of significant stenoses (luminal narrowing, >50%).
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Results |
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TOPABSTRACTINTRODUCTIONMaterials and MethodsResultsDiscussionREFERENCES |
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The improved SNRs and CNRs with the rolling table platform were also reflected in the qualitative analysis. Enhancement of the portal venous system resulted in some venous overlap of the arterial system in the abdomen (n = 3). Selective reformation of the respective vascular region ensured unimpaired display of the arteries in all cases. Similarly, reliable assessment of the renal arteries as far as the hilum was possible in all cases, despite some enhancement of one renal vein. Venous enhancement was also evident in some calf veins (n = 3). Again, interactive multiplanar reformations allowed a comprehensive analysis of the trifurcation arteries.
In the 10 patients, 213 of the 220 arterial segments were depicted at DSA. The suprarenal abdominal aorta could not be assessed in seven of the patients because the catheter was placed directly above the level of branching of the renal arteries. Abnormalities were identified in 43 segments (Table 2). In addition to the 213 segments depicted at DSA, an additional 67 segments were depicted at whole-body 3D MR angiography with the rolling table platform, for a total of 280 arterial segments as a result of the extended coverage. Abnormalities were present in three arterial segments not studied with DSA (Table 3). Analysis was limited to the 213 arterial segments seen with both modalities.
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At whole-body MR angiography, coverage of the entire arterial system depicted three vascular diseases relevant for treatment that were not suspected clinically: two high-grade stenoses of the carotid artery (internal and external) (Fig 3) and one thoracic aortic aneurysm. Although initially unsuspected, the internal carotid lesion was found to be symptomatic after the patient underwent focused questioning. To confirm the diagnosis, high-spatial-resolution single-station 3D MR angiography of the neck arteries was performed, and a 5.2-cm-diameter high-grade stenosis of the internal carotid artery was detected. Close follow-up was chosen for this patient.
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Discussion |
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TOPABSTRACTINTRODUCTIONMaterials and MethodsResultsDiscussionREFERENCES |
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Despite recognition that atherosclerotic disease is a systemic disease that affects the entire arterial system, the diagnostic approach to atherosclerosis has remained segmental, until now. This approach largely reflects limitations inherent in DSA, including the risk for radiation exposure, contrast agent dose limitations, or complications, and economic factors. High diagnostic accuracy coupled with noninvasiveness and lack of contrast material–induced nephrotoxicity have driven the rapid clinical integration of 3D MR angiography for assessment of virtually all vascular territories. Parenchymal enhancement and contrast agent dose limitations had initially restricted this technique to the display of vascular territory in a single 40–48-cm field of view.
By implementing bolus-chase techniques with integrated table motion algorithms, as many as three contiguous vascular territories can be imaged (12). Thus, the pelvic and runoff arteries can be assessed in a single examination (9,10). Results of evaluation of runoff arteries regarding the presence of hemodynamically significant disease have been excellent, with sensitivity and specificity ranging from 89% to 95% and from 93% to 98%, respectively (9,10). However, careful analysis of the image data reveals some technique-related limitations. Reflecting the need to use the body coil for imaging over several vascular territories, these limitations relate to poor SNR and therefore limited spatial resolution. Hence, delineation of small arteries that are potentially needed for surgical grafting can be challenging (6). Recognizing the limitations inherent in a strategy based on use of a body coil for signal reception and transmission, Yamashita et al (11) and Ruehm et al (12) used a surface coil for signal reception. Improved SNRs obviated time-consuming image subtractions (14).
With the latest high-performance imagers and gradients, acquisition time for a complete 3D data set could be reduced further. By shortening the repetition time to 2.1 msec, a 3D data set could be collected in 12 seconds. Thus, as many as five 3D data sets could be collected within the intraarterial contrast phase of slightly more than 60 seconds. Crucial to this concept is the availability of a means for rapid patient relocation from one territory to the next. To acquire five 3D data sets, the patient must be relocated four times. With the rolling table platform, the patient could be moved to each predefined location in 3 seconds. A similar approach for imaging of the lower extremities with a bolus-chase MR angiographic technique performed with another prototype stepping table and coil holder was introduced by Wang et al in 1998 (15).
With reduced repetition times, signal is suppressed in all tissues, which accounts for the lack of a statistically significant difference between SNRs and CNRs in this study. Well-suppressed signal in the tissues surrounding the arteries obviates fat saturation, time-consuming image subtraction algorithms, and collection of nonenhanced data sets for image subtraction. Thus, the examination time is shortened by half, and data postprocessing is greatly facilitated. Reduction in signal intensity in the arteries is compensated by narrowing of the contrast agent bolus and use of a phased-array torso surface coil. In this study, the volunteer data confirm an increase in SNR by a factor of 3 with the surface coil compared to that with the body coil. Improved signal in the arterial system due to use of a phased-array torso surface coil directly translates into an increase in achievable spatial resolution, which was 0.8 x 0.8 x 2.0 mm (postinterpolation pixel size) in this protocol. This increase enabled better delineation of smaller vessels, especially the tibial vessels.
The craniocaudal length of the phased-array torso surface coil is 28 cm, but the field of view extends to 40 cm. However, there can be a decrease in signal intensity on both ends of the coil. Therefore, it is useful to acquire data sets with a minimum 3-cm overlap. By taking the overlap on both ends of territories 2–4 into account, the overall craniocaudal coverage extended to 176 cm. The coverage is sufficient to depict the arterial system from the carotid arteries to the distal trifurcation arteries in most adult patients.
All 10 patients underwent a DSA protocol to depict the runoff vessels, renal arteries, and abdominal aorta. Select catheterization was not necessary at the time of the examination in any of the 10 patients. Although the DSA protocol covered the renal arteries in all cases, whole-body MR angiography displayed 67 more arterial segments, three of which were found to be diseased. Thus, extension of coverage to encompass the entire arterial tree helped detection of significant disease in three of 10 patients. The high degree of concomitant arterial disease in patients with peripheral vascular disease is not surprising but underscores the systemic nature of atherosclerosis. Similar observations have been made regarding the coexistence of coronary and renal artery disease (16). The fact that two unsuspected carotid lesions were identified helps highlight that patient questioning is focused on symptoms too often. Since all 10 patients presented with symptoms suggestive of peripheral vascular disease, the patients’ histories were focused on that region. Only very direct questioning revealed additional symptoms that suggested carotid disease in one patient.
To ensure maximal arterial enhancement, gadobenate dimeglumine, which is a paramagnetic contrast agent with high intravascular relaxivity owing to some degree of albumin binding (17), was used. Gadobenate dimeglumine is not approved for MR angiography. As in many other studies, it was used in an off-label manner. Furthermore, a biphasic injection protocol was used. The first two 3D data sets (thoracic and abdominal aorta) were collected with a relatively high flow rate (1.3 mL/sec), whereas the last three data sets were collected with a lower flow rate (0.7 mL/sec), to minimize venous contamination in the distal stations. This protocol proved robust and easy to use, and diagnostic images of the entire arterial tree were provided in all subjects. Venous overlap caused by the presence of contrast agent in the portal venous system (n = 3), left renal vein (n = 1), and tibial veins (n = 3) did not impair analysis of the arterial system that was based on multiplanar reformations.
Use of the whole-body rolling table platform revealed some deficits. First, the whole-body MR angiographic examination did not cover the intracranial or coronary arteries, which require a dedicated approach for diagnostic assessment. Another limitation of this study relates to the small number of patients and diseased vascular segments. Clearly, the clinical performance of the rolling table platform needs to be validated in larger patient cohorts. Furthermore, only one reviewer interpreted the DSA and MR angiographic images. Finally, examination with the rolling table platform might not be suitable for all patients because there are limitations with regard to a patient’s body width. The rolling table platform reduced the bore height by 5 cm. Examination of very large patients may be precluded, but this was not a problem for the 10 patients in this study.
In conclusion, whole-body MR angiography with the rolling table platform provided images of diagnostic quality for the arterial vasculature and offered craniocaudal coverage of 176 cm. This protocol shows promise for use as one comprehensive examination to assess the entire arterial system for manifestations of atherosclerotic disease.
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FOOTNOTES |
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Author contributions: Guarantors of integrity of entire study, M.G., J.F.D., S.G.R.; study concepts, M.G., H.H.Q., S.G.R.; study design, M.G., M.E.L., M.G., J.F.D., S.G.R.; literature research, M.G., H.H.Q., C.U.H.; clinical studies, M.G., S.B., C.U.H.; data acquisition, M.G., M.E.L., S.B., C.U.H., M.S.; data analysis/interpretation, J.B., H.K., S.G.R.; statistical analysis, M.G., S.G.R., J.B., M.S.; manuscript preparation, M.G., S.G.R.; manuscript definition of intellectual content, M.G., S.G.R., J.F.D.; manuscript editing, M.G., C.U.H.; manuscript revision/review, J.F.D., S.G.R.; manuscript final version approval, M.G., J.F.D., S.G.R.
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