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Published online before print February 19, 2003, 10.1148/radiol.2271020488
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(Radiology 2003;227:277-282.)
© RSNA, 2003

Technical Developments

Detection of Atherosclerosis: Systemic Imaging for Systemic Disease with Whole-Body Three-dimensional MR Angiography— Initial Experience1

Mathias Goyen, MD, Christoph U. Herborn, MD, Knut Kröger, MD, Thomas C. Lauenstein, MD, Jörg F. Debatin, MD, MBA and Stefan G. Ruehm, MD

1 From the Departments of Diagnostic and Interventional Radiology (M.G., C.U.H., T.C.L., J.F.D., S.G.R.) and Angiology (K.K.), University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany. Received April 29, 2002; revision requested June 21; revision received June 28; accepted August 15. Address correspondence to M.G. (e-mail: mathias.goyen@uni-essen.de)


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 Materials and Methods
Results
 Discussion
 REFERENCES
 
In 100 consecutive patients with peripheral vascular disease whole-body three-dimensional magnetic resonance (MR) angiography was performed by using the rolling table platform system with a 1.5-T MR unit and five three-dimensional MR angiographic data sets during 72 seconds (0.2 mol per kilogram of body weight of gadobenate dimeglumine). Apart from the proved peripheral vascular disease, additional clinically relevant disease was found in 33 segments in 25 patients as follows: renal arterial narrowing (n = 15), carotid arterial stenosis (n = 12), subclavian arterial stenosis (n = 2), and abdominal aortic aneurysms (n = 4). Confirmatory studies performed in 11 patients in this study revealed no false-positive or false-negative findings at examination.

© RSNA, 2003

Index terms: Aneurysm, abdominal, 981.73 • Arteries, abnormalities, 9*.721, 9*.7312 • Arteries, extremities, 92.721 • Arteries, MR, 9*.129412, 9*.12942, 92.12942, 98.12942 • Arteriosclerosis, 9*.721


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
Materials and Methods
Results
 Discussion
 REFERENCES
 
As the population ages, atherosclerotic disease is becoming more prevalent. With 90% of identified atherosclerotic lesions being below the aortic bifurcation, the lower limbs are the most frequently affected vascular territory. Presently, peripheral vascular disease (PVD) accounts for 50,000–60,000 cases of percutaneous transluminal angioplasty, implantation of 110,000 vascular prostheses, and 100,000 cases of amputation annually in the United States alone (1,2).

The treatment of a patient adversely affected by PVD has to be seen in the context of the epidemiology of the disease and, in particular, in the context of apparent risk factors or markers that are used to predict spontaneous deterioration (3). Because PVD reflects the systemic nature of atherosclerotic disease, it is frequently associated with coronary, renal, and carotid arterial disease.

Proper treatment of arterial disease requires a comprehensive assessment of the underlying vascular morphology. For therapeutic decision making, it is crucial to localize and gauge the severity of arterial lesions. For this purpose, several imaging modalities, including conventional angiography, duplex ultrasonography (US), as well as computed tomographic angiography and magnetic resonance (MR) angiography, are in clinical use. The lack of ionizing radiation and the use of contrast agents void of any nephrotoxicity (4,5), in conjunction with high diagnostic accuracy, are the desirable qualities that have driven radiologists to secure the rapid implementation of MR angiography as the modality of choice for assessing arterial disease in many centers throughout the world (6–9).

Since atherosclerotic disease affects the entire arterial system, extended imaging that allows the concomitant assessment of the arterial system from the supraaortic arteries to the distal runoff vessels appears desirable. Subsequent parenchymal enhancement and contrast dose limitations had initially curtailed contrast material–enhanced three-dimensional (3D) MR angiography to the display of the arterial territory contained within a single field of view (FOV) that extended from 40 to 48 cm. The implementation of bolus-chase techniques extended imaging to encompass the entire runoff vasculature, including the pelvic, femoral, popliteal, and trifurcation arteries (10–12).

The implementation of faster gradient systems has laid the foundation for a further extension of the bolus-chase technique: Whole-body imaging extending from the carotid arteries to the trifurcation vessels with 3D MR angiography has become possible in just 72 seconds (13). Correlation with a limited number of regional digital subtraction angiographic (DSA) examinations revealed the diagnostic performance of whole-body MR angiography to be sufficient to warrant its consideration as a noninvasive alternative to DSA. The performance of whole-body MR angiography was further improved with the introduction of the rolling table platform (AngioSURF [System for Unlimited Rolling Fields-of-View]; MR-Innovation, Essen, Germany), which integrates the torso surface coil for signal reception. Use of the surface coil results in higher signal-to-noise and contrast-to-noise ratios, which translates into sensitivity and specificity values of 95.3% and 95.2%, respectively, for the detection of significant stenoses (luminal narrowing > 50%) in PVD of the lower extremities (14).

The purpose of this study was to assess the ability of whole-body MR angiography with the rolling table platform to display clinically relevant atherosclerotic lesions beyond the peripheral vasculature in patients who are referred for an MR-based assessment because they are suspected of having PVD.


   Materials and Methods
TOP
 ABSTRACT
 INTRODUCTION
 Materials and Methods
Results
 Discussion
 REFERENCES
 
Background Information
From June 2000 to August 2001, whole-body 3D MR angiography was performed in 102 consecutive patients (78 men, 24 women) who were 44–81 years old (mean age, 62.4 years). All patients were white. All patients were referred from the Department of Angiology for MR imaging assessment of clinically documented PVD. PVD was classified according to the Fontaine grading system (15) as follows: grade IIb, 86 patients; grade III, 11 patients; and grade IV, five patients. Two examinations were technically flawed (ie, hardware failure), and hence two patients were excluded from subsequent evaluation. Thus, analysis included findings of the whole-body MR angiographic examinations of 100 patients. This study was performed according to good clinical practice rules after approval of the local ethics committee. Written informed consent was obtained from all patients. Vital signs and adverse reactions were monitored in all patients for up to 24 hours following the MR imaging examination.

MR Imaging
All imaging was performed with a 1.5-T MR imaging unit (Magnetom Sonata; Siemens, Erlangen, Germany) that was equipped with a high-performance gradient system characterized by an amplitude of 40 mT/m and a slew rate of 200 mT/m/msec. All patients were placed feet first within the bore of the magnet and examined in the supine position on a fully MR-compatible rolling table platform, which had been placed on the existing table top (16). The rolling table platform fits most standard MR imaging systems and is commercially available as an investigational device. It is 240 cm long, and the table platform is placed on seven pairs of roller bearings, which are anchored within the existing patient table. Up to six 3D data sets that include the craniocaudal area and are 380 mm each can be collected in immediate succession. Markers permit adjustment to the desired FOVs. Signal reception is accomplished by using posteriorly located spine coils and an anteriorly located torso phased-array coil. The two utilized elements of the spine coil are integrated in the patient table; however, the standard torso phased-array coil is anchored in a height-adjustable holder, which remains fixed to the stationary patient table. Thus, data for up to six stations are collected with the same stationary coil set positioned in the isocenter of the magnet.

With whole-body MR angiography, five slightly overlapping 3D data sets are acquired in immediate succession. The first data set includes the aortic arch, the supraaortic branch arteries, and the thoracic aorta, whereas the second data set includes the abdominal aorta with its major branches and the renal arteries. The third data set displays the pelvic arteries, and the fourth and fifth data sets include the arteries of the thighs and the calves, respectively.

After a moving-vessel scout image was obtained and the contrast material travel time was determined with a test bolus, slightly overlapping data sets were collected by using a fast low-angle shot 3D sequence (2.1/0.7 [repetition time msec/echo time msec], 25° flip angle, 120-mm slab thickness, 64 interpolated 1.9-mm partitions, 380 x 380-mm FOV, 512 x 512 interpolated matrix, 12-second acquisition time). A 2-cm overlap at the end of each station resulted in a craniocaudal imaging area of 174 cm.

Gadobenate dimeglumine (MultiHance; Bracco Diagnostics, Milan, Italy), a commercially available paramagnetic contrast agent, was administered at a weight-adjusted dose of 0.2 mmol per kilogram of body weight (17). The agent was diluted with normal saline to a total volume of 60 mL. Contrast material was administered with an automatic injector (MR Spectris; Medrad, Pittsburgh, Pa) by using a biphasic protocol: the first half was injected at a rate of 1.4 mL/sec, whereas the second half was administered at a rate of 0.7 mL/sec, followed by a 20-mL saline flush.

Image and Data Analysis
For all patients, the "in-room" time, defined as the time between the patient’s entrance into the MR imaging room for positioning and the patient’s leaving the MR imaging room, was determined.

For image analysis, the arterial tree was divided into 30 segments as follows: segments 1 and 2, right and left internal carotid arteries, respectively; segments 3 and 4, right and left common carotid arteries, respectively; segment 5, brachiocephalic trunk; segment 6, thoracic aorta; segment 7, suprarenal abdominal aorta; segment 8, infrarenal abdominal aorta; segments 9 and 10, right and left renal arteries, respectively; segments 11 and 12, right and left common iliac arteries, respectively; segments 13 and 14, right and left external iliac arteries, respectively; segments 15 and 16, right and left common femoral arteries, respectively; segments 17 and 18, proximal half of right and left superficial femoral arteries, respectively; segments 19 and 20, distal half of right and left superficial femoral arteries, respectively; segments 21 and 22, right and left popliteal arteries, respectively; segments 23 and 24, right and left tibioperoneal trunk, respectively; segments 25 and 26, right and left anterior tibial arteries, respectively; segments 27 and 28, right and left peroneal arteries, respectively; and segments 29 and 30, right and left posterior tibial arteries, respectively.

Image quality was assessed with consensus by two radiologists (J.F.D., S.G.R.) experienced in MR imaging. The display of each arterial segment was characterized as either diagnostic or nondiagnostic. The display was considered diagnostic when relevant vascular disease could be reliably confirmed or excluded.

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 exceeding 50% on the basis of the most severe reduction of the arterial diameter compared with the arterial diameter of the most normal-appearing segment proximal or distal to the area of arterial compromise, (b) vessel occlusion, or (c) aneurysmal disease (documented by using a maximum diameter of the thoracic or abdominal aorta > 4.5 cm).

Analysis was based on maximum intensity projections, available in 12 different projection angles from right to left anterior oblique in steps of 5°, as well as on multiplanar reformations viewed at a 3D workstation (Virtuoso; Siemens). Arterial disease, documented by using whole-body 3D MR angiography outside the peripheral tree, was confirmed if deemed clinically necessary by the referring clinician. Findings of 11 imaging studies performed within 60 days after the whole-body MR angiographic examination were compared with findings of the 3D MR angiographic studies.


   Results
TOP
 ABSTRACT
 INTRODUCTION
 Materials and Methods
Results
Discussion
 REFERENCES
 
For 100 patients (3,000 segments), the examination rendered diagnostic image quality from the carotid arteries to the tibial vessels in 2,976 (99.2%) segments. Twenty-four (0.8%) segments in 11 examinations were rated nondiagnostic. Of these, 19 segments were located in the calves, where venous overlap was the main reason for the inability to confirm or exclude disease. Three arterial segments in the pelvis in one patient were not seen to good advantage because of the presence of oral contrast material in the colon from a previous examination. Finally, two renal arteries in separate patients were not seen; the arteries were not seen because of venous overlap in conjunction with respiratory motion artifacts.

In the peripheral vascular tree, whole-body MR angiography depicted disease in 202 vascular segments in 96 patients: Two blinded readers found stenoses of 50%–99% in 137 segments, occlusion in 63 segments, and aneurysms in two segments (Table).


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  		Assessment of PVD with Whole-Body MR Angiography by Two Blinded Readers in 100 Patients

 
Outside the peripheral arterial tree, the two blinded readers detected 33 segments with unsuspected arterial disease (in 25 patients) with the whole-body 3D MR angiographic examinations that might have been relevant for subsequent patient treatment: Stenoses exhibiting luminal narrowing greater than 50% were identified in 15 renal arteries (13 patients), 12 internal carotid arteries (10 patients), and two subclavian arteries (two patients) (Fig 1). Aneurysmal disease of the aorta, documented by using a diameter greater than 4.5 cm, was identified in four segments (four patients) (Fig 2).



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  		Figure 1. Images obtained in a 67-year-old man with a history of PVD who could walk a distance of less than 200 m without pain. Left: Intraarterial anteroposterior DSA image. Middle: Whole-body 3D fast low-angle shot coronal MR angiogram (2.1/0.7; flip angle, 25°; partitions, 40 interpolated by zero filling to 64; slab thickness, 120 mm; section thickness, 3.0 mm interpolated to 1.9 mm; FOV, 390 x 390 mm; matrix, 256 x 225 interpolated by zero filling to 512 x 512; acquisition time, 12 seconds per station) obtained with the rolling table platform. The DSA image and 3D MR angiogram show diffuse atherosclerotic disease of the peripheral vasculature. Right: Whole-body 3D fast low-angle shot coronal MR angiogram obtained with the same parameters as were used to obtain the middle image depicts a high-grade stenosis of the left subclavian artery (lower arrow) and of the left internal carotid artery (upper arrow). The lesions were initially unsuspected.

 


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  		Figure 2. Whole-body 3D fast low-angle shot coronal MR angiogram (2.1/0.7; flip angle, 25°; partitions, 40 interpolated by zero filling to 64; slab thickness, 120 mm; section thickness, 3.0 mm interpolated to 1.9 mm; FOV, 390 x 390 mm; matrix, 256 x 225 interpolated by zero filling to 512 x 512; acquisition time, 12 seconds per station) obtained in a 63-year-old man with PVD. Because of the extended FOV, the image revealed an infrarenal AAA with a maximum diameter of 5.3 cm, which was clinically not suspected.

 
Within 60 days after imaging, eight patients had undergone a dedicated monostation 3D MR angiographic examination of the renal arteries (ie, nine arteries with luminal narrowing > 50%), and findings confirmed the diagnosis in all nine cases in the eight patients. In three patients, angioplasty of the stenosed renal artery was performed.

In 10 patients, 12 carotid arterial stenoses were detected. To confirm the diagnosis, three patients were referred for a monostation 3D MR angiographic examination of the neck arteries, and findings confirmed high-grade stenoses of the internal carotid artery in all three patients. In one patient, carotid endarterectomy was performed within 60 days of the examination.

Of the four segments with aneurysmal disease in four patients, three segments involved the infrarenal abdominal aorta and one segment involved the thoracic aorta. The maximum diameter of the abdominal aortic aneurysms (AAAs) was 4.9, 5.0, and 5.3 cm. The thoracic aneurysm was 5.2 cm. Within the 60-day follow-up, none of the four patients was referred for a dedicated MR angiographic examination.

The mean in-room time for all patients was 14.3 minutes and ranged between 13.6 and 15.8 minutes.


   Discussion
TOP
 ABSTRACT
 INTRODUCTION
 Materials and Methods
Results
 Discussion
REFERENCES
 
The dose of the contrast agent for whole-body MR angiography with a rolling table platform was identical to that used by most investigators for monostation MR angiography (18,19) and was well within approved limits. The rolling table platform, in conjuncton with the fast gradient system, permitted the rapid chasing of the contrast agent bolus through the different arterial stations. The examination time of less than 15 minutes was very short and exceeded the examination time required for monostation MR angiography by less than 10%.

The diagnostic accuracy of contrast-enhanced 3D MR angiography has been proved for virtually all vascular territories except the intracranial and coronary circulations. While the former is well depicted with time-of-flight and phase-contrast MR angiographic techniques that do not require the administration of any contrast agent (20–22), MR display of the coronary arteries remains challenging (23,24). Encouraging results have recently been demonstrated on the basis of the combined availability of navigator techniques and intravascular contrast agents (25). With contrast-enhanced 3D MR angiography, the select display of the arterial system is based on the presence of T1-shortening gadolinium-based contrast agent in the vascular territory that is under consideration during data acquisition (26).

By using the latest generation of high-performance MR imaging hardware, the acquisition time for a complete 3D data set can be reduced to merely 12 seconds. Thus, up to five 3D data sets can be collected within the short intraarterial contrast time of slightly more than 60 seconds. The diagnostic accuracy of whole-body MR angiography has been documented before (13,14). Similarly, confirmatory studies performed in 11 patients in this study revealed no false-positive or false-negative findings at examination.

Use of a phased-array torso surface coil integrated into the rolling table platform system translated into sufficient signal for high-spatial-resolution imaging. The voxel size was 0.8 x 0.8 x 1.9 mm, and this size enabled excellent delineation, even of smaller vessels such as the trifurcation arteries.

Beyond localization and gauging of the severity of a symptomatic arterial lesion, an optimized therapeutic strategy should be predicated on other clinical factors, including the presence of concomitant arterial disease. This was the case in 25 (25%) of the examined patients; in 11 of these, additional disease could be confirmed within the follow-up period by using dedicated MR angiography. This relatively high number is not surprising: It merely underscores the systemic nature of atherosclerosis. In fact, PVD, caused by atherosclerosis, is rarely an isolated disease process. Findings in studies addressing the prevalence of coronary arterial disease in patients with PVD show that the patient history, the clinical examination, and the electrocardiogram typically indicate presence of coronary arterial disease in 40%–60% of such patients, although coronary arterial disease may often be asymptomatic because it is masked by exercise restrictions (27,28).

Although weaker, the link between PVD and renovascular disease is evident. Approximately one-fourth of patients with PVD have hypertension; in these patients, the possibility of renal arterial compromise should be considered. In 13 (13%) patients, renal arterial disease with a luminal narrowing exceeding 50% was revealed. In eight of these patients, findings at a subsequent investigation deemed necessary for patient treatment confirmed the diagnosis.

There is ongoing controversy about the value of screening all patients with PVD, whether they are symptomatic or not, for carotid arterial disease and AAAs (29,30). On the basis of findings at duplex US, carotid arterial disease could be demonstrated in 26%–50% of patients with PVD (29,31). Although some of these patients have a history of cerebral events or a carotid bruit, others must be considered asymptomatic (32).

The treatment of patients with asymptomatic carotid arterial stenosis is a highly controversial topic. Although findings of this study again confirm that patients with claudication are more likely to have significant asymptomatic carotid arterial disease compared with patients in the general population, the treatment of asymptomatic carotid arterial disease remains controversial (33,34). Whereas findings in more recent studies appear to indicate an unequivocal benefit associated with the treatment of such disease (35), the issue of yield versus cost remains unsettled (36).

When the value of screening patients for AAAs is discussed, several points have to be considered: First, for unknown reasons, the prevalence of AAAs has been increasing steadily during the past 40 years (37). Second, AAAs are rarely symptomatic until they rupture, by which time the opportunity to intervene has usually been lost. The mortality rate for aneurysm rupture is in excess of 80%.

Selection of asymptomatic patients to screen for AAA remains a controversial topic with a wide range of recommendations (38–41). In random screening groups, the incidence of AAA is reported to be 2%–3%, with 75% of the aneurysms found in individuals older than 60 years (42). The likelihood of having an AAA is increased in smokers, in older individuals, in male patients, and in individuals who have coronary arterial disease, PVD (43,44), or a first-order relative with an AAA (45).

Therefore, screening for AAA in patients with PVD may be an important way to eliminate a preventable source of mortality (46), because an AAA is asymptomatic, life threatening, treatable, and detectable by using noninvasive tests.

Noninvasiveness, three-dimensionality, extended coverage, and high contrast conspicuity are the characteristics of whole-body MR angiography with the rolling table platform that combine to allow a quick and comprehensive evaluation of the arterial system in patients with atherosclerosis. The technique is well suited for the assessment of the peripheral vasculature and in addition provides accurate data regarding the remainder of the arterial system.


   FOOTNOTES
 
29*. Vascular system, location unspecified. Back

M.G., T.C.L., J.F.D., and S.G.R. are shareholders of MR-Innovation.

Abbreviations: AAA = abdominal aortic aneurysm, DSA = digital subtraction angiography, FOV = field of view, PVD = peripheral vascular disease, 3D = three-dimensional

Author contributions: Guarantors of integrity of entire study, M.G., J.F.D., S.G.R.; study concepts, M.G., C.U.H., T.C.L.; study design, M.G., K.K, S.G.R.; literature research, C.U.H., T.C.L., K.K.; clinical studies, C.U.H., T.C.L., M.G.; data acquisition, C.U.H., T.C.L., M.G.; data analysis/interpretation, M.G., S.G.R., C.U.H.; statistical analysis, M.G., S.G.R., C.U.H.; manuscript preparation and definition of intellectual content, M.G., J.F.D., S.G.R.; manuscript editing, revision/review, and final version approval, M.G., S.G.R.


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Results
 Discussion
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