Pelvic and Lower Extremity Arterial Imaging
Diagnostic Performance of Three-Dimensional Contrast-Enhanced MR Angiography
Stefan G. Ruehm1,2,
Thomas F. Hany1,
Thomas Pfammatter1,
Ernst Schneider3,
Mark Ladd1,2 and
Jörg F. Debatin1,2
1
Institute of Diagnostic Radiology, University Hospital Zurich, CH-8091 Zurich,
Switzerland.
2
Present address: Department of Diagnostic Radiology, University Hospital
Essen, Hufelandstr. 55, D-45122, Essen, Germany.
3
Institute of Angiology, University Hospital Zurich, CH-8091 Zurich,
Switzerland.
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Fig. 1. —Photograph shows volunteer wrapped in multichannel quadrature-phased
array peripheral vascular coil (Medical Advances, Milwaukee, WI). Coil
consists of four circular arrays. Flexible design of coil allows bilateral
vascular imaging in close proximity to anatomy of interest. Each element
covers territory of 24 cm (total coverage, 96 cm) and can be activated
separately or in combination with one other element. Patients are placed in
coil so that first two coil elements cover pelvis and thighs while second set
covers popliteal artery and trifurcation vessels.
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Fig. 2. —62-year-old man with 10-year history of diabetes. Axial multiphase
gradient-echo image at level of lower thigh after administration of 2-ml
contrast test bolus shows regions of interest (A and B) that are placed over
superficial femoral artery bilaterally to obtain signal-intensity curve for
both sides. Half time to maximum signal intensity is determined in both legs.
Delayed value is used as scan delay. Display is immediately available on
operating console.
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Fig. 3A. —71-year-old man with episodes of right calf claudication. Lateral MR
angiogram with maximum intensity projection shows acquisition volumes of
superior and inferior three-dimensional data set in craniocaudal extension.
Note required anteroposterior offset.
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Fig. 3B. —71-year-old man with episodes of right calf claudication. Frontal
view of MR angiographic data set shows vascular graft extending from
superficial femoral to popliteal artery. Note mild stenosis (arrow)
in distal segment.
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Fig. 3C. —71-year-old man with episodes of right calf claudication.
Corresponding digital subtraction angiogram of femoropopliteal runoff reveals
femoropopliteal graft.
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Fig. 4A. —63-year-old man with bilateral leg claudication. Cut film angiogram
of pelvic region showing severe stenoses of right proximal common iliac
artery, left distal common femoral artery (arrowhead), and proximal
superficial femoral artery (arrow). In anteroposterior projection,
area of femoral bifurcation is difficult to assess.
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Fig. 4B. —63-year-old man with bilateral leg claudication. Three-dimensional
MR angiographic maximum-intensity-projection image in anteroposterior
projection shows good correlation with conventional angiography. Long arrow
indicates left distal common femoral artery; short arrow indicates proximal
superficial femoral artery.
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Fig. 4C. —63-year-old man with bilateral leg claudication. MR angiogram with
30° rotated maximum intensity projection of superior data set provides
better view of severe stenoses of left distal common femoral
(arrowhead) and proximal superficial femoral artery
(arrow).
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Fig. 5A. —81-year-old man with left leg claudication. Conventional angiogram
reveals occlusion of left superficial femoral artery (arrow) in
adductor canal. Occlusion is well collateralized by vessels originating from
deep femoral artery.
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Fig. 5B. —81-year-old man with left leg claudication. Three-dimensional MR
angiographic maximum-intensity-projection image shows occlusion
(arrow). Collateral vessels are also well visualized.
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Fig. 6A. —79-year-old man with claudication of right calf during exercise.
Conventional angiogram shows following findings: irregularity of distal aorta,
severe stenosis of right distal superficial femoral artery (arrow),
mild stenosis of left superficial femoral artery (arrowhead),
proximal occlusion of all trifurcation vessels on right side, proximal
occlusion of proximal anterior and posterior tibial artery on left side, and
severe atherosclerotic changes of left peroneal artery.
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Fig. 6B. —79-year-old man with claudication of right calf during exercise.
Three-dimensional MR projection angiogram reveals good correlation with
findings of conventional angiography. Occlusion of runoff vessels was
correctly diagnosed.
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Fig. 7A. —71-year-old woman with pain in left lower calf during exercise. This
case is example of overestimation of stenosis using MR angiography. This
discrepancy may be caused by projection-related limitations of conventional
angiography. Other findings such as mild stenosis in mid third of left
superficial femoral artery, severe stenosis of distal superficial femoral
artery, and occlusion of popliteal artery on left side were correctly
diagnosed on MR angiography. Trifurcation of runoff vessels as normal variant
on right side and filling of proximal segments of anterior and peroneal artery
after occlusion by collateral vessels on left side are displayed by both
three-dimensional MR angiography and conventional angiography.
Three-dimensional MR angiographic maximum-intensity-projection images in
anteroposterior projection (A) and rotated view (B) show lesion
of external iliac artery (arrow) immediately distal to origin of
internal iliac artery. Lesion was interpreted as severe.
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Fig. 7B. —71-year-old woman with pain in left lower calf during exercise. This
case is example of overestimation of stenosis using MR angiography. This
discrepancy may be caused by projection-related limitations of conventional
angiography. Other findings such as mild stenosis in mid third of left
superficial femoral artery, severe stenosis of distal superficial femoral
artery, and occlusion of popliteal artery on left side were correctly
diagnosed on MR angiography. Trifurcation of runoff vessels as normal variant
on right side and filling of proximal segments of anterior and peroneal artery
after occlusion by collateral vessels on left side are displayed by both
three-dimensional MR angiography and conventional angiography.
Three-dimensional MR angiographic maximum-intensity-projection images in
anteroposterior projection (A) and rotated view (B) show lesion
of external iliac artery (arrow) immediately distal to origin of
internal iliac artery. Lesion was interpreted as severe.
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Fig. 7C. —71-year-old woman with pain in left lower calf during exercise. This
case is example of overestimation of stenosis using MR angiography. This
discrepancy may be caused by projection-related limitations of conventional
angiography. Other findings such as mild stenosis in mid third of left
superficial femoral artery, severe stenosis of distal superficial femoral
artery, and occlusion of popliteal artery on left side were correctly
diagnosed on MR angiography. Trifurcation of runoff vessels as normal variant
on right side and filling of proximal segments of anterior and peroneal artery
after occlusion by collateral vessels on left side are displayed by both
three-dimensional MR angiography and conventional angiography. Corresponding
conventional digital subtraction angiogram shows same lesion as A and
B. Lesion was graded as irregular in presence of plaque
(arrow).
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Fig. 8A. —65-year-old woman with bilateral knee pain during exercise. This
case is example of overestimation of stenosis using MR angiography.
Three-dimensional MR angiographic maximum-intensity-projection images in
anteroposterior (A) and rotated (B) views. Severe stenosis was
diagnosed at origin of left peroneal artery (arrowhead) and mild
stenosis at origin of right peroneal artery (arrow). Rotated view is
of inferior volume.
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Fig. 8B. —65-year-old woman with bilateral knee pain during exercise. This
case is example of overestimation of stenosis using MR angiography.
Three-dimensional MR angiographic maximum-intensity-projection images in
anteroposterior (A) and rotated (B) views. Severe stenosis was
diagnosed at origin of left peroneal artery (arrowhead) and mild
stenosis at origin of right peroneal artery (arrow). Rotated view is
of inferior volume.
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Fig. 8C. —65-year-old woman with bilateral knee pain during exercise. This
case is example of overestimation of stenosis using MR angiography.
Conventional angiograms of right trifurcation arteries (C) and left
trifurcation arteries (D) were interpreted as normal.
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Fig. 8D. —65-year-old woman with bilateral knee pain during exercise. This
case is example of overestimation of stenosis using MR angiography.
Conventional angiograms of right trifurcation arteries (C) and left
trifurcation arteries (D) were interpreted as normal.
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Fig. 9A. —51-year-old male smoker. This case is example of underestimation of
stenosis using MR angiography and points to semantic difficulties associated
with classification of vascular morphology and can be regarded as example of
interobserver variability rather than failure of MR angiography to accurately
estimate vascular disease. Anteroposterior projection of three-dimensional MR
angiographic maximum-intensity-projection image shows multiple irregularities
of right superficial femoral artery. Lesion in distal third of superficial
femoral artery (arrow) was characterized as mild.
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Fig. 9B. —51-year-old male smoker. This case is example of underestimation of
stenosis using MR angiography and points to semantic difficulties associated
with classification of vascular morphology and can be regarded as example of
interobserver variability rather than failure of MR angiography to accurately
estimate vascular disease. Conventional angiogram shows same lesion
(arrow) as that in A. Lesion was characterized as severe.
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Fig. 10A. —55-year-old man who underwent imaging for assessment of vascular
graft. Conventional angiogram (A) and MR angiographic
maximum-intensity-projection image (B). Aneurysmal changes of vascular
graft can be reliably assessed on three-dimensional MR angiography. Metallic
clip in midhalf of graft shows typical artifact (arrow).
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Fig. 10B. —55-year-old man who underwent imaging for assessment of vascular
graft. Conventional angiogram (A) and MR angiographic
maximum-intensity-projection image (B). Aneurysmal changes of vascular
graft can be reliably assessed on three-dimensional MR angiography. Metallic
clip in midhalf of graft shows typical artifact (arrow).
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