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Time-Resolved Contrast-Enhanced MR Angiography of Renal Artery Stenosis

Diagnostic Accuracy and Interobserver Variability

Markus Völk1, Michael Strotzer, Markus Lenhart, Christoph Manke, Wolfgang R. Nitz, Johannes Seitz, Stefan Feuerbach and Johann Link

1 All authors: Department of Diagnostic Radiology, University Hospital of Regensburg, Franz-Josef-Strauss-Allee 11, D-93042 Regensburg, Germany.



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  		Fig. 1A. —25-year-old woman with arterial hypertension (170 over 90 mm Hg) caused by fibromuscular dysplasia. Selective intraarterial digital subtraction angiogram in posteroanterior projection shows significant concentric stenosis of right renal artery (arrow) (mean value of all four observers was 54.3%). Note no further stenosis was recognized.

 


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  		Fig. 1B. —25-year-old woman with arterial hypertension (170 over 90 mm Hg) caused by fibromuscular dysplasia. Three-dimensional anteroposterior fast low-angle shot MR angiogram (3.8/1.49 [TR/TE], 25° flip angle, 10-sec acquisition time, 1.5-mm partition thickness) of first measurement after power injection of contrast material followed by saline solution reveals significant concentric stenosis (arrow) of right renal artery, which was slightly underestimated on contrast-enhanced MR angiography (mean value of all four observers was 51.4%). Degree of stenosis was confirmed on additional views (not shown).

 


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  		Fig. 1C. —25-year-old woman with arterial hypertension (170 over 90 mm Hg) caused by fibromuscular dysplasia. Three-dimensional anteroposterior fast low-angle shot MR angiogram (3.8/1.49, 25° flip angle, 10-sec acquisition time, 1.5-mm partition thickness) of second measurement after power injection of contrast material revealed arterial (solid arrow) and venous (open arrow) enhancement. Note, in this later-phase image, areas of corrugation or "narrow string of beads," typical sign of fibromuscular dysplasia, are more visible and degree of stenosis appears to be more severe than in early arterial phase. This variability in degree of stenosis between phases might be potential pitfall of this method.

 


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  		Fig. 2A. —54-year-old man with arterial hypertension (185 over 95 mm Hg) and suspected renal artery stenosis. Intraarterial digital substraction angiogram in posteroanterior projection shows significant stenosis of right renal artery (solid arrow) (mean value of all four observers was 61.7%). Note no stenosis in left renal artery (mean value of all four observers was 0%). Also note aneurysmal dilatation of suprarenal aorta (open arrow) was seen.

 


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  		Fig. 2B. —54-year-old man with arterial hypertension (185 over 95 mm Hg) and suspected renal artery stenosis. Three-dimensional anteroposterior fast low-angle shot MR angiogram (3.8/1.49 [TR/TE], 25° flip angle, 10-sec acquisition time, 1.5-mm partition thickness) of first measurement after power injection of contrast material followed by saline solution reveals significant stenosis (solid arrow) of right renal artery, which was slightly overestimated at contrast-enhanced MR angiography (mean value of all four observers was 68.3%). Degree of stenosis was confirmed on additional views (not shown). Note no stenosis in left renal artery (mean value of all four observers was 0%). Also note aneurysmal dilatation of suprarenal aorta (open arrow).

 


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  		Fig. 2C. —54-year-old man with arterial hypertension (185 over 95 mm Hg) and suspected renal artery stenosis. Three-dimensional anteroposterior fast low-angle shot MR angiogram (3.8/1.49, 25° flip angle, 10-sec acquisition time, 1.5-mm partition thickness) of second measurement after power injection of contrast medium revealed arterial (solid arrow) and venous (open arrow) enhancement. Note, in this later-phase image, stenosis again appears more severe than in early arterial phase, as in Figure 1C.

 


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  		Fig. 3A. —56-year-old man with arterial hypertension (175 over 95 mm Hg) and suspected renal artery stenosis. This case shows disagreement regarding grading of stenosis with contrast-enhanced MR angiography and digital subtraction angiography. Intraarterial digital substraction angiogram in posteroanterior projection shows no significant stenosis in left renal artery (arrow) (mean value of all four observers was 34.8%; range, 31-43%). Note no significant stenosis in right renal artery (mean value of all four observers was 45.5%; range, 43-49%).

 


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  		Fig. 3B. —56-year-old man with arterial hypertension (175 over 95 mm Hg) and suspected renal artery stenosis. This case shows disagreement regarding grading of stenosis with contrast-enhanced MR angiography and digital subtraction angiography. Three-dimensional anteroposterior fast low-angle shot MR angiogram (3.8/1.49 [TR/TE], 25° flip angle, 10-sec acquisition time, 1.5-mm partition thickness) of first measurement after power injection of contrast material followed by saline solution reveals significant stenosis (arrow) of left renal artery (mean value of all four observers was 73%; range, 60-90%). Degree of stenosis was confirmed on additional views (not shown). Note significant stenosis in right renal artery (mean value of all four observers was 68%; range, 63-77%). Contrast-enhanced MR angiography overestimated both stenoses significantly.

 


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  		Fig. 4. —62-year-old man with arterial hypertension (190 over 95 mm Hg) and suspected renal artery stenosis. Three-dimensional anteroposterior fast low-angle shot MR angiogram (3.8/1.49 [TR/TE], 25° flip angle, 10-sec acquisition time, 1.5-mm partition thickness) of first measurement after power injection of contrast material followed by saline solution reveals significant stenosis of upper left accessory renal artery (open arrow) correctly detected and graded by all four observers. Note significant stenosis (solid arrow) of left renal artery (mean value of all four observers was 62.3%). Degree of stenosis was confirmed on additional views (not shown). Note no stenosis in right renal artery (mean value of all four observers was 6.7%).

 

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