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In Vivo Evaluation of Patency and In-Stent Stenoses After Implantation of Nitinol Stents in Iliac Arteries Using MR Angiography

Okka W. Hamer1, Thomas Finkenzeller1, Ingitha Borisch1, Christian Paetzel1, Niels Zorger1, Stefan Feuerbach1 and Wolfgang Nitz1

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



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  		Fig. 1A —Self-expandable stents made of nitinol were implanted in iliac arteries for treatment of chronic iliac stenoses. Three-dimensional MR angiography was performed within 3 days and again 99-258 days after stent implantation. Each time, reference standard was intraarterial digital subtraction angiography (DSA). Three blinded observers assessed degree of residual or recurrent in-stent stenoses on DSA and MR angiography images independently of each other. Mean of all three observers' measurements on DSA and MR angiography images are given. Measurements refer to DSA (solid line) and MR angiography (dotted line) images obtained immediately after procedure (DSA 1 and MR angiography 1), in which 32 stents were evaluated.

 


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  		Fig. 1B —Self-expandable stents made of nitinol were implanted in iliac arteries for treatment of chronic iliac stenoses. Three-dimensional MR angiography was performed within 3 days and again 99-258 days after stent implantation. Each time, reference standard was intraarterial digital subtraction angiography (DSA). Three blinded observers assessed degree of residual or recurrent in-stent stenoses on DSA and MR angiography images independently of each other. Mean of all three observers' measurements on DSA and MR angiography images are given. Measurements refer to DSA (solid line) and MR angiography (dotted line) images obtained at 6-month follow-up (DSA 2 and MR angiography 2), in which 23 stents were evaluated.

 


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  		Fig. 2A —Images show right common and external iliac arteries 6 months after placement of self-expandable nitinol stent (diameter, 10 mm; length, 68 mm) in 56-year-old woman. Nonsubtracted (A) and subtracted (B) digital subtraction angiography (DSA) images show diagnostic catheter crossing stent. Dimensions of stent are better appreciated on nonsubtracted than on subtracted image (stent ends indicated by arrows). In-stent stenosis of about 50% (arrowhead) due to intimal hyperplasia in distal portion of stent is visible.

 


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  		Fig. 2B —Images show right common and external iliac arteries 6 months after placement of self-expandable nitinol stent (diameter, 10 mm; length, 68 mm) in 56-year-old woman. Nonsubtracted (A) and subtracted (B) digital subtraction angiography (DSA) images show diagnostic catheter crossing stent. Dimensions of stent are better appreciated on nonsubtracted than on subtracted image (stent ends indicated by arrows). In-stent stenosis of about 50% (arrowhead) due to intimal hyperplasia in distal portion of stent is visible.

 


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  		Fig. 2C —Images show right common and external iliac arteries 6 months after placement of self-expandable nitinol stent (diameter, 10 mm; length, 68 mm) in 56-year-old woman. Maximum-intensity-projection reconstruction of MR angiography image acquired on same day as DSA. Minimal bandlike artifact is detectable at distal stent end (stent ends indicated by arrows). In-stent stenosis in distal portion of stent can be well identified (white arrowhead). MR angiography exaggerates degree of minor stenosis in proximal portion of stent (black arrowhead).

 


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  		Fig. 3A —All images show right common and external iliac artery after implantation of self-expandable nitinol stent (diameter, 10 mm; length, 44 mm) in 66-year-old man. Intraarterial digital subtraction angiography (DSA 1) of right iliac artery shows diagnostic catheter crossing stent. No in-stent stenosis is seen (stent ends indicated by arrows).

 


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  		Fig. 3B —All images show right common and external iliac artery after implantation of self-expandable nitinol stent (diameter, 10 mm; length, 44 mm) in 66-year-old man. Maximum intensity projection reconstruction of MR angiography image acquired immediately after procedure (MR angiography 1). Bandlike artifacts are present at both ends of stent (stent ends indicated by arrows). Artifact at proximal stent end is more pronounced and was misinterpreted by all three observers as stenosis. Signal in stent is inhomogeneous and weakened in comparison with adjacent vessel segments.

 


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  		Fig. 3C —All images show right common and external iliac artery after implantation of self-expandable nitinol stent (diameter, 10 mm; length, 44 mm) in 66-year-old man. Intraarterial DSA image 8 months after stent placement (DSA 2) (stent ends marked by arrows) shows diagnostic catheter crossing stent. Minor focal stenosis has developed at proximal stent end (arrowhead); examination was otherwise unremarkable.

 


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  		Fig. 3D —All images show right common and external iliac artery after implantation of self-expandable nitinol stent (diameter, 10 mm; length, 44 mm) in 66-year-old man. Maximum intensity projection reconstruction of MR angiography image acquired 8 months after stent placement (MR angiography 2) (stent ends marked by arrows) on same day as DSA image in C. Bandlike artifact at distal stent end is not visible any more. Bandlike artifact at proximal stent end is less pronounced than on MR angiography 1 (B) and was correctly identified by all observers. Minor stenosis at proximal stent end can be identified as well as in corresponding DSA image (arrowhead). In-stent signal is less weakened and in-stent signal pattern is more homogeneous than on MR angiography 1. Delineation of inner contour of stent is better than on MR angiography 1. Although individual scanning delay was determined by a timing run for MR angiography 1 and 2, uptake of contrast material by abdominal organs is less pronounced on MR angiography 2 than on MR angiography 1 because of slight differences in timing.

 

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