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Peripheral vessels imaging: MSCT, MR

Peripheral vessels imaging: MSCT, MR. Jan Baron K. Gruszczyńska Dept. of Radiology and Nuclear Medicine Silesian University School of Medicine, Katowice. Diseases of the peripheral vessels:. Different diseases – 2%: - inflammation - fibro-muscular dysplasia Atherosclerosis - 98%.

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Peripheral vessels imaging: MSCT, MR

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  1. Peripheral vessels imaging: MSCT, MR Jan Baron K. Gruszczyńska Dept. of Radiology and Nuclear Medicine Silesian University School of Medicine, Katowice

  2. Diseases of the peripheral vessels: • Different diseases – 2%: • - inflammation • - fibro-muscular dysplasia • Atherosclerosis - 98% Noszczyk W, Andziak P: Chirurgia tt. i żył obwodowych. PZWL, W-wa 1998 N Engl J Med. 1992; 326: 381–386

  3. The importance of the peripheral arteries atherosclerosis • Peripheral atherosclerosis = 4x increased risk of death because of the diseases of cardiovascular system • 15 x critical and clinically significant peripheral atherosclerosis N Engl J Med. 1992; 326: 381–386

  4. Peripheral atherosclerosis – epidemiology • Peripheral Arterial Disease, Awareness, Risk and Treatment: • New Resources for Survival (PARTNERS): • - patients >70y; • - smokers 50-69 lat - 29% • JAMA. 2001; 286: 1317–1324 • Western Europe, patients < 50y - 2% • - Poland: patients> 20y: 2,4% Noszczyk W, Andziak P: Chirurgia tt i żył obwodowych. PZWL, W-wa 1998 Meaney JMF: Magnetic resonance angiography of the peripheral arteries: current status. Eur Radiol, 2003, 13, 4, 836-852

  5. Visualization of whole aorta and peripheral arteries Peripheral vessels imaging Localisation of critical stenosis Visualization of run-off vessels

  6. Diagnostic methods DSA AngioCT US AngioMR

  7. Time of flight TOF MRA of peripheral vessels CE-MRA Phase-contrast MRA

  8. Peripheral MRA • CE-MRA: signal acquisition in arterial phase after i.v. contrast injection • Replaces TOF MRA • Good clinical acceptance Hentsch A: Importance of CE-MRA in various body regions: comparison with i.a. DSA. Eur Radiol 2004, 14 (suppl 5): M8-M11

  9. CE-MRA of the aorta - indications • Screening examinations - suspicion of aortic aneurysm (Marfan Syndrome) - Takayashu arteritis - Future: atherosclerotic plaque screening Circulation. 2004;109:2626-2633

  10. Aortic CE-MRA: • Aortic dissection: - False and the true lumen - dissection - localisation of intimal flap - flow in true and false lumen - aortic branches - intramural haematoma Early phase Late phase

  11. Ascending aorta aneurysm – flow imaging

  12. CE-MRA Takayashu arteritis • Visualisation of the whole aorta and the degree of the stenosis • Imaging of the aortic wall after GDTPA: early stage of the disease Nastri MV et al: RadioGraphics 2004; 24: 773-786.

  13. Renal arteries CE-MRA • Degree of the stenosis - diagnostic accuracy - sensitivity 91-100%, specificity: 71-100% • No nephrotoxix contrast Left renal artery stenosis

  14. Renal arteries CE-MRA

  15. Peripheral CE-MRA • 'peripheral angio' coil – increased spatial resolution • "care bolus" - optimalisation of contrast amount in arteries • ‘moving table’  1 2 3

  16. Peripheral CE-MRA - indications • Choosing the therapeutic method • Diagnostic accuracy in evaluation of the stenosis: femoro-popliteal segments: • - Sensitivity 94-100% specificity: 99-100% • Subpopliteal segments: • - sensitivity: 91-94% specificity: 100% • Future: • plaque imaging • guiding of the interventions Left iliac a.occlusion James F. M. Meaney: Eur. Radiol, 2002, 12, 1649

  17. Peripheral CE-MRA: diagnostic accuracy James F. M. Meaney: Eur. Radiol, 2002, 12, 1649

  18. CE-angioMR 15ml c.m. iv, flow 0,4ml/s Left common iliac a.occlusion, critical stenosis of right common iliac a.

  19. CE-angioMR 15ml c.m., flow 0,4ml/s Occlusion of left common iliac a., 50% stenosis of left external iliac a.

  20. Peripheral MRA : TOF, PC - Dark blood – vessel wall imaging - Bright blood - TOF: imaging of the veins, complementary technique to CE-MRA - PC-contrast – flow imaging flow direction, critical stenosis evaluation in subclavian steal syndrome Hentsch A: Importance of CE-MRA in various body regions: comparison with i.a. DSA. Eur Radiol 2004, 14 (suppl 5): M8-M11

  21. Flow imaging in PC MRA • Future: • - routine technique in flow visualisation in the point of stenosis • - differentiation between the critical stenosis and occlusion • - evaluation of the degree of the stenosis Hentsch A: Eur Radiol 2004, 14 (suppl 5): M8-M11

  22. CE-MRA – new techniques • New sequences: - SENSE (sensitivity ecncoding) - SMASH (simultaneous acquisition at spatial harmonics) increased spatial resolution decrease acquisition time – no problems with vein overlapping • New contrast agents: - Gadovist (Gadobutrol): extracellular c.m. – increased amount of contrast in the vessels during ‘first pass’ - ‘blood pool’ contrast agents– prolonged vessel presence • Dedicated coils with high spatial resolution Hentsch A:. Eur Radiol 2004, 14 (suppl 5): M8-M11

  23. MSCT

  24. MSCT • ADVANTAGES -short examination time - high spatial resolution - high diagnostic accuracyin stenosis evaluation - no flow artefacts - good visualisation of calcifications and stents • DISADVANTAGES: - ionising radiation - nephrotoxic contrast agent Anderson GB et al: Stroke 2000,31(9):2169

  25. MSCT of the renal arteries • Diagnostic accuracy: • sensitivity: 89 - 98%, specificity 89-100% • evaluation before interventional therapy and in renal donors • evaluation of stents patency • fibro-muscular dysplasia • DIASADVANTAGE – nephrotoxic contrast!!!! Stent in renal artery

  26. Renal arteries Pelvic kidney, double renal arteries

  27. Peripheral MSCT • Visualisation of whole length of peripheral arteries after single contrast injection • evaluation: 2D & 3D reconstructions • examination quality depends of contrast timing • Diagnostic accuracy of MSCT in peripheral vessels imaging: • sensitivity: 98%, specificity: 94% • Non-invasive modalities - first choose before DSA • DSA: interventional therapy

  28. Peripheral MSCT Stent in left femoral artery

  29. Peripheral MSCT Femoro-femoral by-pass

  30. MSCT – stenosis quantification Good correlation with 3D DSA Eur. Radiol. 2004, 14 (4)

  31. USG, CTA, MRA - comparison CP Kaiser. Diag. Imag. Online January 28, 2004

  32. CTA, MRA - comparison • CTA & MRA: quick, safe • good diagnostic accuracy in evaluation of length and degree of stenosis • spatial resolution DSA: 200 μm • CTA: 400 μm • MRA: 1000 μm • 3D reconstructions & virtual endoscopy • evaluation of both vessel lumen and surrounding structures CP Kaiser. Diag. Imag. Online January 28, 2004

  33. MSCT vs MRA – indications • MRA: • renal insufficiency • flow visualisation • easy post-processing • specific contraindications • CTA • good spatial resolution • better toleration by patients • bony structures – good topographic points • calcifications & visualisation before angioplasty MRA & CTA complementary techniques: Radiologist should tailor the examination for clinical situation CP Kaiser. Diag. Imag. Online January 28, 2004

  34. Atherosclerotic plaque imaging in MR • MR: T2 • MR high contrast resolution – differentiation of early and advanced plaques • Plaque classification – ac to AHA • evaluation of inflammation with special dedicated i.v. contrast agents • control studies after therapy • MR Disadvantages : • small spatial resolution – intravascular coils, intravenous, intra-arterial Cai J-M, Hatsukami TS, Ferguson MS et al: 2002;106:1368 Diagnostic Imaging Online, September 9, 2004

  35. Vessel wall imaging U-King-Im JM, TrivedivRA, Sala E et al.: Eur Radiol 2004, 14 (7): Atherosclerotic plaque in MR imaging

  36. Vessel wall imaging U-King-Im JM, TrivedivRA, Sala E et al.: Eur Radiol 2004, 14 (7):1154-62 ulcerated ICA stenosis in DSA & MR brigh blood imaging

  37. Intravasular MR coils Invest Radiol. 2004 Oct; 39(10):619-625

  38. New MR contrast agents - USPIO Invest Radiol. 2004 Oct; 39(10):619-625 USPIO: Ultrasmall Super paramagnetic Particles of Iron Oxide Iron oxide - nanoparticles (30nm) Prolonged stained in the vessels Accumulation in macrophages of unstable atherosclerotic plaque Decreased MR signal

  39. Plaque visualisation in PET/CT Circulation. 2002;105:2708 PET CT PET/CT Plaque rupture is the consegence of inflammatory changes Increased 18FDG uptake in unstable plaque

  40. Arterial visualisation in MRA, MSCT – future trends: American Heart Association Science Advisory and Coordinating Committee.Circulation. 2004;109:2626-2633 • MRA: • - evaluation of morphology & function • - Whole body MRA – screening examination for diagnosis of atherosclerotic changes • - cellular and metabolic imaging • - interventional therapy • MSCT: • - Flat-panel: decreased examination time, increased diagnostic accuracy • - guiding of interventions • - whole body imaging with vessels and plaques evaluation • ~ screening

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