Rationale and Objectives
To retrospectively analyze the significance of 3.0-T contrast-enhanced (CE) magnetic resonance angiography (MRA) with calf compression in the lower limbs of diabetic patients with peripheral vascular disease.
Materials and Methods
Sixty-one type 2 diabetes patients underwent both MRA and digital subtraction angiography (DSA) within 1 week. The patients were divided into two groups: one with (pressure) and one without (conventional) calf compression during MRA. Two radiologists evaluated the quality of MRA images and compared the two groups. Cohen’s kappa statistic was used to determine the concordance between MRA and DSA.
Results
Image quality in the calf and foot was better in the group with calf pressure than the conventional group without applied pressure ( P = .001 [calf], 0.008 [foot]). Significantly more runoff vessels in the calf were detected with MRA than with DSA ( P = .0043 [conventional], 0.0031 [pressure]). The kappa values were 0.928 in the conventional group and 0.979 in the pressure group, but in the conventional group, the diagnostic accuracy of CE-MRA was lower than that of DSA ( P = .002). Diagnostic accuracy in the pressure group was significantly higher than that in the conventional group ( P = .009). The overall sensitivity and specificity for >50% stenosis or occlusion was 93.8% and 98.5%, respectively, in the conventional group and 98.7% and 99.6%, respectively, in the pressure group. With calf compression, venous overlap ( P = .0396, .0425) and deep vein overlap ( P = .022, .022) were significantly reduced in the leg and foot.
Conclusion
Calf compression with 3.0-T CE-MRA was convenient and practical and could improve image quality and diagnostic accuracy in diabetic patients with peripheral vascular disease by reducing venous overlap.
The evolution of magnetic resonance angiography (MRA) has been dramatic. MRA has played a major role in treatment planning and follow-up . The higher signal-to-noise ratio (SNR) offered by the introduction of the 3.0-T magnetic resonance (MR) system into clinical practice has been confirmed in several studies. In our opinion, 3.0-T contrast-enhanced (CE), four-station, bolus-chase MRA still has limitations in depicting lower extremity and runoff vessels in diabetic patients with peripheral vascular disease, particularly in the calf and foot, because of venous overlap.
The risk of developing critical limb ischemia is 11 times higher for patients with diabetes than for those without . Diabetic peripheral vascular disease preferentially involves arteries below the knee, with late involvement of the pedal arteries, and commonly presents as a diffuse, severe, bilateral disease that affects the proximal vessels . A clinical assessment of the arterial tree should include the distal vessel; this assessment may be used as a preoperative preparation for arterial bypass grafts.
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Materials and methods
Patients
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Table 1
Detailed Conditions of Patients
Convention Pressure Numbers (male) 30 (20) 31 (17) Average age (y) 72.48 ± 6.61; 58–85 69.67 ± 8.59; 50–83 Duration of diabetes (y) 11.71 ± 6.60; 4–28 11.47 ± 5.49; 0.1–20 Symptom Lower limb coldness, numbness 26 29 Intermittent claudication 4 8 Rest pain 7 6 Sign Lower skin temperature 24 27 Dorsalis pedis pulse disappeared 20 23 Black toe skin 3 2 Infection 1 1 Ulcers, gangrene 2 2 Renal complications Phase III kidney disease 1 2 GFR <35 mL/min 4 4 Supplementary examination ABI 0.66 ± 0.22 0.64 ± 0.16 Transcutaneous oxygen pressure 19.95 ± 13.05 18.55 ± 12.05 FPG (mmol/L) 8.91 (4.08–19.85) 8.23 (5.30–17.97) HbA1c (mmol/L) 13.11 (7.10–24.00) 14.83 (7.03–25.00) Risk factors Heart disease 14 10 Hypertension (y) 11.25 ± 6.67; 4–28 14.29 ± 10.98; 0.1–42 Hyperlipidemia 15 13 Smoking history (y) 21.43 ± 9.07; 13–40 32.17 ± 7.76; 20–40 Treatment history Oral medication 7 3 Insulin 15 18 Drugs combined with insulin 8 10 Surgical treatment 1 (amputated toe) 2 Intervention 2 3
ABI, ankle-brachial index; FPG, fasting plasma glucose; GFR, glomerular filtration rate.
Continuous data using mean ± standard deviation. ABI recorded the results of body lesions, which were recorded 0 as not detected.
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MR Imaging
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Table 2
Contrast Agent Injection Process in Lower Extremity Vascular Imaging
Order Drugs Order Speed (mL/s) Dose (mL) 1 0.9% saline A 2.5 20 2 Magnevist B 2.5 20 B 2.0 20 3 0.9% saline C 2.5 20
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Specific Steps
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Table 3
Imaging Parameters in Lower Extremity MRA at 3.0T Phillips
Imaging Parameter Abdomen Pelvic Upper Leg Lower Leg Repetition time (ms) 3.4 3.5 3.6 4.3 Echo time (ms) 1.13 1.23 17.2 1.56 Stacks slices 51 57 64 111 FOV (mm) FH/RL/AP 375/325/102 375/321/103 375/321/90 450/267/354 Dynamic scan time (s) 10.8 13.9 17.7 01:03.8 ACQ matrix m∗p (mm) 204/158 304/177 304/199 428/336 ACQ voxel mps (mm) 1.84/2.05/4.00 1.23/1.81/3.60 1.23/1.61/2.80 0.88/0.95/1.80 REC voxel size (mm) 0.73/0.74/2.00 0.73/0.74/1.80 0.73/0.74/1.40 0.73/0.73/0.90 Scan percentage (%) 89.9 68.1 76.5 92.3 CE-angio profile order Rev-linear Linear Centra Centra
ACQ, acquisition; AP, anteroposterior; CE, contrast enhanced; FH, foot-head; FOV, field of view; REC, reconstructed; RL, right-left.
All flap angles 20°; reconstruction mode real time; slice thickness 6 mm.
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DSA
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Image Analysis
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Statistical Evaluation
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Results
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Image Quality
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Grade of Stenosis
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Table 4
Cohen’s Kappa and McNemar: Compared MRA with DSA
Locations Conventional Group >50% Stenosis or Occlusion Kappa Value_P_ Value Sensitivity Specificity Both Neither Only MRA Only DSA Total Numbers Abdomen and pelvis 2 208 0 0 210 1.000 1.000 100% 100% Thigh 29 88 3 0 120 .934 .250 90.6% 100% Calf 93 137 0 10 240 .914 .002 90.3% 100% Foot 26 90 4 0 120 .907 .125 100% 95.7% Total 150 453 7 10 630 .928 .629 93.8% 98.5%
Locations Pressure Group >50% Stenosis or Occlusion Kappa Value_P_ Value Sensitivity Specificity Both Neither Only MRA Only DSA Total Numbers Abdomen and pelvis 3 214 0 0 217 1.000 1.000 100% 100% Thigh 27 95 0 2 124 .954 .500 93.1% 100% Calf 90 157 1 0 248 .991 1.000 100% 99.4% Foot 31 91 2 0 124 .958 .500 100% 97.8% Total 151 495 3 2 651 .979 1.000 98.7% 99.6%
DSA, digital subtraction angiography; MRA, magnetic resonance angiography.
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Venous Overlap
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Discussion
Theoretical Basis of Pressure MRA in Lower Leg Extremity
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MRA image Quality of Lower Limb
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MRA History and Innovation
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Limitation of this Research
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Conclusion
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