Rationale and Objectives
Noncontrast magnetic resonance angiography (NC-MRA) of pedal artery remains challenging because of the global and regional disease load, tissue integrity, and altered microcirculation. This study aims to investigate the feasibility of the NC-MRA of pedal arteries with flow-sensitive dephasing–prepared steady-state free precession (FSD-SSFP) and to explore the effect of disease load of type II diabetes on the vessel depiction.
Materials and Methods
FSD-SSFP was performed on a 1.5-T magnetic resonance system before the contrast-enhanced MRA (CE-MRA) as a reference standard in 39 consecutive diabetic subjects (29 men and 16 women, aged 57.9 ± 11.4 years). Two experienced radiologists evaluated the overall artery visibility (VA) and the contamination from soft tissue (SC) and veins (VC) with a four-point scale. Chronic complications and measures including random blood glucose (RBG), lipid panel, body mass index, risk of diabetic foot ulcers (RDF), and glycated hemoglobin (HbA1c) by the imaging were recorded as disease load indicators. Spearman rank correlation and ordinal regression were performed to investigate the effect of disease load on the depiction of pedal arteries.
Results
The measurement of RBG and RDF were significantly correlated with the VC in CE-MRA and with the overall visibility of pedal arteries in NC-MRA ( P < .025 and P < .001, respectively). Blood pressure was the only parameter that was significantly associated with SC in NC-MRA with FSD-SSFP ( P < .025). For CE-MRA the effect of RDF on the overall VA manifested a significant linear trend ( P < .001), and the level of RBG was substantially associated with the VC ( P < .025) without significantly impacting VA and SC. Hypertension only correlated with SC in NC-MRA. VA was found independent of the presence of diabetic nephropathy, coronary artery disease, abnormal lipid panel, HbA1c (75.0%), or optimized m 1 value that ranged from 70 to 160 mT⋅ms 2 /m (mean, 125 ± 18 mT⋅ms 2 /m) in this study.
Conclusions
FSD-SSFP proved to be a useful modality of NC-MRA for pedal artery imaging in diabetic patients. The vessel depiction is subject to the local and systemic disease load of type II diabetes. Technical optimization of the flow-sensitive dephasing gradient moment and properly choosing candidate would help augment the potential of this technique in patient care of peripheral artery disease.
Peripheral artery disease (PAD) is a typical macrovascular complication that typically affects arteries below the knee in type II diabetes . The awareness and detection of PAD may be limited as a substantial proportion of patients are asymptomatic or have atypical manifestations , although significant impairment of blood flow may have already occurred . Effective screening would be useful to facilitate the early identification of PAD, thus improving prognosis and lowering the cost of the disease .
Morphological and functional parameters of peripheral arteries derived from noninvasive assessments are well accepted in clinical practice. Ankle–brachial index (ABI) is commonly used as a convenient tool in PAD screening with high sensitivity and specificity, especially for populations aged greater than 50 years with significant hemodynamic abnormalities . However, the range and severity of the diseased arteries may not be readily indicated by this index, and the reliability of ABI can be compromised by the presence of arterial calcification. Pulse wave velocity, computed tomography angiography (CTA), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA) are valuable imaging modalities that provide morphological and functional details of the diseased arteries for the purposes of determining revascularization and grafting or stent patency. However, a substantial population of diabetic patients is excluded from CTA or contrast-enhanced MRA (CE-MRA) in clinical practice concerning the high dose of ionizing radiation and/or contrast agent–induced nephropathy . Therefore, the development of MRA techniques that requires no contrast medium becomes a need of significant importance for the purpose of peripheral artery imaging in diabetes.
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Methods
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![Figure 1, Illustration of normal pedal artery anatomy. (a) Anterior view. (1) Distal anterior tibial artery, (2) dorsal artery of foot, (3) lateral tarsal arteries, (4) arcuate artery, (5) deep perforating artery, (6) dorsal metatarsal artery for hallux. (b) Lateral view. (1) Distal anterior tibial artery, (2) dorsal artery of foot, (3) lateral tarsal artery, (5) deep perforating artery, (8) lateral and (9) medial plantar arteries, (10) pedal arch, (11) distal posterior tibial artery [Courtesy of Chomel et al. (16) ]. Visibility of arteries numbered 2, 3, 4, 8, 9, and 10 was assessed in this study.](https://storage.googleapis.com/dl.dentistrykey.com/clinical/NoncontrastMRAofPedalArteriesinTypeIIDiabetes/0_1s20S1076633214004565.jpg)
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Results
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Table 1
Summary of the Distribution of Abnormal Clinical Laboratory Tests, Measures, and Complications of the 39 Subjects
Measure Lipid Panel RBG HbA1c BMI LDL Triglycerides HDL TC Abnormality rate (%) 90.9 88.9 62.5 60 86.7 71.8 43.5 Complication DR Atherosclerosis Dneuro Dnephro Hypertension FW CAD % 100 84.6 69.2 56.4 53.8 30.8 23.1
BMI, body mass index; CAD, coronary artery disease; Dnephro, diabetic nephropathy; Dneuro, diabetic neuropathy; DR, diabetic retinopathy; FW, diabetic foot wound; HbA1c, glycated hemoglobin; HDL, high-density lipoprotein; LDL, low-density lipoprotein; RBG, random blood glucose; TC, total cholesterol.
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Table 2
Summary of the Scoring of the Overall VA, SC, and VC Based on the MIP FSD-SSFP Images of 234 Main Proximal Pedal Runoffs
Image Quality Scoring (Mean ± Standard Deviation) SC VC VA CE-MRA 2.4 ± 0.7 2.0 ± 0.7 2.3 ± 0.8 FSD-SSFP MRA 2.0 ± 1.2 1.4 ± 0.5 2.6 ± 0.9
CE, contrast enhanced; FSD-SSFP, flow-sensitive dephasing–prepared steady-state free precession; MIP, maximum-intensity projection; MRA, magnetic resonance angiography; SC, soft tissue contamination; VA, visibility of arteries; VC, venous contamination.
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Table 3
Correlation Coefficient Between Disease Indicators and Image Quality for Both NC-MRA with FSD-SSFP and CE-MRA
Image Quality Indicator MRA RBG RDF Dnephro Blood Pressure HbA1c CAD m 1 VA NC 0.42* 0.39* — — — — — CE — — — — — — — VC NC — — — — — — — CE 0.44* 0.62** △△ — — — — — SC NC — 0.38* △ — 0.42* — — — CE — — — — — — —
CAD, coronary artery disease; CE, contrast enhanced; Dnephro, diabetic nephropathy; FSD-SSFP, flow-sensitive dephasing–prepared steady-state free precession; HbA1c, glycated hemoglobin; m 1 , first-order gradient moment; MRA, magnetic resonance angiography; NC, noncontrast; RBG, random blood glucose; RDF, risk of diabetic foot ulcer; SC, soft tissue contamination; VA, visibility of pedal artery; VC, vein contamination.
Bonferroni approach was applied to control the type I error.
∗ Spearman rho correlation and △ Cochran–Armitage trend test. * ,△ P < .025; ∗∗,△△ P < .001; — P > .05.
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Discussion
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Conclusions
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