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Rapid High-resolution, Self-registered, Dual Lumen-contrast MRI Method for Vessel-wall Assessment in Peripheral Artery Disease

Posted Mar 31, 2016 Updated Apr 10, 2023
By Michael C. Langham PhD , Benoit Desjardins MD PhD , Erin K. Englund BE , Emile R. Mohler MD , Thomas F. Floyd MD , Felix W. Wehrli PhD
13 min read

Rationale and Objectives

Contrast-enhanced angiographic evaluation by magnetic resonance imaging (MRI) and computed tomography (CT) is the reference standard for assessing peripheral artery disease (PAD). However, because PAD and diabetes often coexist, the prevalence of renal insufficiency is a major challenge to contrast-based angiography. The objective of this work is to describe and demonstrate a new application of three-dimensional double-echo steady-state (3D DESS) as a noncontrast vascular MRI method for evaluating peripheral atherosclerosis at 3 Tesla (3T).

Materials and Methods

A water-selective 3D DESS pulse sequence was designed to simultaneously collect two steady-state free-precession signals (free induction decay and Echo) yielding “black blood” (BB) and “gray blood” (GB) images. For completeness Bloch equation, simulations were performed to characterize DESS signals of various tissues including blood at different velocities and to assess two healthy subjects for the purpose of pulse sequence optimization. Exploratory studies were performed as an add-on protocol to an existing study involving patients with PAD. To evaluate the method’s specificity for detecting calcification, images from select patients were compared against CT angiography.

Results

Simulations agreed qualitatively with in vivo images supporting DESS’ potential for generating distinct lumen contrast (GB vs BB). Lesions representing calcium were easily identifiable on the basis of signal void occurring on both image types and were confirmed by CT angiography. Further, BB allowed visualization of stent restenosis, and data suggest its ability to visualize acute thrombus by virtue of T2 weighting.

Conclusion

Preliminary investigation and results suggest noncontrast 3D DESS to have the potential to improve diagnosis of PAD patients by providing detailed structural assessment of vessel-wall architecture.

Introduction

Peripheral artery disease (PAD) is a common manifestation of systemic atherosclerosis affecting 8–12 million individuals in the United States. Patients with PAD have a fivefold and a two- to threefold greater risk of heart attack and stroke, respectively, and higher mortality rate relative to those without PAD . Among subjects aged 50 years and older with diabetes mellitus and a history of smoking, the prevalence of PAD can be as high as 30% . The most common clinical symptom is intermittent claudication or cramp-like pain in the legs and buttocks induced by exercise, which contributes to a poor quality of life and a high rate of depression . The progression of the disease can lead to critical limb ischemia where blood flow is severely impaired to the lower limbs due to stenosis.

Maximum intensity projections of contrast-based angiography can rapidly provide a “roadmap” of large vascular segments for the assessment of severity and extent of PAD. Typical spatial resolution of contrast-enhanced magnetic resonance angiography (CE-MRA) is limited to 1 mm, and the luminal images cannot provide tissue information such as vessel-wall thickening and calcification. Computed tomographic angiography (CTA) is often preferred for speed and high-isotropic resolution, allowing reformation in any direction. However, diffuse calcification can confound diagnosis, particularly in smaller infrapopliteal arteries, which are common sites of PAD in diabetics . The gold standard for evaluating vascular diseases is catheter-based digital subtraction angiography (DSA), often utilized for planning surgical revascularization and angioplasty. Both CTA and DSA expose patients to ionization radiation. The greatest challenge of contrast-based angiography occurs in patients with compromised renal function, where prevalence is estimated at 27–36% because PAD and diabetes often coexist . Paradoxically, this is the patient population most indicated for angiographic examination, but these patients have a greater risk of contrast-induced acute renal failure, a source of significant morbidity and mortality.

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Methods

Blood Signal Attenuation in 3D DESS

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Figure 1, Water-selective three-dimensional double-echo steady-state pulse sequence. The free induction decay is read out with higher bandwidth to minimize TR and increase muscle tissue SNR of echo. Interpulse time is computed based on the chemical shift value of lipid CH 2 protons at 2.89 T (−418 Hz relative to H 2 O). G x , Gradient pulses in x-axis; G y , Gradient pulses in y-axis; G z , Gradient pulses in z-axis. (Color version of figure is available online).

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Numerical Simulation

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In Vivo Study

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SNR, CNR, and Fat Attenuation Level

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Results

Numerical Simulations

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Figure 2, Flow sensitivity and off-resonance effects of 1–1 binomial pulse. Simulation of steady-state signal under different flow condition for ( a ) SSFP-free induction decay (FID) and (b ) SSFP-Echo. Significant SSFP-Echo signal attenuation even at low velocity of 0.5 cm/s supports excellent blood suppression observed even near the walls of peripheral veins, e.g. Figure 3b and f . ( c ) FID as a gradient-recalled echo is much less tolerant of static field inhomogeneity. The simulation suggests that it is possible to discern intermuscular fat from vessel wall up to 100 Hz off-resonance. (Color version of figure is available online).

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In Vivo Study

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Figure 3, Dual lumen contrast of DESS images. The images of ( a ) SSFP-free induction decay (FID), and ( b ) SSFP-Echo, clearly demonstrate distinct lumen contrast in the superficial femoral artery, i.e. moderate (gray blood [GB], black arrow ) signal in the lumen ( a ) versus full suppression (black blood [BB], white arrow ) of the blood signal ( b ). White circles highlight variation of fat attenuation due to spatially dependent static field inhomogeneity. From left to right, the fat signal reduction is 54%, 67%, and 75%, respectively, compared to the ( c ) GB image acquired without fat attenuation. At the same ROIs in ( b ) the fat signal reduction is 70%, 88%, and 92% compared to ( d ), collected simultaneously with ( c ). Magnified view of femoral and popliteal arteries ( dashed box ) of ( e ) SSFP-FID and ( f ) SSFP-Echo from proximal to the distal edge of the slab (seven slices out of 240, each separated by 45 mm). The signal in ( e ) is strongly location dependent, being highest in the most proximal location due to inflow enhancement, getting gradually lower in the more distal slices.

Table 1

SNR and CNR Measured from Black-blood Images

Lumen and Vessel-wall SNR and CNR \*

(SNR l /SNR w ) Subject Common Fem. Superficial Fem. Popliteal 1 4.7/15.4 5.0/23.7 7.3/27.3 2 8.5/15.4 9.5/30.8 6.0/20.1 3 10.9/19 11.7/36.7 8.6/31.8 4 8.5/20.1 10.1/27.3 8.8/29.6 5 5.7/13.0 6.9/17.8 5.6/21.3 6 10.7/34.4 15.4/39.1 13.0/55.7 7 5.8/16.6 6.3/23.7 8.1/17.8 8 5.5/17.8 7.3/28.4 6.8/19.0 9 7.9/15.4 7.1/35.5 6.6/24.9 10 6.6/17.8 6.3/21.3 5.1/13.0 11 7.7/28.4 7.9/37.9 7.2/27.3 12 6.4/19.0 6.9/22.5 6.9/27.3 13 8.9/17.8 7.5/23.7 8.5/37.9 14 8.6/21.3 8.3/28.4 8.2/23.7 15 10.5/29.6 8.6/23.7 9.5/33.2 16 9.1/23.7 9.4/30.8 9.5/36.7 17 6.6/14.2 7.1/21.3 6.3/36.7 18 11.3/34.4 8.5/16.6 9.5/32.0 19 11.8/32.0 13.0/35.5 9.7/32.0 20 10.4/26.1 9.5/29.6 8.9/29.6 Average

SNR w (SD)/

SNR l (SD)

8.3 (2.2)/

21.6 (6.9)

8.6 (2.5)/

27.7 (6.7)

8.0 (1.8)/

28.8 (9.3) Average:

CNR (SD)

13.2 (5.4)

19.1 (5.4)

20.8 (7.9)

SNR w , SNR of vessel-wall; SNR l , SNR of vessel lumen; SD, standard deviation; Fem., femoral.

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Table 2

SNR and CNR Measured from Gray-blood Images

Lumen and Vessel-wall SNR and CNR \*

(SNR l /SNR w ) Subject Common Fem. Superficial Fem. Popliteal 1 51.3/38.0 50.7/39.3 22.0/32.0 2 16.7/19.3 20.0/28.7 15.3/24.0 3 38.0/26.7 34.0/55.3 32.0/44.7 4 50.0/32.7 28.0/34.7 30.0/44.0 5 24.7/27.3 25.3/29.3 20.0/28.0 6 57.9/46.7 59.6/45.8 24.2/33.3 7 29.3/21.3 33.3/38.0 16.0/22.0 8 21.3/22.0 53.3/42.7 26.0/29.3 9 37.3/33.3 44.0/44.0 26.7/34.0 10 30.7/20.0 19.3/32.0 21.3/29.3 11 32.7/41.3 35.3/41.3 33.3/44.0 12 54.0/28.7 51.3/40.0 26.7/36.0 13 68.0/46.0 37.3/32.0 35.3/50.5 14 48.0/45.3 18.7/28.7 16.0/26.7 15 36.0/32.7 15.3/28.0 20.0/34.7 16 47.3/45.3 42.7/42.7 28.7/40.7 17 16.7/21.3 15.3/26.7 21.3/38.0 18 30.7/45.3 53.3/52.7 34.7/38.0 19 21.3/30.0 35.3/38.7 50.0/45.3 20 22.0/28.0 16.7/28.0 36.7/42.7 Average

SNR w (SD)/

SNR l (SD)

32.6 (9.7)/

36.7 (14.8)

37.4 (8.4)/

34.4 (14.4)

35.8 (7.8)/

26.8 (8.6) Average:

CNR (SD)

−4.1 (10.7)

3.0 (9.6)

9.0 (4.9)

SNR w , SNR of vessel-wall; SNR l , SNR of vessel lumen; SD, standard deviation; Fem., femoral.

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Figure 4, Identification of calcium in peripheral artery disease using double-echo steady state. On both ( a ) gray blood and ( b ) black blood images calcium ( white arrows ) is hypointense with distinct lumen contrast allowing detection of calcium. ( c ) Proof of calcium ( white arrows ) in iliac arteries on computed tomography angiography. The lumen ( dashed arrow ) is also well visualized from the contrast medium that has a higher radiodensity than surrounding tissue. The patient is a 71-year-old female with ankle-brachial index (ABI) = 0.77 and 0.58 in left and right leg, respectively.

Figure 5, Detection of calcium. Visualization of calcium ( arrows ) in right common iliac artery aneurysm on ( a ) gray blood (GB) and ( b ) computed tomography angiography (CTA) images (same patient as in Fig 4 ). ( c ) Magnified view of 10 contiguous slices representing 1.5 cm of the right tibial-peroneal arterial segment ( arrow ) in a 66-year-old type-2 diabetic patient with ABI = 0.57. Spatially registered ( d ) GB and ( e ) black blood images corroborate calcium ( white arrow ) and obstruction ( dashed arrow ) in ( e ) detected by ( f ) CTA in left superficial femoral artery (SFA). Hypointense lumen signal ( dashed arrow ) surrounded by calcium ( white arrow ) in right superficial femoral arteries indicates obstruction.

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Figure 6, Unambiguous assessment of lesion burden with black-blood images in a 51-year-old male with ABI = 0.83 (left) and 0.9 (right): ( a ) 20 slices spanning 300 mm cranio-caudally from the common femoral artery (CFA) to distal superficial femoral arteries (SFA); slice spacing 15 mm. ( b ) The luminal narrowing seen on the quiescent interval single-sho magnetic resonance angiography ( white arrow ) is consistent with the axial images of ( a ) ( blue dashed arrow ). The dashed box indicates the commonly observed B 1 inhomogeneity-induced signal loss in the right proximal femoral artery at 3T. The signal attenuation is also observed in ( a ) but is less pronounced ( dashed box ) such that the visualization of the lesion burden and eccentricity is still possible. Solid blue arrow points to an eccentric lesion. (Color version of figure is available online).

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Figure 7, In-stent restenosis in a 57-year-old male with ABI = 0.51 (right) and 0.93 (left): ( a ) MIP in the anterior–posterior direction of quiescent interval single-shot magnetic resonance angiography with stent in medial to distal superficial femoral arteries ( rectangle ). ( b ) Select black blood (left column, signal void imply stent patency) and gray blood (right column) images showing in-stent restenosis. Top and bottom rows show end rungs of stent (signal voids distributed symmetrically around the circumference, dashed arrow ). In the middle, three rows signal void ( blue arrows ) near the vessel wall are attributed to the stent rather than calcification. (Color version of figure is available online).

Figure 8, Arterial thrombus in a 63-year-old patient with peripheral artery disease with ABI = 0.73 and 1.04 in left and right leg, respectively. Hyperintense signal of left superficial femoral arteries lumen ( arrows ) on both ( a ) gray blood (GB) and ( b ) black blood (BB) image suggests a newly formed arterial thrombus. ( c ) GB ( top row ) and BB images of superficial ( thick arrow ) and deep ( thin arrow ) femoral arteries 8.9 cm distal from the common femoral artery bifurcation. The reduced signal level relative to the adjacent muscle tissue as compared to ( a ) indicates that the thrombus is several weeks old.

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Discussion

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Conclusion

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Acknowledgment

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Academic Radiology, Volume 23, Issue 4
Journals General Radiology
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