principles of imaging in vascular disease - · pdf fileprinciples of imaging in vascular...
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PRINCIPLES OF IMAGING IN
VASCULAR DISEASE
Professor Antoinette S. Gomes, M.D.2nd Annual UCLA /SVS Symposium
Beverly Hills, California2017
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ACKNOWLEDGMENTS
• SIEMENS MEDICAL• GE MEDICAL SYSTEMS• PHILIPS MEDICAL SYSTEMS• TOSHIBA• MEDICAL MEDIA SYSTEMS-M2S• VITAL IMAGES• TERARECON
• No financial disclosures
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IMAGING MODALITIES
• DOPPLER ULTRASOUND• DIGITAL SUBTRACTION ANGIOGRAPHY
(DSA)• MR ANGIOGRAPHY• CT ANGIOGRAPHY
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DIGITAL SUBTRACTION ANGIOGRAPHY
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CONVENTIONAL ANGIOGRAPHY (DSA)
• “GOLD STANDARD”– High Resolution– Rapid Acquisition– Arterial and Venous Imaging– Diagnostic Angiography and
Intervention Same Sitting – May Repeat Injections
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CONVENTIONAL ANGIOGRAPHY
• DISADVANTAGES– Invasive
• Patient Monitoring– Ionizing Radiation– Iodinated Contrast Media Nephrotoxicity– Multiple Injections for Multiple Views
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ROTATIONAL ANGIOGRAPHY
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3D Rotational Angio Process
Propeller – 4 sec. Roll – 6 sec.Acquisition:
Rotational Angio Run on Console:
Initial Reconstruction: 45-75 sec.
Click to play Click to play
Click to play
Click to play
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Radiation Safety
• Portable C-arm• Comparable power output to fixed suites• Less shielding
• Greater exposure from scatter/ leakage radiation
• FDA mandate all flouro machines report dose metrics
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Radiation Safety
• Rad = radiation absorbed dose (.01 joules/kg)• 1 Gray = 100 rads
• Dose area product (DAP) = absorbed dose x area irradiated (Gy/cm2)
• Kerma - kinetic energy released in matter/unit mass (air)
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Radiation Dosimetry
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Radiation Safety
Deterministic skin effects:Patients receiving cumulative air kerma > 3000 mGy at risk skin injury
Patient A - 8 weeks post angio Patient B - post multiple procedures
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CTA AND MRA
• DIFFERENT TECHNOLOGIES• Non Invasive• Volume Acquisition
– Image Post Processing• MIP• MPR• 3D Volume Rendering
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(MRI) MAGNETIC RESONANCE IMAGING
• Images generated based on behavior of hydrogen nuclei
– when exposed to Magnetic Field Gradients
– and Radiofrequency Waves
• 1.5 TESLA 3 TESLA
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MR ANGIOGRAPHY
• PULSE SEQUENCE S
• Non- Contrast:• Time of flight angiography (2D OR 3D) • Phase contrast angiography
• Gd enhanced 3D TOF angiography(CE-MRA)
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3D CE-MRA
• ADVANTAGES– Non Invasive– No Ionizing Radiation– Contrast “Less Nephrotoxic”– Post Processing Fast
• Rapid Subtraction• Good Bone Removal
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cyyyy
cyyyyY
YCE-MRASUBTRACTIONPROCESS
Pre contrast
Contrast
Y
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o
MAXIMUM INTENSITY PROJECTION ALGORITHM MIP
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MIP PROJECTION
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CE-MRA
• LIMITATIONS– Study Time – Patient Cooperation
• Motion Artifact Degrades Image– Post Processing Times– Calcifications Not Well Seen– Resolution Less Than Angiography
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MR CONTRAST AGENTS
• Contain gadolinium (Gd)– Highly paramagnetic
• Free Gd toxic– Metal bound to chelate ligand (e.g
DTPA)
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Gd BASED CONTRAST AGENTS
• Used since 1985• Numerous safety studies
– Dose : 0.1mmol/kg (0.2ml/kg)• Moderately severe bronchospasm, facial edema,
tachycardia, arrhythmias, urticaria 1 in 5,000• Severe Anaphyllactoid reactions 1 in 400,000
Goldstein et al. Radiology 1990;174:17-23
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NEW DISEASE:NEPHROGENIC SYSTEMIC FIBROSIS
• Described 1999• Fibrosis of skin,
connective tissue, organs, contractures
• Potentially fatal
• Relationship to Gdcontrast agents suggested in 2006
Cowper SE. Nephrogenic Fibrosing Dermopathy [NFED/NSF] Website
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NEPHROGENIC SYSTEMIC FIBROSIS
• Increased risk NSF in patients– with acute or chronic severe renal
insufficiency (GFR <30ml/min/1.73m2)
• FDA alert 2006, updated 5/23/07• Boxed warning all agents: Magnevist,
Multihance, Omniscan, OptiMARK, ProHance
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NEPHROGENIC SYSTEMIC FIBROSIS FDA 9/9/10
• Magnevist, Omniscan, Optimark contraindicated in patients with AKI or chronic severe kidney disease
• Screen all patients for renal dysfunction: Hx and/or lab tests
• Avoid use in patients with known risk • Do not exceed dose in product labeling• Monitor for signs and symptoms in at risk patients• Hemodialysis patients: consider prompt hemodialysis
post administration
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NSF• Occurs weeks to months following exposure
• Associated with “Pro-inflammatory conditions”
• Risk in patients with mild to moderate renal insufficiency unknown
• NSF has not been reported in patients with normal renal function
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INCIDENCE
• RARE
• Registries:– Cowper (ICNSFR): 380 patients– FAERS : 1395– Legal data set: 382
• Mortality 4/13 = 31%
Edwards Br J Radiol 2014; Sadowski. Radiology 2007:243;145
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CE-MRA
• APPLICATIONS– Carotid vessels– Thoracic aorta– Abdominal aorta and pelvic vessels– Renal arteries– Mesenteric vessels– Peripheral vessels– Venous system
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R
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Accuracy of MRA for internal carotid artery disease: meta-analysis
>70% Stenosis
0cclusion
sens spec sens spec
TOF MRA 91.2% 88.3% 94.5% 99.3%
CE MRA 94.6% 91.9% 99.4% 99.6%
Debrey SM. Stroke 2008:39;2237
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Accuracy of MRA for internal carotid artery disease: meta-analysis
Moderately severe stenosis ( 50-69%)
Sens Spec
TOF MRA 37.9% 92.1%
CE MRA 65.9% 93.5%
Debrey SM. Stroke 2008;39:2237
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CE-MRA AORTA
Arterial phase
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CE-MRA ABDOMINAL AORTA
• ANEURYSMS– Monitoring Size– Considerations:
• Renal Function• Patient Ability to Cooperate
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CE-MRA CHRONIC AORTIC DISSECTION
• MRA ADVANTAGES: • No Ionizing Radiation• Serial Follow-up• Multiplanar Viewing
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CHRONIC AORTIC DISSECTION WITH GRAFT
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CHRONIC AORTIC DISSECTION WITH GRAFT
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RENAL ARTERY STENOSIS
• MRA widely used for screening• Detect presence or absence of stenosis• If abnormal, arteriography recommended
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CE-MRA RENAL ARTERY STENOSIS
• LIMITATIONS– Assessment stenosis severity may be
difficult– Fibromuscular dysplasia problematic– Stents produce signal dropout
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RENAL ARTERY STENOSIS
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MRA RENAL ARTERY STENOSIS
Thin MIP
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RENAL ARTERY STENT
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RENAL TRANSPLANT
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1709144_lef_renal_SMA7.jpg
MRAMESENTERIC ISCHEMIA
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TAKAYASU’S AORTITIS
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CE-MRA PERIPHERAL VESSELS
• 1.5T OR 3T SYSTEM• STATIONARY TABLE• MOVING TABLE
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3D TOF Gd ENHANCED MRA
• MOVING TABLE - COMBINATION– SINGLE STATION CALF (7CC - 21CCVOL)– STEPPING TABLE
• Aortoiliac-Pelvis, Thighs (11CC - 31CC VOL)
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Meta-analysis: Accuracy of CE-MRAfor Assessing steno-occlusions in PAD
• 32 studies compared CE-MRA to DSA • N= 1,022 patients• For diagnosis stenosis < 50% vs > 50% or
occlusion• Pooled sensitivity CE-MRA 94.7%
specificity CE-MRA 95.6%
Menke J. et al. Ann Intern Med 2010;153:325-334
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Meta-analysis: Accuracy of CE-MRAfor Assessing Steno-occlusions in PAD
• CE-MRA: Correctly classified 95.3% steno-occlusions
Overstaged 3.1% Understaged 1.6%
• Conclusion: MRA high accuracy for identifying or excluding clinically relevant lesions in patients with PAD symptoms.
Menke J. et al. Ann Intern Med
2010;153:325-334
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MR IMAGINGVASCULAR MALFORMATIONS
• MRI important in diagnosis and follow-up• MRI: delineates size lesion, extent of
soft tissue involvement• MRA shows vascular supply
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MRI
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AVM
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MRA
AVM
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VENOUS MALFORMATION
MRI MRA
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CENTRAL VEIN OBSTRUCTION
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NEWER APPLICATIONS:
Total Body MRATime resolved MRA
3D Turbo spin echo MR angiography
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TOTAL BODY MRA
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TOTAL BODY MRA
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TOTAL BODY MRA
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TOTAL BODY MRA
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AVM
Left Distal Thigh
Time Resolved MRA
3cc Magnevist
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Newer MR contrast agent
• Feraheme (ferumoxytol)– Ultrasmall superparamagnetic iron oxide
nanoparticle (USPIO)
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Courtesy Paul Finn, MD. UCLA
5 y.o. ESRD. Non-Gd CE-MRA: Feraheme
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CT ANGIOGRAPHY
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CT BREAKTHROUGH: CTAMULTIDETECTOR-ROW ARRAY
• Combined HELICAL (SPIRAL) CT– Continuous CT Gantry Rotation– With continuous movement of table
through scanner
• Multiple - Row Detector Array
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2-320 rows
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MULTIDETECTOR-ROW CT
• Fast Gantry Rotation Time• Powerful X-Ray Tubes• Improved reconstruction algorithms
• Increased data collection with each rotation • Rapid data acquisition
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MULTIDETECTOR-ROW CT
• Shorter scanning time• Greater longitudinal coverage• Thinner Sections Large Territories
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MULTIDETECTOR CTA
• ADVANTAGES– Fast– High Resolution
• DISADVANTAGES– Iodinated Contrast Agent– Ionizing Radiation– First Pass Technique – Single Bolus
Injection
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32 ROW MIP
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32 ROW
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CTA AORTIC DISSECTION
• ACUTE DISSECTION
• HIGH RESOLUTION• FAST• AVAILABILITY
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ABDOMINAL AORTA
• ANEURYSMS
– Monitoring Of Size– CTA or MRA– Considerations:
• Patient ability to cooperate• Renal function
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AORTIC ENDOGRAFTS
• CTA
– Advantages:
• Size Measurement for EndograftSelection
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ENDOGRAFT FOLLOW-UP
• CTA
– Less artifact from metallic components Endograft
– Endoleaks better seen– Specialized software M2S, Terarecon,
Vitrea
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THORACIC AORTIC ANEURYSM
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THORACIC ENDOGRAFT
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CTA RENAL ARTERIES
• CTA or MRA• Choice determined by clinical question• Patient renal function
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CTA RENALS
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RENAL ARTERY CTA
• Renal Donors– CTA Resolution better for accessory
arteries
• Renal Artery Stenosis– Useful for renal stent evaluatiom
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RENAL ARTERY STENTS
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CTA RENAL ARTERY ANEURYSM
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MESENTERIC ISCHEMIA
• CTA: Acute Ischemia
• MRA: Chronic Ischemia– Elderly patient screening
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STENT
SUPERIOR MESENTERIC ARTERY
CTA MESENTERIC STENT
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CTA MRA
MigratedStent
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Stent Migration - 3D ReconstructionCTA MRA
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CTA PERIPHERAL VESSELS
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CTA PERIPHERAL VESSELS REQUIREMENTS
• Need to cover large volume– 100cm– Aortic bifurcation to feet
• Image acquisition during arterial phase
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16 ROW MDCT CTA
• Advantages:• Large Volume Coverage In Shorter Time
– 100cm In 21.4 Sec– 5x Faster Than 4 Row MDCT
• Same Resolution And Slice Thickness• Comparable Or Lower Dose Than 4 Row MDCT
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16 ROW
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16 ROW
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16 ROW OR HIGHER MDCT SCANNER:
TOTAL BODY SCAN
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64 ROW
MDCTA
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MULTDETECTOR- ROW HELICAL CT
• ISSUES:– Large Number Transverse Images
Produced: 908-2,131– Workstation viewing
• POST PROCESSING REQUIRED– Bone and soft tissue removal
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IMAGE POST PROCESSING
• MPR• MIP• 3D VOLUME RENDERING• TRANSPARENCIES• EDITING AND SEGMENTATION
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MPR
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IMAGE POST PROCESSING
• Critical for accurate diagnosis • Time consuming• Dedicated personnel
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MULTIDETECTOR-ROW CT
ACCURACY OF TECHNIQUE ?
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CTA in PAD Meta-analysis 2009
• 909 studies: 20 met inclusion criteria (2.2%)• 957 patients• CTA
• Sensitivity > 50% stenosis or occlusion = 95%• Specificity = 96%
Met R, et al. JAMA 2009;301:415
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CTA in PAD: Meta-analysis 2009
• Occlusions correctly identified in 94% segments
• >50% stenosis in 87%• Absence stenosis in 96% segments• Overstaging in 8%• Understaging 15%
Met R, et al. JAMA 2009; 301:415
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MDCT-CTA VS ANGIOGRAPHY
• DSA Higher Resolution• Both require large volume contrast• CTA One Injection• CTA - Timing Critical:
– Venous Contamination– Small Vessels e.g. Foot
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16 ROW MDCT
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16 ROW
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16 ROW
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16 ROW
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16 ROW
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RADIATION EXPOSURE
• CALCULATED EFFECTIVE DOSE INDEXES– 0.93 cSV 4 Row MDCT– 3.62 cSV Conventional angiography
• Radiation exposure 3.9x greater with angiography
• 16 Row, 64 Row dose modulation techniques
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Diagnostic Performance CTA and CE-MRA in CLI and IC
Systematic Review and Meta-analysis
• 1995-2013• 12 CTA articles 673 patients• 30 CE-MRA articles 1404 subjects
Jens SJ, et al. Eur Radiol 2013
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Diagnostic Performance CTA and CE-MRA in CLI and IC
Systematic Review and Meta-analysis
Aortotibial Sensitivity Specificity
CTA 96% 95%
CE-MRA 93% 94%
Jens SJ, et al. Eur Radiol 2013
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Diagnostic Performance CTA and CE-MRA in CLI and IC
Systematic Review and Meta-analysis
• CTA CE-MRA both accurate for diagnosis PAD
• Performance not different in CLI or IC• Separate imaging of tibial arteries by CE-MRA
preferred
Jens SJ, et al. Eur Radiol 2013
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NEWER DEVELOPMENTS
DSA-CT COMBINATION
DUAL SOURCE CT
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CT-DSA COMBINATIONXperCT
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DUAL SOURCE CT
Lv, P. et al. AJNR 2014
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DUAL ENERGY CT
Meyer B C, Eur J Radiology 2008
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CONCLUSION
• VARIETY OF IMAGING TECHNIQUES AVAILABLE
• SELECTION DETERMINED BY CLINICAL QUESTION AND CLINICAL STATUS OF THE PATIENT
• TECHNICAL RESOURCES
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THANK YOU
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QUESTIONS
Nephrogenic systemic fibrosis is:
1) A common disease True False2) Associated with Iodine containing contrast
agents True False3) Seen in patients with normal renal function
True False
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QUESTION
The imaging modality most helpful for initial imaging in patients with suspected acute aortic dissection is:
1) MR/MRA True False2) CT/CTA True False
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QUESTION
Which of the following are true:
1) MRA and CTA are equally good for assessing stent patency
2) Calcifications are better seen on MR imaging
3) CT imaging is faster than MR imaging
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