Unmasking pedal arteries in patients with critical ischemia using time-resolved contrast-enhanced 3D MRA.
OBJECTIVE
To test the diagnostic relevance of fast Gadobenate dimeglumine (Gd-BOPTA) enhanced, time-resolved, three-dimensional magnetic resonance angiography (t3D MRA) of distal calf and pedal vasculature in critical limb ischemia in a prospective comparison with conventional selective digital subtraction angiography (DSA) and high-resolution duplex ultrasound (US) scan.


METHODS
From April 2007 to June 2008, 34 feet of 29 consecutive patients suffering from limb-threatening ischemia underwent diagnostic US scan, DSA, and t3D MRA before treatment. The investigations took place within 3 days. A t3D MRA was performed using a 3 Tesla whole-body magnetic resonance (MR) system with an eight-element phased-array coil. Image quality and diagnostic findings were subjectively analyzed by two radiologists and one vascular surgeon. Each distal calf and foot was divided into six arterial segments for DSA and t3D MRA, and four segments were investigated by US scan. Patency or occlusion was studied with all the techniques, whereby DSA and t3D MRA were additionally evaluated in patients having greater or less than 50% stenosis. Finally, images were visually assessed by the three observers by applying a six-point grading scale. The acquired data was statistically analyzed using McNemar's test and Wilcoxon's matched-pairs signed-rank sum test. The P values of less than an alpha level of .05 were considered to be statistically significant.


RESULTS
We achieved MRA images of diagnostic quality in all patients. Significantly more patent pedal arteries were identified by applying t3D MRA than DSA (P < .001) and US scan (P < .02). For estimating the degree of stenosis, no technique proved to be superior (P > .28). Overall image quality was rated best for t3D MRA. Additionally, potential bypass target vessels could be clearly discriminated from pedal veins due to the temporal resolution.


CONCLUSIONS
In our prospective study, t3D MRA has been proven to be superior to DSA and US scan in pedal vasculature imaging in critical limb ischemia. This is a valuable, noninvasive method for detecting potential pedal bypass target arteries.
Langer
Stephan
S
European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, Maastricht, The Netherlands. slanger@ukaachen.de
Krämer
Nils
N
Mommertz
Gottfried
G
Koeppel
Thomas A
TA
Jacobs
Michael J
MJ
Wazirie
Noor A
NA
Ocklenburg
Christina
C
Spüntrup
Elmar
E
D000368:Aged; D000369:Aged, 80 and over; D015901:Angiography, Digital Subtraction; D001157:Arterial Occlusive Diseases / Q000150:complications / Q000000981:diagnostic imaging / Q000473:pathology*; D001158:Arteries / Q000473:pathology; D003251:Constriction, Pathologic; D003287:Contrast Media; D016638:Critical Illness; D005260:Female; D005528:Foot / Q000098:blood supply*; D006801:Humans; D007089:Image Enhancement; D007090:Image Interpretation, Computer-Assisted; D021621:Imaging, Three-Dimensional; D007511:Ischemia / Q000000981:diagnostic imaging / Q000209:etiology / Q000473:pathology*; D018810:Magnetic Resonance Angiography / Q000379:methods*; D008297:Male; D008536:Meglumine / Q000031:analogs & derivatives; D008875:Middle Aged; D009942:Organometallic Compounds; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012720:Severity of Illness Index; D013997:Time Factors; D018616:Ultrasonography, Doppler, Duplex; D014654:Vascular Patency
D003287:Contrast Media; D009942:Organometallic Compounds; C064572:gadobenic acid; D008536:Meglumine