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Optimized Assessment of Hand Vascularization on Contrast-Enhanced MR Angiography with a Subsystolic Continuous Compression Technique

¹ Department of Diagnostic Radiology, University Hospital of Basel, Petersgraben 4, Basel CH-4031, Switzerland.
² Department of Angiology, University Hospital of Basel, Basel CH-4031, Switzerland.

Received April 28, 2003; accepted after revision July 21, 2003.

 
Address correspondence to D. Bilecen (dbilecen{at}uhbs.ch).

Introduction

Top Introduction Subjects and Methods Results Discussion References

 
Digital subtraction angiography is still the gold standard for hand angiography, even though it is cost-intensive, invasive, and requires ionizing radiation. Contrast-enhanced MR angiography of the hand as an alternative for diagnostic evaluation remains challenging. In contrast to MR angiograms of the body, the much smaller caliber of digital arteries demands considerably longer acquisition times for obtaining contrast-enhanced MR angiograms of the hand. However, a prolonged acquisition of an arterial signal is difficult to achieve because of early venous contamination, which is due to short arteriovenous transit time [1–3].

In this study, subsystolic continuous compression MR angiography is proposed to reduce venous overlay of the hand on contrast-enhanced MR angiography. Continuous compression is achieved by the inflation of a conventional blood-pressure cuff on the upper arm.

Subjects and Methods

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Nine healthy subjects with a mean age of 33.5 years (age range, 26–42 years) without vascular disease were enrolled in this study. All participants gave informed consent, and the study was approved by the local hospital's ethics committee. Upper arm compression was applied 3 min before measurement with a standard blood-pressure cuff to allow arteriovenous flow equilibration. The subsystolic pressure was adapted 30% below the brachial systolic blood pressure. The cuff was applied unilaterally so that an intraindividual comparison of venous contamination between the compressed and noncompressed sides was possible.

All subsystolic continuous compression MR angiography examinations were performed on a 1.5-T whole-body scanner (Magnetom Sonata, Siemens, Erlangen, Germany) using a surface coil for signal transmitting and receiving. Volunteers were placed prone, head first, arms extended above the head, and hands closely attached to the coil in the scanner. Contrast-enhanced MR angiograms of the hands were obtained by a high-resolution T1-weighted 3D gradient-echo sequence (matrix size, 512 x 176; field of view, 320 x 200 mm²; partitions per slap, 56; partition thickness, 1.0 mm; TR/TE, 4.45/1.28; acquisition time, 20 sec/slap; flip angle, 25°; time to center, 7.1 sec; filling, 0). Seven measurements were performed continuously, resulting in a total scanning time of 140 sec. A standard dose of 0.2 mL/kg body weight of gadoterate dimeglumine (Dotarem, Guerbet, Aulney-sous-Bois, France) was administered with a power injector (Spectris, Medrad, Pittsburgh, PA) at an injection rate of 1.5 mL/sec via the antecubital vein of the noncompressed side, followed by a flush of 20 mL saline solution (0.9%). The contrast agent bolus was applied at the beginning of the first MR measurement. Maximum intensity projections (MIPs) were reconstructed from T1-weighted partitions, with the first measurement serving as a mask.

For evaluation purposes, venous contamination of the compressed and noncompressed sides was rated by three experienced radiologists on each MIP as 0, no venous contrast agent filling; 1, minor venous overlay and no reduction in diagnostic value; 2, major venous overlay and reduction in diagnostic value; or 3, no diagnostic value. The noncompressed side served as the reference for standard contrast-enhanced MR angiography. A paired t test was applied for each MIP to evaluate the significance of the level of venous contamination between the compressed and noncompressed sides.

Results

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Subsystolic continuous compression MR angiography was well tolerated by all volunteers. Exemplarily, all six MIP-reconstructed contrast-enhanced MR angiograms of one volunteer are presented in Figure 1A, 1B, 1C, 1D, 1E, 1F. Compression was applied on the left side. A delay of arterial inflow is observed on the side of compression. Deep palmar arterial arch and palmar metacarpal arteries are sequentially enhanced from the first to the fourth MIP. The superficial palmar arch is absent as a variant. Minor venous overlay is visible from the third MIP onward. On the noncompressed side, major venous contamination is observed already on the first MIP, masking all arterial segments. Venous overlay equilibrates at the end of measurement in the fifth and sixth MIPs for both sides.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —Maximum intensity projections (MIPs) from reconstructed 3D contrast-enhanced MR angiograms of hands of 32-year-old man. Subsystolic cuff compression was applied to left upper arm. Delay of arterial filling and reduced venous overlay on compressed side are observed. MIPs obtained 20 sec after bolus injection.

View larger version (107K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —Maximum intensity projections (MIPs) from reconstructed 3D contrast-enhanced MR angiograms of hands of 32-year-old man. Subsystolic cuff compression was applied to left upper arm. Delay of arterial filling and reduced venous overlay on compressed side are observed. MIPs obtained 40 sec after bolus injection.

View larger version (72K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —Maximum intensity projections (MIPs) from reconstructed 3D contrast-enhanced MR angiograms of hands of 32-year-old man. Subsystolic cuff compression was applied to left upper arm. Delay of arterial filling and reduced venous overlay on compressed side are observed. MIPs obtained 60 sec after bolus injection.

View larger version (116K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1D. —Maximum intensity projections (MIPs) from reconstructed 3D contrast-enhanced MR angiograms of hands of 32-year-old man. Subsystolic cuff compression was applied to left upper arm. Delay of arterial filling and reduced venous overlay on compressed side are observed. MIPs obtained 80 sec after bolus injection.

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1E. —Maximum intensity projections (MIPs) from reconstructed 3D contrast-enhanced MR angiograms of hands of 32-year-old man. Subsystolic cuff compression was applied to left upper arm. Delay of arterial filling and reduced venous overlay on compressed side are observed. MIPs obtained 100 sec after bolus injection.

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1F. —Maximum intensity projections (MIPs) from reconstructed 3D contrast-enhanced MR angiograms of hands of 32-year-old man. Subsystolic cuff compression was applied to left upper arm. Delay of arterial filling and reduced venous overlay on compressed side are observed. MIPs obtained 120 sec after bolus injection.

The mean venous contamination scores of all six MIPs are graphically presented in Figure 2. In contrast to the venous contamination scores on the noncompressed side, significantly lower contamination scores were observed on the side of compression of the first through fourth MIPs, with a p value less than 0.02. The significance level between the compressed and noncompressed sides of the fifth and sixth MIPs decreases to a p value less than 0.1.

View larger version (12K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2. —Bar graph shows mean values of contamination scores and corresponding SDs for maximum intensity projections (MIPs) 1–6 for noncompressed side (gray) and compressed side (black).

Discussion

Top Introduction Subjects and Methods Results Discussion References

 
Generally, the arteriovenous circulation time of the hand is very short. Thus, early venous contamination occurs. A decrease of venous overlay is difficult to achieve with standard contrast-enhanced MR angiography protocols. However, subsystolic continuous compression MR angiography has been shown to reduce venous overlay significantly. This effect is explained by a reduction of flow of blood and contrast agent through the superficial and deep veins [4] and a decreased arterial blood velocity and, hence, an increased arterial transit time that allows arterial imaging before venous enhancement. This delay in arterial filling is caused by the external compression of the brachial artery due to the inflated cuff and presumably by the venous–arterial back-pressure mechanism via the arteriovenous capillary bed. In contrast to timed arterial compression MR angiography [1], a test bolus is not required for subsystolic continuous compression MR angiography.

Subsystolic continuous compression MR angiography is easily applicable on all types of scanners and does not depend on the latest MR technology. Based on a prolonged venous-free interval, increased signal-to-noise ratio or in-plane resolution of the image can be expected when acquisition time is increased. However, the precise physiologic mechanism of subsystolic compression and its diagnostic impact on the assessment of arterial visualization under pathologic conditions are the subject of further investigation.

References

Top Introduction Subjects and Methods Results Discussion References

 

1. Wentz KU, Froehlich JM, von Weymarn C, Patak MA, Jenelten R, Zollikofer CL. High-resolution magnetic resonance angiography of hands with timed arterial compression (tac-MRA). Lancet2003; 361:49 –50[Medline]
2. Winterer JT, Scheffler K, Paul G, et al. Optimization of contrast-enhanced MR angiography of the hands with a timing bolus and elliptically reordered 3D pulse sequence. J Comput Assist Tomogr 2000;24:903 –908[Medline]
3. Goldfarb JW, Hochman MG, Kim DS, Edelman RR. Contrast-enhanced MR angiography and perfusion imaging of the hand. AJR2001; 177:1177 –1182[Abstract/Free Full Text]
4. Bernstein EF. Vascular diagnosis, 4th ed. St. Louis, MO: Mosby, 1993:205 –223

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