Peripheral vessels. Could we replace conventional angiography? K. Genova National cardiology hospital Sofia

Peripheral vessels. Could we replace conventional angiography? Objectives To provide an overview of current clinical application of peripheral CT and MRI angiography Overview fundamental principles of MSCT technology Review strengths and limitations of MSCT Review the place, strengths, limitations of MRI peripheral angiography Bulgarian Endovascular Course

Peripheral vessels. Could we replace conventional angiography? Current clinical indication Intermittent claudication Chronic Limb-threathenic ischemia Aneurysms Acute ischemia Follow-up and surveillance after surgical or percutaneous revascularization Vascular trauma Vascular mapping Other indications Bulgarian Endovascular Course

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Department of Health Western Australia.

Peripheral vessels. Could we replace conventional angiography? Current generation scanners Spatial resolution 0.4 mm - conventional angiography mm Temporal resolution (shutter speed) improved to 83 msec (64-MDCT SSR); 60msec (Dual-Source CT DSR) – conventional angiography 6 msec Up to 64 slices in one rotation Larger coverage- speed of table movement increased thus widening range of the study Less contrast is required Bulgarian Endovascular Course

Peripheral vessels. Could we replace conventional angiography? CT angiography allows: Acquisition of high-resolution volumetric date sets (near-isotropic voxels) that can be viewed in multiple planes Variety of visualization techniques (MPR, curved MPR, MIP, volume rendering) Grater speed of scanning with increase longitudinal coverage Detected non-vascular findings To visualize segments of arteries distal to occlusion that were not visible on routine DSA Bulgarian Endovascular Course

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Transverse volumetric data sets

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course VRT images

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course MIP images

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Intraluminal analyses Axial image

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Intraluminal analyses Axial image MIP

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Postoperative evaluation Occlusion of the left branch Occlusion of the distal anastomosis of the right branch Collaterals Visualize segments of arteries distal to occlusion MIP- images

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course VRTIntraluminal analyses

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course VRTThrombosis of AP dex

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course MIP

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Intraluminal analyses

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course MIPVRT

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course MIP Intraluminal analyses

Peripheral vessels. Could we replace conventional angiography? 19 Author No. of patients No. of analyzed segments No. of detectors Reported sensitivity (%) Reported specificity (%) Assessed segments Stenosis category (%) Poletti et al /96ns >50 Portugaller et al Total treearea >70 Romano et al , Total treens Romano et al , Total treens Stueckle et al ns482100Total treens Edwards et al , Total tree50–99 Fraioli et al ,425496–9994–96Total tree50–99 Schertler et al Popliteo-crural>50 Willmann et al , Total tree>50 Unpooled mean9194 Validity of CT angiography in peripheral arterial disease (PAD) Bulgarian Endovascular Course 2011

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Limitations of peripheral CT angiography Image interference from calcified arteries Need for potentially nephrotoxic contrast agent Radiation exposure

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Technical consideration for peripheral MR angiography Improvement in spatial resolution-( mm in- plane; 1-3mm through-plane); reduction in the SNR Increase anatomic coverage (multi-station protocol, continuously moving table date acquisition, Total imaging matrix-Tim RF receiver coil) Increase speed of image acquisition- parallel imaging, high performance gradients

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course MRI techniques used for peripheral MR angiography Vessel wall (black-blood) imaging Contrast-enhanced MRA (3D gradient echo sequences- FLASH, SPGR, FFE, RF-FAST) Non Contrast-Enhanced MRA Time-of-Flight MRA Steady-State Free Precession MRA Phase-Contrast MRA

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Vessel wall (black-blood) imaging Black-blood ECG-gated TSE image in axial plane of the level of mid left thigh AFS-absence of atherosclerotic disease

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Contrast-enhanced MRA- 3D gradient-echo Four-station peripheral CE-MRA- multistation moving-table technique Coronal plane The positioning of the volumes are critical to avoid the exclusion of vascular territories Overlap between sequential volumes Correct timing of image acquisition in relation to contrast injection to ensure adequate arterial opacification

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Contrast-enhanced MRA- 3D gradient-echo Continuously moving table technic peripheral CE-MRA (MIP) High-quality large FOV Full anatomic coverage Lack of discontinuity artifacts Reduction of the time for planning the examination on two date sets (FastView and VesselScout) Higher spatial resolution of the two lower stations- better visualization of the small arterial vessels

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course D coronal MIP peripheral CE-MRA Three-step multistation protocol Continuously moving table technic

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Non Contrast-enhanced MRA (NCE-MRA) Time-of-flight MRA- most commonly used NCA- MRA technic for peripheral vessels (2D TOF, 3D TOF) Flow-related enhancement; suppressed background signal Scanning plan- perpendicular to the vessels ECG-gating- systolic gating to time the image acquisition during the peak blood flow

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Non Contrast-enhanced MRA (NCE-MRA) 2D TOF MRA Occlusion of the AFS bilateraly Collaterals from profunda fem. Flow in the calves throgh collateral arteries

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Non Contrast-enhanced MRA -TruFISP ECG-gated

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Time-resolved MRA or dedicated CE-MRA To reduce venous contamination at the level of the distal station (calf and pedal vessels) in patients with rapid AV transit times The dynamic visualization of contrast in the vessels At least one acceptable angiographic date sets at the level of distal vessels Better delineation of distal bypass Better visualization of collateral vessels AV-shunts, malformation, high-vascularized tumor etc.

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Time-resolved MRA initialintermediatelate

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Time-resolved MRA The vascular malformation enhances late compared with the arteries and that there are no large draining veins. This is a low-flow vascular malformation.

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Dedicated CE-MRA MIP reconstruction High-vascularised Tu of the left calf

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Time-resolved MRA or dedicated CE-MRA VRT reconstructions in different planes

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Diagnostic accuracy of CE-MRA for the detection of significant stenosis in patients with known or suspected PAD

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Major advantages and disadvantages of the principal diagnostic modalities employed for clinical imaging of peripheral vessels

Peripheral vessels. Could we replace conventional angiography? Bulgarian Endovascular Course Suggested diagnostic algorithm in patients with known or suspected peripheral artery disease