Radiol Clin N Am 40 (2002) xi – xii
Preface
Vascular imaging
Klaus D. Hagspiel, MD
Guest Editors
It has been 7 years since an issue of Radiologic
Clinics of North America was devoted to vascular
imaging. Now, as then, cardiovascular disease
remains the leading cause of death and morbidity in
the United States; however, in the ensuing 7 years,
noninvasive vascular imaging modalities have
improved significantly, and there has also been a
significant change in their utilization pattern.
Gadolinium-enhanced 3D magnetic resonance
angiography (MRA) has matured into a robust and
accurate vascular imaging technique. Its use is no
longer confined to a few dedicated centers; rather, 3D
gadolinium-enhanced MRA is now successfully used
in many clinical settings throughout the world and
has replaced other diagnostic imaging modalities in a
number of vascular territories.
Although it was not considered a primary vascular
imaging modality 7 years ago, computed tomography
angiography (CTA) has experienced a technological
quantum leap forward. The introduction of multislice
detector systems with isotropic imaging capabilities
has enabled CTA to surpass MRA with regard to
spatial resolution. In many centers, CTA is now the
modality of choice for the diagnosis of pulmonary
embolism and the assessment of diseases of the aorta.
The acquisition of CTA data is rapid, and the post-
processing algorithms continue to improve, allowing
for the use of various fly-through and 3D reconstruc-
tions. In addition, in its most recent implementation
using an EKG-gated technique, CTA allows for the
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Alan H. Matsumoto, MD
acquisition of images of the coronary arteries with
resolution and vessel definition surpassing those of
coronary MRA.
Another innovation in vascular imaging is the
development of both MR and CT for the detection
and characterization of atherosclerotic plaque. The
ability to define plaque morphology reveals a whole
new realm of vascular imaging application. It has
become apparent that atherosclerotic plaques are
heterogenous, with some being more prone to calcify,
rupture, or progress depending on the constitution of
the plaque. In addition, by being able to more clearly
define a plaque and its morphology, the effect of
various therapies on the progression or regression of
plaque can be monitored.
Catheter-based angiography is now synonymous
with digital subtraction angiography (DSA). Al-
though DSA is used less in the setting of vascular
diagnosis, its application in interventional procedures
or to reconcile the inconsistencies of noninvasive
studies continues. Newer, catheter-based methods
have also been developed and refined to add to our
armamentarium. 3D rotational angiography and the
use of alternative contrast media are two examples of
catheter-based techniques that have been developed in
the past decade. Nevertheless, there can be no doubt
that the role of catheter-based angiography as a
diagnostic tool will be further reduced over the next
decade given the rapid pace of technological advance-
ments in both CT and MR imaging. In addition, the
xii Preface / Radiol Clin N Am 40 (2002) xi–xii

field of interventional MRI has progressed to a level Klaus D. Hagspiel, MD

that vascular interventions are now feasible in an MR Associate Professor of Radiology
environment and may ultimately challenge fluoro- Department of Radiology
scopically guided techniques. Division of Angiography and
We hope that this issue of Radiologic Clinics of Interventional Radiology
North America provides the reader with a greater University of Virginia Health System
understanding of some of the recent developments Charlottesville, VA 22908 – 0170, USA
in the field of vascular imaging and helps to put
their potential use and application into a practical Alan H. Matsumoto, MD
clinical context. We would like to thank the authors Professor of Radiology
for their outstanding and timely contributions. Division Head
Undoubtedly, vascular imaging is an area within Department of Radiology
the field of cardiovascular medicine that is experi- Division of Angiography and
encing rapid growth, and every radiology depart- Interventional Radiology
ment should attempt to become intimately involved University of Virginia, Health System
in its clinical application. Charlottesville, VA 22908-0170, USA
 Radiol Clin N Am 40 (2002) 689 – 692

The future of catheter-based angiography: implications for

the vascular interventionalist
Barry T. Katzen, MD*
Miami Cardiac and Vascular Institute, Baptist Hospital, 8900 North Kendall Drive, Miami, FL 33176, USA
Department of Radiology, University of Miami School of Medicine, Miami, FL 33176, USA

The title of this article implies that there is a
problem that will result in changes in the way
invasive angiography is performed or used. Clearly
the impact of less invasive imaging methods will
result in reduced need and benefit of catheter-based
angiography in the future. Does this mean the need
for angiographic equipment, qualified intervention-
alists, and catheter technologies will be eliminated?
Before addressing these questions, it is important to
understand the current clinical applications of inva-
sive angiography and the modalities that may offer
practical replacements.
Current applications of
catheter-based angiography
Historically, catheter-based angiography has pro-
vided the gold standard for visualization of the
circulatory system. After Seldinger’s historic descrip-
tion of a simple technique to introduce catheters into
the circulation without surgical incision in 1953,
angiography was explored for its value in providing
diagnostic information about a broad spectrum of
disease entities. These included not only atheroscle-
rotic occlusive disease and other primary vascular
diseases, but also neoplastic diseases and other
masses [1]. With the advent of computed tomography
(CT) in the 1970s and body CT in the latter part of
that decade, there was a gradual transition away from
* Correspondence. Miami Cardiac and Vascular Insti-
tute, Baptist Hospital, 8900 North Kendall Drive, Miami, FL
33176, USA.
the vascular anatomy as a distinguishing character-
istic. Technology also affected the safety and efficacy
of angiography in the late 1970s and early 1980s. The
advent of digital techniques and, specifically, digital
subtraction angiography (DSA) made angiographic
examinations much safer with reduction in contrast
and significant reduction in size of sheaths and
catheters necessary to perform procedures. Following
a short period of time where intravenous (IV) contrast
was used to promote outpatient procedures, it became
rapidly apparent that with smaller catheters and
meticulous technique, outpatient angiography could
be a reality. Because imaging was far superior with
arterial compared with venous injections of contrast
material, arterial DSA became the standard. Image
quality improved to the point that film changers were
eliminated and replaced by DSA components that
produced real-time information, with reduced con-
trast needs and the potential for filmless and dynamic
imaging. This improvement in imaging was accom-
panied by the development and advancement of
catheter-based therapeutic procedures, including
angioplasty, thrombolysis, and stent placement. Over
the past fifteen years, angiography has become irrele-
vant in the diagnosis of pancreatitis, cancer of the
pancreas, liver, kidney, and other organs. Yet it re-
mains critical to the detection and pretreatment plan-
ning for vascular occlusive disease by either surgical
or endovascular techniques.
Catheter-based angiography remains the primary
method of evaluating the severity and specific location
of occlusive disease of the extracranial carotid arteries,
the renal and visceral arteries, and the thoracic and
abdominal aorta and peripheral arteries. Invasive
approaches also are used widely for assessment of

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690 B.T. Katzen / Radiol Clin N Am 40 (2002) 689–692
venous structures and vascular malformations. Ana-
tomic evaluation of the coronary arteries also is
completed predominantly by invasive angiography.
Clearly other modalities are improving their spatial
and contrast resolution and ability to demonstrate
simply the vasculature. As a result, even at the time
of this writing, change that will affect the future of
invasive imaging is occurring rapidly.
Advances in percutaneous therapeutic techniques
Since the first description of transluminal angio-
plasty by Dotter in 1963, percutaneous therapy for
vascular occlusive disease, and other forms of vas-
cular disease, has become the standard of care for
many patients. The radiologist and other specialists
are dependent on high-quality imaging to make the
complex treatment decisions necessary to insure
high-quality outcomes with low morbidity [2]. Some
of the components of endovascular therapy include:
1. Percutaneous revascularization. In the treat-
ment of noncoronary vascular disease, per-
cutaneous techniques are the first line of
management in many patients. Techniques
such as percutaneous transluminal angioplasty
(PTA), intravascular stent placement, and use
of thrombolysis have proven efficacy, but
depend on high-quality imaging to identify
patients who might be candidates. In addition,
imaging is critical in determining the specific
anatomic features of lesions, distal runoff
vessels, presence of collateral flow, and other
characteristics for the interventionalist to per-
form adequately treatment planning. Areas of
application include all parts of the circulatory
tree including the aorta, iliac and femoral
arteries, renal and visceral branches, and the
brachiocephalic circulation.
2. Embolization. A large part of vascular inter-
vention includes the occlusion of blood vessels
for therapeutic purposes. Conditions such as
neoplasm, vascular malformations, aneurysm,
and hemorrhage may require the skills of the
interventionalist. Recently, uterine fibroid em-
bolization has become an important interven-
tional alternative in symptomatic patients. The
role of imaging is not only to detect disease,
but also to provide sufficient information for
treatment planning.
3. Drug delivery. In the treatment of neoplastic
disease, patients may benefit from direct
delivery of agents for greater efficacy. Throm-
bolytic agents, and perhaps other agents
directed at restenosis, may become more im-
portant as a therapeutic technique. Other agents
include vasodilators for cholesterol emboliza-
tion, and vasoconstrictors for some types of
gastrointestinal hemorrhage.
4. Endograft placement. Endografts represent a
combination of fabric and stent technology and
can be used to treat a variety of types of
aneurysm disease in large- and medium-sized
vessels. These include disease in the abdominal
and thoracic aorta and branch aneurysms, such
as visceral and brachiocephalic. Additionally,
this technology may have benefit in occlusive
disease, particularly in the future, perhaps in
conjunction with the delivery of drug.
For all these procedures, catheter-based angiog-
raphy is the gold standard in obtaining information
for treatment planning, but if noninvasive modalities
could provide sufficient quality information, the need
for invasive angiography for diagnosis alone would
be greatly reduced.
Current status of vascular imaging
Vascular imaging has changed significantly in the
past decade and this rate of change is accelerating
dramatically. These changes are of great benefit to
patient care through early detection of disease in some
cases and avoidance of invasive procedures in others.
The development of ultrasound-based technolo-
gies, including imaging, Doppler shift velocity meas-
urements, and combinations resulting in color-flow
imaging, allow precise physiologic and morphologic
measurements of significant occlusive disease. While
there are limitations to these technologies in deeper
vessels, superficial vessels such as carotid, infrain-
guinal, and other arteries are reliably imaged without
difficulty. The rapid expansion of noninvasive vas-
cular laboratories and vascular imaging programs
within imaging departments has facilitated early
detection of disease and stimulated multidiscipli-
nary accrediting bodies such as the Intersocietal
Commission on the Accreditation of Vascular Lab-
oratories. For many clinical problems, ultrasonogra-
phy offers the benefit of reduced cost, in addition to
being noninvasive.
CT has also advanced rapidly as scan times are
reduced by spiral and multidetector technologies
[3,4]. Using iodinated contrast and rapid CT scanning
 B.T. Katzen / Radiol Clin N Am 40 (2002) 689–692
techniques, many vascular structures can be imaged
effectively. The detection of renal artery stenosis,
carotid artery disease, diseases of the thoracic, and
abdominal aorta is accomplished effectively with
relatively short imaging times. Even the infrainguinal
peripheral circulation can be identified. The advantage
of volumetric acquisition and data analysis associated
with CT is useful, especially in the diagnosis and
treatment of aneurysms. Despite these benefits, CT
angiography requires large volumes of iodinated con-
trast and significant doses of radiation. Dynamic
imaging is possible but not optimal with this modality.
Magnetic resonance angiography (MRA) [5] has
improved rapidly in resolution and speed of acquisi-
tion and has thereby become a more practical modal-
ity for general application in angiography. The lack
of ionizing radiation and use of non-nephrotoxic
contrast agents offer great advantages to our patients,
in particular those with abnormal renal function or
allergic manifestations to contrast agents. A variety of
techniques allow high-resolution angiography of vir-
tually all parts of the circulation [6 – 11]. In addition,
dynamic imaging of cardiac structures can be
achieved without contrast injections. The potential
for ‘‘head-to-toe’’ angiography represents an exciting
possibility for changing how patients with vascular
disease are assessed. MRA is not applicable in
patients with pacemaker implants and has limited
use in the presence of indwelling metallic implants.
Detection of in-stent restenosis is not possible, but if
implants are altered or developed to be more MR
‘‘friendly,’’ certainly this could change.
The quality of MRA varies from excellent to
substandard. Nonetheless, overall it has improved to
the point that many types of invasive angiographic
procedures are significantly reduced, but not entirely
eliminated. Some pitfalls of MRA include overestima-
tion of the degree of stenosis and other occasional
artifacts. With the use of gadolinium, accuracy and
image quality increase significantly. MRA is useful in
detection of renal artery stenosis and other types of
peripheral vascular disease.
What does it all mean for invasive angiography?
Is the catheter for diagnosis finished?
Two trends are converging and diverging signifi-
cantly. The movement toward less invasive therapies
is growing and involving more procedures, more
disease processes, and more disciplines of medicine
in the delivery of vascular care. This growth in
treatment methods and efficacy is associated with
dramatic improvement in noninvasive imaging tech-
691
niques. In many ways, these changes will complete
the transition, which has occurred in our discipline
during the past two decades, from angiographers
to interventionalists.
The improvement in the quality of MRA, CT an-
giography, and color-flow duplex imaging increases
early and late diagnosis of vascular disease, which
will result in significant increases in the vascular
interventional case volume. At the Miami Cardiac
and Vascular Institute, these predictions are incorpo-
rated into our capital equipment and space planning. It
is reasonable to ask whether diagnostic angiography
will be eliminated by these technologies. Clearly,
most types of stand-alone elective diagnostic proce-
dures will be eliminated. The author believes that
diagnostic angiography will increase, but as an imme-
diate prelude to therapeutic procedures. The interven-
tionalist will have very precise anatomic information
available prior to therapy, but will perform documen-
tary angiography prior to intervention. Thus, the use
of diagnostic catheters will remain necessary.
What is the impact of these changes on
the interventionist?
It is of critical importance for the interventionist
to be involved in new imaging modalities to avoid
being excluded from patient care algorithms and
maintain patient access. Harvey et al [12] and others
prove that high-quality patient- and clinically-oriented
vascular imaging programs, linked to the interven-
tional service, are effective in the detection of vascu-
lar disease and linkage to endovascular solutions for
appropriate stages of disease. Conversely, if all vas-
cular imaging excludes the interventionalist, the risk
of being excluded from interventional therapy is
significant [13].
Summary
Based on the assumptions mentioned previously,
the author makes the following predictions regarding
catheter-based angiography and related procedures:
1. Most diagnostic angiography will be per-
formed with noninvasive methods. In the
peripheral circulation, MRA will be the pre-
dominant method, with CTA having an
important role in aortic imaging and coronary
imaging. MRA will have increased use for
elective diagnosis and in clinical emergencies.
692 B.T. Katzen / Radiol Clin N Am 40 (2002) 689–692
2. Catheter-based angiography will have an impor-
tant role as an adjunct or preliminary procedure
related to interventions. This is significant for
planning catheter development and function-
ality of future angiographic equipment.
3. The need for angiographic equipment will con-
tinue to grow despite this decrease in diag-
nostic application,as a result of increase in
interventional therapy. This increase in therapy
will be a result of a variety of factors, including
aging population, early diagnosis, and increas-
ing acceptance of less invasive therapy.
4. Interventionists should be considering and
planning for vascular imaging devices—
MRA, CTA, and US—to be included as part
of the interventional sections and the workload.
5. Cardiovascular imaging should be a clinical
imaging specialty, with patient interaction at
the time of imaging.
6. These changes should be embraced by vascular
interventionalists, who should incorporate
these tools into their clinical practice.
7. The changes, if they occur as predicted, will
create significant problems in training skilled
interventionists who will not have the founda-
tion of diagnostic angiography on which to
build complex endovascular skills.
References
[1] Seldinger SI. Catheter replacement of needle in percu-
taneous arteriography: new technique. Acta Radiol
(Stockh) 1953;39:368.
[2] Dotter CT, Judkins MP. Transluminal treatment of ar-
teriosclerotic obstruction: description of a new tech-
nique and a preliminary report of its application.
Circulation 1964;30:654 – 70.
[3] Rubin GD, Shiau MC, Schmidt AJ. Computed tomo-
graphic angiography: historical perspective and new
state-of-the-art using multi detector-row helical com-
puted tomography. J Comput Assist Tomogr 1999;
33(Suppl):S83 – 90.
[4] Katz DS, Hon M. CT Angiography of the lower ex-
tremities and aortoiliac system with a multi-detector
row helical CT scanner: promise of new opportunities
fulfilled. Radiology 2001;221:7 – 10.
[5] Prince MR. Peripheral vascular MR angiography: the
time has come. Radiology 1998;206:592 – 3.
[6] Serfaty JM, Chirosel P, Chevallier JM. Accuracy or
three-dimensional gadolinium-enhanced MR angiog-
raphy in the assessment of extracranial carotid artery
disease. AJR Am J Roentgenol 2000;175:455 – 63.
[7] Korst MB, Joosten FB, Postma CT, et al. Accuracy
of normal-dose contrast-enhanced MR angiography
in assessing renal artery stenosis and accessory renal
arteries. AJR Am J Roentgenol 2000;174:629 – 34.
[8] Nelson H, Gilfeather M, Holman J, et al. Gadolinium-
enhanced breathold three-dimensional time of flight
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renal donors. JVIR 1999;10:175 – 81.
[9] Ernst O, Asner V, Sergent G, et al. Comparing
contrast-enhanced breath-hold mr angiography and
conventional angiography in the evaluation of mes-
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433 – 9.
[10] Kreitner KR, Kalden P, Neufang A, et al. Diabetes and
peripheral arterial occlusive disease: prospective
comparison of contrast-enhanced three dimensional mr
angiography with conventional digital subtraction an-
giography. AJR Am J Roentgenol 2000;174:171 – 9.
[11] Baum RA. Peripheral vascular diagnosis using mag-
netic resonance angiography [abstract]. JVIR 1999;10
(Suppl 5):387.
[12] Harvey RT, Soulen MC, Siegelman ES. Impact of
screening mr angiography on referrals for percutaneous
intervention in renovascular disease. JVIR 1999;10:
559 – 64.
[13] Stein B, Katzen BT. Magnetic resonance angiography
– use it or lose it. . . .ALL. SCVIR Newsletter MRA.
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 Radiol Clin N Am 40 (2002) 693 – 710

Gadolinium-based contrast agents in angiography and

interventional radiology
David J. Spinosa, MD*, J. Fritz Angle, MD, Gary D. Hartwell, DSc,
Klaus D. Hagspiel, MD, Daniel A. Leung, MD, Alan H. Matsumoto, MD
Department of Radiology, University of Virginia Health System, Post Office Box 800170, Charlottesville, VA 22908, USA

Limited use of gadolinium-based contrast agents
(Gd) in place of iodinated contrast material for angiog-
raphy and interventional procedures in patients with
renal insufficiency or a history of a severe reaction to
iodinated contrast material can be helpful. Contrast
nephrotoxicity is reported to occur in approximately
10% to 30% of patients with pre-existing renal insuf-
ficiency when intravascular iodinated contrast mater-
ial is used [1 – 4]. Although recovery of renal function
occurs in most patients, a 10% to 25% incidence for
a transient need for dialysis in patients developing
contrast nephrotoxicity is reported, particularly when
oliguria develops [5,6]. In addition, in up to 30% of
the patients, renal function fails to return to baseline
[6]. Equally disturbing are reports of a mortality rate
of 34% in patients developing contrast nephrotox-
icity while hospitalized, compared with a mortality
rate of 7% in similar patients who do not develop
contrast nephrotoxicity [7]. Even though significant
coexisting medical problems such as sepsis and
transient hypotension contribute to deterioration in
renal function in some patients, contrast nephrotox-
icity results in prolongation of the hospital stay, the
occasional need for dialysis, and predisposition of
some patients to permanent worsening of renal
function and death.
Occasionally, patients with a history of a severe,
life-threatening reaction to iodinated contrast material
require an iodinated contrast study. More frequently,
some patients state that they are told ‘‘never’’ to
receive iodinated contrast material because of a pre-
* Corresponding author.
E-mail address: djs4m@virginia.edu (D.J. Spinosa).
vious ‘‘reaction’’ that they or their physician may not
be able to recall. In these patients, the radiologist
must decide whether or not to administer iodinated
contrast material.
Frequently, traditional diagnostic angiograms or
venograms can be avoided and noninvasive studies,
such as duplex sonography or magnetic resonance
angiography/venography, can be performed. When
these noninvasive studies are inconclusive, however,
or if a percutaneous procedure for treatment is con-
templated, angiographic studies requiring the use of
an intravascular contrast agent may be necessary.
Recently, fenoldopam and acetylcysteine have
been proposed as possible premedications to reduce
the risk for contrast-induced nephrotoxicity [8,9].
Both strategies require the administration of the drug
for some period of time prior to the procedure.
Although there is limited clinical experience with
these two agents, nephrotoxicity can occur [9], and
these agents do not obviate the risk for a contrast-
induced allergic reaction. Use of carbon dioxide
(CO2) as a contrast agent is advocated in selective
patients to reduce the risk of nephrotoxicity [10].
With experience, CO2 can serve as a satisfactory
alternative to iodinated contrast material for many
diagnostic angiograms and interventional procedures.
CO2 is non-nephrotoxic and inexpensive. Unfortu-
nately, CO2 is not approved by the Food and Drug
Administration (FDA) for intravascular use. In addi-
tion, CO2 angiography has limitations in defining the
anatomy of large diameter vessels, such as the aorta
or inferior vena cava (IVC), and in high-resistant
vascular ‘‘beds,’’ such as the tibial vessels in patients
with poor runoff [11,12]. Cerebral arteries should
not be studied with CO2. Use of small amounts of

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694 D.J. Spinosa et al / Radiol Clin N Am 40 (2002) 693–710
iodinated contrast material can be used to supplement
a CO2 study; however, it is unclear if the amount of
iodinated contrast material used correlates with the
risk for developing contrast nephrotoxicity [13,14].
The use of Gd in place of iodinated contrast
material, either alone or in conjunction with CO2, is
another strategy recently employed. Because of the
ability of Gd to attenuate radiographs, its use with
digital subtraction angiography (DSA) can produce
diagnostic images for angiography and interventional
radiologic procedures [15 – 18]. When used in doses
similar to those recommended for magnetic reso-
nance imaging (MRI), use of Gd during angiography
is reported to result in a markedly reduced incidence
of contrast nephrotoxicity when compared with iodi-
nated contrast material. The safety of intravenous
(IV) Gd administration in patients with pre-existing
renal insufficiency for MRI studies is well known
[19 – 21].
Adverse effects
Even though there is substantial literature docu-
menting the clinical safety of Gd agents, adverse
reactions are reported in association with their ad-
ministration. The total incidence of adverse effects is
less than 5%, and the incidence of a severe adverse
event is less than 1% in all patients [22]. The most
common side effects with Gd use are nausea, head-
aches, and emesis.
Anaphylactoid reactions also are reported with the
use of Gd. The incidence of these reactions probably
is in the range of 1 in 100,000 to 1 in 500,000 [23].
Not surprisingly, the risk of adverse reactions is
Table 1
Gadolinium chelates
Trade name Chemical compound
Magnevist Gadopentetate
dimeglumine
(Gd-DTPA)
Omniscan Gadodiamide
(Gd-DTPA-BMA)
OptiMARK Gadoversetamide
(Gd-DTPA-BMEA)
ProHance Gadoteridol
(Gd-HP-DO3A)
a
Approved for venous administration (total dose).
b
Mosmol/kg water at 37°C.
c
Higher values are better.
higher (approximately doubled) in patients with a
history of a reaction to iodinated contrast material
[24,25].
The intra-arterial use of Gd represents an ‘‘off-
label’’ use of these FDA-approved contrast agents.
The FDA-approved dosages for IV use are listed in
Table 1. Deterioration in renal function, although
infrequent, has been reported when doses up to and
above the 0.3 to 0.4 mmol/kg dose limits are used
[26,27]. It is unclear, however, whether the Gd alone
is responsible for the deterioration in renal function
in these patients. Therefore, even though higher
doses of Gd ( > 0.4 mmol/kg) are administered safely
in some patients [28], the clinical use of these higher
doses has not been studied to any great extent. Thus,
it seems prudent to limit the total dose of Gd used
for angiographic studies to 0.3 to 0.4 mmol/kg at
this time.
Properties of gadolinium agents
Free Gd, a rare earth element, is toxic and ex-
creted by the body slowly, with a biologic half-life of
several weeks [23]. Therefore, free Gd must be
chelated to another chemical that limits the availa-
bility of free Gd in solution, thereby limiting its
toxicity. Four Gd-based contrast agents are available
for use in the United States: gadodiamide (Gd-
DTPA-BMA, Omniscan1, Nycomed, Princeton, NJ),
gadopentetate dimeglumine (Gd-DTPA, Magnevist1,
Berlex, Wayne, NJ, United States, and Schering, AG,
Germany), gadoteridol (Gd-HP-DO3A, ProHance1,
Bracco Diagnostics, Princeton, NJ), and Gadoverseta-
mide (Gd-DTPA-BMEA, OptiMARK1, Mallinckrodt
Thermodynamic
equilibrium constantc
FDA-approved dosea Osmolalityb log keg
0.1 mmol/kg 1960 22.2
0.3 mmol/kg 783 16.9
0.2 mmol/kg 1110 16.6
0.3 mmol/kg 630 23.8
 D.J. Spinosa et al / Radiol Clin N Am 40 (2002) 693–710 695

Inc, St. Louis, MO) (see Table 1). These four agents
have similar biodistributions, pharmakinetics, and
half-lives [29 – 32]. The biologic half-life of these
agents is approximately 1.5 hours. These chelated
agents demonstrate a 500-fold increase in renal ex-
cretion when compared with the excretion of free
Gd [33,34].
These chelates have a high affinity for Gd (see
Table 1). Nevertheless, when Gd complexes remain
in the body for prolonged periods of time, Gd ions

Fig. 1. (A) Gadolinium abdominal aortogram performed using a pigtail catheter injecting 10 ml in 0.5 seconds demonstrates a
high-grade stenosis (small arrow) at the origin of the left renal artery and probable occlusion of the proximal right renal artery
(large arrow). (B) Injection of 6 ml of gadolinium via a vascular sheath demonstrating a widely-patent origin of the left renal
artery after stenting (small arrow) and occlusion of the proximal right renal artery (large arrow). (C) Injection of 5 ml of
gadolinium via an end-hole catheter into the origin of the right renal artery after recanalization and stenting (arrow) demonstrates
a widely-patent right renal artery.
696 D.J. Spinosa et al / Radiol Clin N Am 40 (2002) 693–710
Fig. 2. (A) Injection of 8 ml of gadolinium via a vascular
sheath demonstrates a severe stenosis at the origin of the
right main renal artery (arrow). (B) Injection of 8 ml
of gadolinium via the vascular sheath demonstrates a
widely-patent right renal artery origin after renal artery
stenting (arrow).
can be released in the presence of a high concentra-
tion of competing cations such as copper and zinc.
These circulating cations can displace Gd ions from
the chelating complex (transmetalation) and result in
the release of free Gd. Transmetalation is observed
in vitro and in vivo [35 – 38]. In patients with normal
renal function, excretion of the Gd complexes is rapid
and the concentration of free Gd is very low. In
patients with markedly reduced renal function, the
half-life of Gd chelates is up to 10 times longer than
normal, creating a theoretical concern for the accu-
mulation of free Gd [25]. Despite this theoretic
concern regarding the in vivo release of free Gd, no
harmful effects in humans are reported from the
clinical use of these agents [39]. In patients with
renal insufficiency who receive IV Gd chelates for
MRI studies, there is no evidence to suggest that
these agents result in Gd toxicity or deterioration in
renal function [19 – 21,25,40 – 42]. More than 96% of
Fig. 3. (A) Injection of 16 ml of gadolinium at 8 ml/second
via an end-hole catheter into the right common iliac artery
demonstrates high-grade stenosis in the midtransplant renal
artery (arrow). (B) Injection of 10 ml via an end-hole
catheter in the right common iliac artery demonstrates a
widely-patent renal transplant artery after intravascular
stenting (arrow).
 D.J. Spinosa et al / Radiol Clin N Am 40 (2002) 693–710 697

suspected stenosis or occlusion seen during CO2

angiography and to help guide endovascular inter-
ventions. Intraarterial gadolinium is less effective in
evaluating the aorta because of its large diameter and
high flow rate. In these situations, Gd is useful as a
‘‘problem solver’’ to supplement CO2 angiography.
In contrast to the vascular system, full-strength Gd is
visualized satisfactorily in the genitourinary (GU)
system and biliary tree with fluoroscopy.
The osmolality of the Gd agent also plays an
important role in obtaining quality DSA images.
Lower-osmolality contrast agents, such as gadodia-
mide or gadoteridol, are helpful in evaluating upper
and lower extremities because their use is associated
with less pain, which helps to minimize patient
motion during image acquisition (see Table 1).
Finally, the K-edge of Gd (50.2 KeV versus 33 KeV
for iodine) allows imaging with a higher range of
kilovoltages (77 – 96 KVp) compared with those typ-
ically used for iodinated contrast studies (63 – 73 KVp).
The ability to use higher KVps for Gd angiography can
result in a decrease in skin radiograph exposure
compared with the lower-kilovoltage techniques used
with iodinated contrast material [44]. This benefit,

Fig. 4. Injection of 18 ml of gadolinium at 9 ml/second using

a power injector via a multisided-hole catheter positioned
in the left common iliac artery demonstrates high-grade
stenosis at the origin of the transplant renal artery (arrow).
‘‘Quantum mottle’’ effect, a result of the steep angulation
(57°) required to profile the transplant renal artery origin,
is evident.

Gd can be removed from the circulation after three

dialysis sessions [41]. Gadolinium also can be re-
moved using peritoneal dialysis; however, approxi-
mately three weeks is required to clear approximately
70% of the circulating Gd [43].

Technical considerations and imaging

Gadolinium is difficult to visualize with fluoro-

scopy because of the high flow rates typically
present in the arterial system, the low concentration
(0.5 mmol/ml) of agents, and the recommended total
dose limits of Gd (0.3 – 0.4 mmol/kg). To maximize
image quality, full-strength Gd should be adminis-
tered for intraarterial injections, and high-quality Fig. 5. Injection of 16 ml of gadolinium at 8 ml/second
DSA techniques limiting motion and distortion delivered with a power injector via an end-hole catheter
should be used. Gadolinium is best used with selec- demonstrates a web-like stenosis (small arrow) in the right
tive angiography in small- to medium-sized vessels common iliac artery. Note the patent renal transplant artery
(less than 1 cm in diameter) to confirm areas of (large arrow).
698 D.J. Spinosa et al / Radiol Clin N Am 40 (2002) 693–710

however, is partially offset by the need to increase the
radiation dose administered for each radiograph expo-
sure to help decrease the noise (predominantly
quantum mottle effect) in the image.
In general, for an average-sized adult patient,
obtaining radiographs at 96 KVp results in reducing
the skin dose by approximately 50%. Because of the
reduced concentration of Gd agents, however, the
authors typically increase the dose by approximately
180% to reduce the quantum mottle effect. Therefore,
there is approximately a 10% overall reduction
in radiation dose to the patient from adjusting
the imaging acquisition parameters. The benefit in-
creases as patient size decreases and decreases as pa-
tient size increases.
Laboratory phantom experiments demonstrate that
radiographic images of Gd and various dilutions of
iodine containing agents result in Gd images that
exhibit image contrast equal to an iodine preparation
containing 37.5 to 75.0 mg/ml of iodine (ie, one
eighth- to one quarter-strength of a 300-mg/daily
iodine preparation). As ‘‘soft-tissue’’ attenuation in-
creases, however (body parts increase in thickness),
image contrast remains relatively unchanged at these
higher KVps for Gd, but deteriorates with iodine
images. Therefore, when imaging using a 20 cm of

Fig. 6. (A) Gadolinium angiogram demonstrates total occlusion of the left popliteal artery by an embolus (arrow). (B) A
multisided-hole infusion catheter is placed across the occlusion in the left popliteal artery. Injection of 8 ml of gadolinium into
the multisided-hole catheter after a six-hour infusion of tissue plasminogen activator (TPA). The study demonstrates persistent
thrombus in the left popliteal artery (arrow) with excellent filling of the distal popliteal artery and proximal peroneal artery. (C)
Injection of 10 ml of gadolinium via a vascular sheath in the left common femoral artery after 22 hours of TPA and balloon
angioplasty of the left popliteal artery demonstrates a widely-patent left popliteal artery (arrow).
 D.J. Spinosa et al / Radiol Clin N Am 40 (2002) 693–710
Fig. 6 (continued ).
water phantom model, image contrast with full-
strength Gd seems similar to an iodine preparation
containing approximately 100 to 150 mg/ml of iodine
(ie, one third- to one half-strength of a 300-mg/daily
iodine preparation). Increased tissue attenuation re-
sults in ‘‘hardening’’ of the radiograph beam (shift in
the spectrum of energy towards higher energy values).
Beam ‘‘hardening’’ results in increased image contrast
for a given concentration of Gd relative to that of
iodine and accounts for some of the differences noted
between the theoretical model calculations and in vivo
observations of image contrast.
Gadolinium agents in angiography and
interventional radiology
Typically, Gd agents are used either alone or
to supplement CO2 angiography to answer diagnos-
tic questions and guide interventional procedures
[15 – 18,27]. When used alone, dose limitations
reduce the number of angiographic images that are
acquired. Gadolinium can be administered with the
use of a power injector or by hand injection. Total
699
dose (0.3 – 0.4 mmol/kg) considerations necessitate
careful planning prior to each injection. It is para-
mount to use the smallest amount of contrast agent
possible, but each angiogram should be performed
with enough Gd to produce diagnostic images.
Optimization of Gd use typically takes some practice
as the interventionalist learns to account for vessel
size, vessel flow, and vessel location. As stated
previously, Gd agents are best used as ‘‘problem
solvers’’ to confirm the findings of CO2 angiography,
define areas incompletely evaluated with CO2 angi-
ography, guide interventional treatment, or replace
CO2 when CO2 injections are not well tolerated by
the patient (ie, abdominal pain).
Gadolinium agents are used in many vascular
beds, most frequently renal and peripheral (upper
and lower extremities) vascular beds, and with dialy-
sis fistulography. Upper extremity venography, trans-
jugular intrahepatic portosystemic shunts (TIPS)
construction and repair, IVC filter placement, and
interventional urinary and biliary procedures also can
be performed with use of these agents. Although CO2
angiography should not be used to evaluate upper
extremity or cerebral arterial anatomy, gadolinium
agents are used safely in these vascular territories.
Renal vascular disease
An abdominal aortogram usually can be obtained
with the use of CO2. The renal arteries can be
identified and the optimum projection for profiling
the origin can be defined with CO2 angiography. If
the renal artery is incompletely visualized, or confir-
mation of the results of the CO2 angiogram is desired,
Gd can be injected, acquiring the DSA images in the
optimum projection. An injection of 10 to 20 ml in
0.5 seconds via a pigtail catheter positioned just
above the renal arteries usually provides diagnostic
images of the aorta and renal artery origins at
the level of the renal arteries and renal artery origins
(Fig. 1A). This method is particularly useful in
confirming the presence of renal artery occlusion.
Once proceeding with a renal intervention, a small
hand injection of 2 to 4 ml of Gd via an end-hole
catheter, while acquiring DSA images, confirms satis-
factory catheter position across the renal artery lesion
and opacifies the distal main renal artery and its
branches. The intervention is monitored with the use
of small hand injections (4 – 8 ml) of gadolinium
through a vascular sheath or catheter (Fig. 1B,C).
CO2 angiography usually is adequate to allow precise
positioning of the intravascular stent, so that it covers
the origin of the main renal artery. In patients with
700 D.J. Spinosa et al / Radiol Clin N Am 40 (2002) 693–710

Fig. 7. (A) Left lower-extremity Gd angiogram performed using a stepping-table technique. A single 40-ml bolus of Gd was
injected at 5 ml/second using a power injector via an end-hole catheter in the midleft superficial femoral artery. ‘‘Stations’’ at the
knee, calf, and foot were obtained. Gadolinium angiogram demonstrates high-grade stenosis at the level of the mid-left popliteal
artery (small arrow) and at the origins of the left anterior tibial and peroneal arteries (large arrow). (B) Gadolinium angiogram
demonstrates a patent peroneal artery (small arrow) to the level of the ankle and poor flow distally in the anterior tibial artery
(large arrow). (C) Angiogram at the level of the left foot demonstrates reconstitution of the left posterior tibial artery (small
arrow) from peroneal collaterals. Note that the left anterior tibial artery is occluded at the level of the ankle (large arrow). (D)
Delayed images of the left foot demonstrate a patent left plantaris pedis artery (small arrow) and occlusion of the left anterior
tibial artery above the ankle (large arrow).
 D.J. Spinosa et al / Radiol Clin N Am 40 (2002) 693–710 701

Fig. 7 (continued ).

extensive bowel gas, marked irregularity of the ab-
dominal aorta as a result of severe atheromatous
plaque formation, or aneurysmal dilatation of the aorta
at the renal artery level, the renal artery and its origin
often are identified better using Gd angiography
(Fig. 2A,B). Gadolinium images are particularly help-
ful in defining complications that occur during the
intervention, such as dissection or intravascular throm-
bus formation. Gadolinium angiography also provides
a more detailed completion angiogram, especially for
evaluating the intrarenal branches for dissection, per-
foration, spasm, or thrombus/embolus after treatment.
In renal transplant patients in whom there is
concern for renal vascular disease, CO2 angiography
usually is adequate. If the CO2 angiogram study is
suboptimal, however, power injection of 16 to 20 ml
702 D.J. Spinosa et al / Radiol Clin N Am 40 (2002) 693–710

provides adequate visualization of the inflow iliac

artery, transplant artery, and intrarenal branches
(Figs. 3 – 5). CO2 angiograms still are helpful as the
initial study to determine the optimum projection in
which to perform the Gd study.

Peripheral vascular disease

The volume of Gd agent necessary to perform a

Fig. 8. Injection of 6 ml of gadolinium via an angiocatheter
in the arterial limb of an upper arm arteriovenous dialysis
graft refluxed into the brachial artery demonstrates a widely-
patent arterial anastomosis (arrow).
of Gd at a rate of 8 to 10 ml/second via a pigtail
catheter in the lower-abdominal aorta or multisided-
hole straight catheter in the ipsilateral iliac artery
complete angiographic study of the lower extremity
usually exceeds the total recommended dose limits;
therefore, CO2 angiography is used to evaluate as
much of the lower-extremity anatomy as possible.
The use of Gd agents is reserved for answering
specific questions not answered by the CO2 angio-
gram and is especially helpful in ‘‘problem solving’’
during interventional therapy (Fig. 6A – C). CO2
angiography usually is adequate in defining lower-
extremity anatomy to the level of the popliteal artery,
especially when using stacking-software algorithms
that are available on most current DSA equipment.
Occasionally, small amounts of Gd delivered by hand
injection via an end-hole catheter are necessary to
answer specific questions regarding disease in the
iliac vessels obscured by overlying bowel gas. When
CO2 angiography fails to visualize the infrapopliteal
vessels, positioning of an end-hole catheter in the

Fig. 9. Injection of 10 ml of gadolinium via a vascular sheath in a left upper arm arteriovenous gortex dialysis graft after balloon
angioplasty of a high-grade stenosis at the junction of the left brachiocephalic vein and superior vena cava (arrow) demonstrates
excellent flow into the superior vena cava.
 D.J. Spinosa et al / Radiol Clin N Am 40 (2002) 693–710 703

mid- or distal superficial femoral artery (SFA) in CO2 into the vertebral arteries seizures [46]. Therefore,
conjunction with small boluses (5 – 10 ml) of Gd Gd angiography can be used to evaluate more safely
can be used to image these vessels. the arterial anastomosis (Fig. 8) and to verify the
If the SFA is patent, but there is significant distal
occlusive disease, larger volumes of Gd are necessary
to visualize the more distal outflow and runoff vessels.
A digital subtraction ‘‘stepping’’ program to evaluate
the lower two stations of the extremity of interest
(lower leg and foot) frequently maximizes the in-
formation obtained when injecting a single large bolus
(5 – 6 ml/second for a total volume of 30 – 40 ml) of
Gd (Fig. 7A – D). Reducing patient motion is critical
under these circumstances. In the authors’ experience,
lower-osmolar contrast agents, such as gadodiamiole
or gadoteridol, cause less discomfort and less patient
motion than the higher osmolar Gd preparations.
If the SFA is occluded, but numerous collaterals are
present, the use of larger volumes of Gd (40 – 50 ml)
usually is necessary to offset the dilutional effects. The
quality of the lower-extremity angiogram in this set-
ting is variable. Fortunately, CO2 angiography is
particularly useful in visualizing the runoff vessels
when there is a lower-resistance vascular ‘‘bed’’ in the
lower leg and foot because of a proximal occlusion and
less helpful when there is a high resistance vascular
‘‘bed’’ in the lower leg and foot because of distal
occlusive disease.
Evaluation of the proximal upper extremity can be
performed with the use of a selective hand injection of
8 to 10 ml of Gd in the subclavian, axillary, or proximal
brachial artery. The evaluation of the forearm vessels
and palmar arch requires the use of larger volumes of
contrast injected via a power injector (15 – 36 ml
delivered at 5 – 6 ml/second via an end-hole catheter
positioned in the distal axillary or proximal brachial
artery). Again, use of lower-osmolality agents results
in less patient discomfort and motion, thereby pro-
ducing better quality images. Because of total dose
limits, it is best to evaluate and treat only one extremity
at a time. Evaluation and treatment of the other
extremity should be delayed until the majority of Gd
is cleared from the patient’s system (2 – 5 days in
patients with moderate to severe renal insufficiency).

Central veins and dialysis access
Gadolinium and CO2 are used in the evaluation of
arteriovenous grafts and fistulas [45]. CO2 is useful for
evaluation of the arterial-venous graft and outflow
veins. CO2 angiography, however, occasionally over-
estimates the degree of stenosis present, and attempts
at refluxing CO2 to evaluate the arterial anastomosis
are reported occasionally to result in retrograde flow of
Fig. 10. Gadolinium cavogram performed injecting 30 ml at
15 ml/second using a power injector via a calibrated pigtail
catheter (small arrow) positioned in the lower inferior vena
cava above the iliac vein bifurcation demonstrates a widely
patent inferior vena cava without evidence of thrombus. Note
the origin of the left and right (large arrows) renal veins,
hepatic vein inflow (open arrow), and left and right iliac veins
(hatched arrows). The ‘‘double exposure’’ appearance of the
pigtail catheter is a result of catheter motion during the study
and image ‘‘stacking’’ during image postprocessing.
704 D.J. Spinosa et al / Radiol Clin N Am 40 (2002) 693–710
severity of disease in the dialysis graft or outflow
veins. The central veins can be imaged using a hand
injection of approximately 8 to 10 ml of Gd via an end-
hole catheter positioned in the axillary or subclavian
vein or by delivering 20 to 25 ml of Gd at a rate of 4 to
5 ml/second via a catheter in the fistula (Fig. 9).
A hand injection of 8 to 10 ml of Gd also can be
used for evaluating malfunctioning central catheters
to detect the presence of a thrombus or fibrin sheath
in patients. An injection of Gd at 10 to 15 ml/second
for two seconds is adequate for evaluating the IVC
in preparation for IVC filter placement (Fig. 10).
Inferior vena cavograms also can be obtained using
half-strength gadolinium and higher total volumes
(50 – 60 ml) [47]. IVC size, renal vein location, the
presence of IVC thrombus, and IVC anatomy all can
be determined with Gd cavography if CO2 inferior
vena cavography does not successfully define the
IVC anatomy.
Aortography and visceral angiography
Imaging of the aorta and mesenteric vessels is
limited by the total recommended dose of Gd (0.3 –
Fig. 11. Gadolinium abdominal aortogram performed injecting 32 ml at 16 ml/second with a power injector via a pigtail catheter
positioned in the upper abdominal aorta.
0.4 mmol/kg). A single injection of Gd at 20 to 25 ml/
second for 2 seconds produces reasonable images of
the thoracic aortic arch and origins of the great
vessels [48]. An abdominal aortogram can be ac-
quired by administering Gd at 15 to 16 ml/second for
two seconds (Fig. 11). Assessment of aortic aneurysm
disease is more difficult because of the higher vol-
umes of Gd that are needed. As stated previously,
when evaluating for renovascular disease, CO2 angio-
grams are useful in determining the optimal angle to
visualize the renal artery origins prior to performing
a Gd aortogram. Fortunately, MR angiography with
Gd enhancement provides diagnostic images in most
of these patients.
A selective celiac or mesenteric artery injection is
helpful for evaluating the origin and proximal por-
tions of these vessels, but is not helpful for evaluating
the more distal anatomy because of dilution of the
Gd. Therefore, it is best to use gadolinium for
‘‘problem solving’’ or for selective injections of
visceral branches when evaluation of more distal
anatomy is required. CO2 particularly is helpful in
evaluating the origins of the celiac and superior
mesenteric arteries because of their anterior position
when the patient is supine (Fig. 12A, B).
 D.J. Spinosa et al / Radiol Clin N Am 40 (2002) 693–710 705

Miscellaneous gadolinium applications
Cerebral angiograms also are obtained using Gd.
Selective carotid angiograms with Gd can be per-
formed to evaluate for carotid artery stenosis in
patients with renal insufficiency or a history of a
severe contrast reaction [49]. After a hand injection of
2 to 3 ml of Gd confirms catheter position within
the common carotid artery, a power injection of Gd at
7 ml/second for a total volume of 11 ml is performed.
Additional projections are obtained as needed to
visualize the extent of carotid artery disease. Cerebral

Fig. 12. (A) CO2 angiogram demonstrates what seems to be a high-grade stenosis (small arrow) in the origin of the superior
mesenteric artery and mildstenosis in the origin of the celiac artery (large arrow). (B) Lateral abdominal aortogram performed
injecting 15 ml of Gd in 0.5 seconds by power injector via pigtail catheter demonstrates no evidence of significant stenosis involving
the origin of the superior mesenteric artery (small arrow). There is mild stenosis at the origin of the celiac artery (large arrow).
706 D.J. Spinosa et al / Radiol Clin N Am 40 (2002) 693–710

Fig. 13. After creation of a transjugular intrahepatic portosystemic shunt (TIPS), a final Gd angiogram is performed injecting
18 ml at 9 ml/second by power injector via a multisided-hole catheter positioned in the portal vein. Note the widely-patent TIPS
shunt (arrow).

angiograms to evaluate the intracerebral circulation
also are performed using Gd agents [50,51].
TIPS also can be evaluated using Gd angiography
in patients with renal insufficiency or hepatorenal
syndrome (Fig. 13). Gadolinium portal-vein studies
are useful for confirming anatomy, evaluating ste-
notic or occluded TIPS shunts, and studying and
treating varices. Hand injections of 8 to 10 ml of Gd
via an end-hole or multiside-hole catheter typically
provides diagnostic images, while power-injecting 16
to 20 ml at a rate of 8 to 10 ml/second via a multiside-
hole catheter is helpful in defining a high-flow portal
system (Fig. 14).
the biliary and genitourinary tracts, although the
images are inferior to images obtained with full-
strength iodinated contrast agents.
A hand injection of 6 to 10 ml of Gd into a
drainage catheter frequently can determine catheter
patency and confirm satisfactory positioning of the
catheter (genitourinary or biliary). Percutaneous neph-
rostomy can be aided by Gd injection into the renal
pelvis or calyx if a CO2 injection into the urinary
collecting system is difficult to visualize. In patients
with a history of severe iodine reactions, percutaneous
transhepatic cholangiography and biliary drainage
catheter placement also can be performed using Gd
as the sole contrast agent (Fig. 15A – C).

Genitourinary and biliary studies

Opacification of the urinary and biliary tracts can
be performed by direct injection of Gd into the renal
pelvis or intrahepatic biliary tree [52]. These images
are similar to images obtained with approximately
100 to 150 mg/ml iodine contrast agent preparations.
Use of Gd is particularly helpful in patients with a
history of a severe reaction to iodinated contrast
material. Unlike Gd injected into arteries and high-
flow veins, Gd can be visualized fluoroscopically in
Summary
Gadolinium is useful as an alternative contrast
agent for diagnostic angiographic and interventional
procedures in patients with renal insufficiency or a his-
tory of a severe reaction to iodinated contrast mate-
rial. Gadolinium usually is used as a ‘‘problem solver’’
to answer specific diagnostic questions or guide inter-
ventional procedures that cannot adequately be
defined with CO2 angiography. Because of dose limi-
 D.J. Spinosa et al / Radiol Clin N Am 40 (2002) 693–710 707

Fig. 14. (A) Splenic-vein angiogram performed in a patient with renal insufficiency, splenomegaly, and gastric varices. A
noninvasive study suggests narrowing of the splenic vein near its hilum. An end-hole catheter was positioned in the distal splenic
vein placed via a transhepatic portal vein puncture. Gadolinium angiogram performed injecting 10 ml of Gd demonstrates a high-
grade stenosis of the splenic vein at the splenic hilum (arrow). (B) Delayed images of the Gd splenic venogram demonstrate the
remainder of the splenic vein (small arrow) and portal vein (large arrow) to be patent.
708 D.J. Spinosa et al / Radiol Clin N Am 40 (2002) 693–710

Fig. 15. (A) A percutaneous transhepatic cholangiogram is performed injecting 8 ml of Gd into a 22-gauge needle with its tip
positioned within a small branch of the right biliary ductal system (small arrow). Note opacification of the right (large arrow)
and left (open arrow) intrahepatic ducts and high-grade obstruction at the anastomosis of the common hepatic duct with the
Roux-en-Y limb (hatched arrow). (B) Access into a larger right intrahepatic bile duct is obtained and a guide wire passed across
the obstruction into the Roux-en-Y limb (arrow). (C) A biliary drainage catheter (arrow) is successfully placed across the
obstruction into the Roux-en-Y limb.
 D.J. Spinosa et al / Radiol Clin N Am 40 (2002) 693–710
Fig. 15 (continued ).
tations with Gd, careful planning is required prior to its
use with angiography or interventional procedures.
Acknowledgment
A special thanks to Sherry Deane, Geneva
Shifflett, and Shirley Naylor for their expert assis-
tance in preparation of this manuscript.
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 Radiol Clin N Am 40 (2002) 711 – 728
Current technology and clinical applications of
three-dimensional angiography
Richard P. Klucznik, MD
Department of Radiology, Division of Interventional Neuroradiology, Baylor College of Medicine,
The Methodist Hospital, 6565 Fannin Street, Houston, TX 77030-2707, USA
History of three-dimensional imaging
There has been a recent evolution in the angio-
graphic evaluation of patients with the development
of three-dimensional (3D) rotational angiography. To
understand this evolutionary process, it is worthwhile
to understand the history of 3D imaging.
The first 3D images were produced by a British
scientist, Charles Wheatstone, in the 1830s. Other
British inventors, David Brewster and the famous 3D
photographer Louis Daguere, created photographs
with dimension, providing the basis for much of 3D
imaging. Two separate photographs of an individual
object were taken 2.5 inches apart (the distance
between a human’s pupils). Using stereoscope lenses,
which directed the image to its corresponding eye, the
images were viewed side by side, giving the percep-
tion of depth. By the early 20th century, 3D pho-
tography was commonplace. William Gruber, an
organ maker from Portland, OR, and Harold Graves
created a device that became known as ‘‘The View-
master.’’ ‘‘The Viewmaster’’ was designed princip-
ally for taking scenic photography, but it came into
prominence during World War II when it was used to
produce pictures for the United States government to
aide in military site identification and range estima-
tion. In 1952, 3D cinema began with the films Bwana
Devil and House of Wax.
The world of 3D imagery in medicine also has
changed dramatically. With the need for precise
anatomic definition, 3D imaging has grown slowly
E-mail address: rklucznik@tmh.tmc.edu
(R.P. Klucznik).
0033-8389/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 2 3 - 4
from holographic images of the spine to true 3D
pictures of the body using a variety of cross-sectional
modalities. Digital subtraction angiography (DSA)
has made great advances and has gradually become
the gold standard for the delineation of vascular
anatomy. With the development of endovascular
treatments for occlusive vascular disease, aneurysms,
arteriovenous malformations, and tumors, it became
necessary to visualize the specific and detailed vas-
cular anatomy on a more real-time basis. Three-
dimensional angiography was first proposed by
Cornelius and advanced into clinical practice by
Voigt in 1975 [1]. Since then, a variety of improve-
ments have been developed as a result of the in-
creased speed and data transfer afforded by modern
computers. Recent publications by Fahrig and others
[2 – 6] have brought 3D angiographic imaging to the
forefront. The 3D evaluation of cerebral aneurysms
and arteriovenous malformations no longer is a clin-
ical curiosity, but an absolute necessity.
Techniques
In the Endovascular Center, Department of Radi-
ology at The Methodist Hospital (Houston, TX), all
3D rotational studies are performed on a biplane
neuroangiography unit (Neurostar Plus, Siemens,
Erlangen, Germany). The procedure can be per-
formed with the patient awake using neuroleptic
analgesia. The best images, however, are obtained
with the patient under general anesthesia, where
absolute control of the patient’s movements and
respiration is maintained. The patient is situated in
the isocenter of the C-arm of the angiographic unit.
712 R.P. Klucznik / Radiol Clin N Am 40 (2002) 711–728

Fig. 1. A diagramatic representation of the C-arm movement during an acquisition. The first 200° C-arm provides the mask
images. With a prolonged contrast injection, the return sweep of the C-arm acquires the data for creation of the 3D images.

Fig. 2. The approximate contrast injection for the varied parameters. All images are obtained using Omnipaque 300 mg/ml
(Amersham Health, Princeton, NJ). The contrast flow rates and duration of contrast injection match the speed of rotation with a
more prolonged injection for a 14-second acquisition.
 R.P. Klucznik / Radiol Clin N Am 40 (2002) 711–728
Fig. 3. Adjusting the speed of rotation to more than 40°/
second results in decreased image sharpness. The optimum-
imaging mode for the 3D acquisition is approximately 40°. A
20° swing offers good spatial resolution, but may involve
higher contrast loads.
The C-arm rotates in a continuous 200° arc around
the patient’s head in a period of 5 seconds.
The initial acquisition phase has two actions. The
first sweep of the C-arm acts as the mask for the
subsequent data acquisition during the injection of
contrast. The return sweep of the C-arm in an arc of
200° is performed while contrast is injected during the
Fig. 4. Strother has quantified the accuracy of 3D angiographic imaging relative to intravascular ultrasound using a bifurcation
model of an aneurysm (Courtesy of Charles Strother, MD, University of Wisconsin).
713
entire period of data acquisition (Fig. 1). The rotating
C-arm is calibrated for correction of distortion as a
result of deviations in the rotational path. For cerebral
arteriography, the usual injection is approximately 2.5
to 3 mL/second for a total of 30 to 35 mL (Fig. 2).
Abdominal imaging requires higher contrast injection
rates, with a typical rate of 10 mL /second for a total of
150 mL.
The speed of rotation can be varied, with the rate
selected based on the area of interest. The rotational
speed can be 5, 8, or 14 seconds. All image acquisi-
tion is performed at a constant rate of 10 frames/
second. Therefore, depending on the speed of rota-
tion, the number of projection images is between 50
and 140 images. The maximum rotational speed is
40°/second. There currently is no benefit to faster
C-arm rotation. Increasing the speed of rotation to
60°/second tends to decrease the resolution of the
acquisition (Fig. 3). Typically, the image intensifier is
set at either a 33- or 20-cm field of view.
Once the acquisition is performed, the images are
transferred via a high-speed data link to the 3D
Virtuoso workstation (Siemens Medical), which can
perform high-speed data manipulation. The 2D
images are then converted into pseudo-computed
tomography (CT) slices using the convolution back
projection technique (fan beam principle). Instead of
714 R.P. Klucznik / Radiol Clin N Am 40 (2002) 711–728

Fig. 5. The pitfall with 3D pictures is the potential of inappropriate window and level settings obscuring anatomic detail on the
images. If the viewing parameters are set to create ‘‘shadows,’’ the size of the dome and neck of tan aneurysm may be
underestimated. If the window and level are set to bright, the dome size and neck measurements may be overestimated (Courtesy
of Charles Strother, MD, University of Wisconsin, 2001).

a CT detector, the Dynavision system (Siemens for image intensifier and contrast distortion. The data
Medical) uses the image intensifier as a multiline is reconstructed into a volume-rendered technique
detector. Specific algorithms are performed to correct (VRT) (Fig. 4). In addition, other methods visualize

Fig. 6. Biplane digital angiography dose is listed on the left side of the chart. As one proceeds from a 5-second to 14-second
acquisition, the dose with the 3D angio increases, but not significantly above that of a routine biplane digital subtraction acquisition.
 R.P. Klucznik / Radiol Clin N Am 40 (2002) 711–728 715

the images, including surface-shaded display (SSD),
maximum intensity projection (MIP), or multiplanar
reformatting (MPR) (Fig. 7). The most beneficial and
widely-used postprocessing technique is the volume-
rendered technique, where the image is viewed at any
chosen angle.
True stereo 3D images with depth can be seen at
the computer monitor, using glasses manufactured by
Stereographics Corp (Crystal Eyes III, Stereographics
Corp, San Raphael, CA). The Virtuoso workstation
manipulates the images and transfers them to each
corresponding eye at a rate of speed fast enough to
allow for the perception of depth. All 3D imaging is
based on the principle that if images are separated
by 7° or more, they can be viewed in stereo. In a
14-second acquisition, more than 260 images are
obtained, including the mask images. Therefore, true
stereoscopic images can be rendered in any projec-
tion. In the initial acquisition phase, before the
transfer is made to the Virtuoso workstation, the

Fig. 7. Some of the methods to display intracranial aneurysms are illustrated. The typical representation (A) is a volume-rendered
(VR) acquisition, which has exquisite anatomic delineation. This is a carotid terminus aneurysm with a relatively wide patulous
neck that extends directly superiorly. The vessels can be made radiolucent (shadow) in order to evaluate to the aneurysm neck
(B). Notice some contrast resolution is lost with this technique, and one may underestimate the size of the neck, but it still can be
useful for seeing the entrance into the aneurysm in an end-on position. A grid can be used, which accurately depicts vessel size
(C). In addition, direct distance measurements can be made on the VR image. Another aneurysm is used to show that a geometric
box can be placed on the image (D), which delineates all quadrants, so that while reviewing the image in real time, a sense of
orientation can be maintained.
716 R.P. Klucznik / Radiol Clin N Am 40 (2002) 711–728

Fig. 8. A single image from a biplane acquisition (A) shows a large left paraophthalmic segment aneurysm with a wide patulous
neck. The 3D images (B,C) illustrate how the anatomic delineation of the true size and nature of the aneurysm is visualized as it
extends over the cribriform plate, and the true size of the neck is identified. The indentations on the fundus are from intra-aneurysmal
clot. Comparison can then be made to a 3D CT acquisition (D,E), which may show the overall relationship of the aneurysm and the
remainder of the cerebral vasculature to the bone of the cribriform plate and anterior cranial fossa. The 3D CT does not have the
contrast and spatial resolution necessary to decide the planned treatment. The wide patulous nature of the neck excludes the patient
from constructive endovascular treatment. The patient requires either an attempt at surgical clipping or parent vessel occlusion.
 R.P. Klucznik / Radiol Clin N Am 40 (2002) 711–728 717

Fig. 8 (continued ).

images can be delivered either in a subtracted or a
nonsubtracted mode. Transferring images in the sub-
tracted mode naturally will double the transfer and
volume reconstruction time. The total process from
the acquisition of data to the rendering of 3D images
varies, depending on the mode selected. The fastest
method is a 5-second acquisition transferred in a
nonsubtracted mode, where the reconstruction time
can be as little as 5 minutes. If, however, one selects a
14-second acquisition delivered in a subtracted mode,
the total time from acquisition to image rendering can
be as long as 15 minutes.
Conspicuity is a combination of spatial and
contrast resolution. The typical spatial resolution in
718 R.P. Klucznik / Radiol Clin N Am 40 (2002) 711–728

Fig. 9. Middle cerebral artery aneurysms may be difficult to treat via an endovascular approach as branches of the middle
cerebral artery often originate from the aneurysm base. Multiple digital-subtraction acquisition runs are usually necessary to
quantify the aneurysm neck. A single image from the biplane acquisition is represented, showing the irregular nature of the
ruptured aneurysm. The 3D acquisition allows quantification of the true size of the neck, making endovascular treatment of this
aneurysm possible.

the isotropic volume obtained is between 0.2 and
0.3 mm. Even smaller objects (eg, microcatheter
systems) may be visible although not fully resolved.
The limitations in spatial resolution are secondary to
patient movement, breathing, swallowing, and
hemodynamics, including cardiac output. Other limi-
tations include C-arm reproducibility, as the system
may not remain in perfect calibration. The selected
volume of interest is set at the workstation and
adjusted to outline the specific region of interest
(ie, the anterior communicating artery rather than the
entire cerebral vasculature) and is used to determine
the theoretical resolution. Most reconstruction algo-
rithms involve a 256  256 matrix. Higher matrices
are available (512  512 and 1024  1024) but
involve a longer reconstruction time for little overall
increase in resolution.
The contrast resolution depends on the speed and
volume of contrast injection. Three-dimensional
imaging requires an increased volume of contrast
 R.P. Klucznik / Radiol Clin N Am 40 (2002) 711–728 719

injection. For neuroimaging, 35 mL is injected for a
single acquisition. Abdominal imaging can require
120 to 150 mL of contrast for a single acquisition.
The resolution also depends on the number of pro-
jections obtained and the radiation dose setting
(quantum noise is a function of the dose setting on
the digital equipment). There also are choices for
recontruction algorithms (sharp versus smooth). The
sharp (or edge-enhancement algorithm) is used
mostly when metallic devices, stents, or surgical clips
are in the field of the view. This algorithm increases
the dose to produce a sharper image.
There is always a question of accuracy of images
procured. The accuracy of rotational angiography has
been compared with intravascular ultrasound (IVUS)
in an animal model (Charles Strothers, MD, Univer-
sity of Wisconsin, personal communication, 2001).
An excellent correlation between the measurements

Fig. 10. In patients who harbor multiple intracranial aneurysms, delineation of the nature of each aneurysm is difficult, because they
begin to overlie each other on different projections. This patient harbors three aneurysms on the left side, which cannot fully be
appreciated on the digital acquisition runs. (A) The patient harbored two additional aneurysms on the right, one of which was treated
via an endovascular approach at the time of rupture. The 3D images (B,C) are two rotated views and can be compared with the single
digital subtracted angiographic image. Here, all three aneurysms are visualized, the necks delineated, and the relationship to the
internal carotid identified. On the Virtuoso workstation, these images are manipulated into any angle, allowing quantification of any
of the three aneurysms before deciding on a treatment course. The left posterior communicating artery aneurysm was treated via an
endovascular approach. The patient is to return for possible endovascular treatment of the remaining aneurysms.
720 R.P. Klucznik / Radiol Clin N Am 40 (2002) 711–728

obtained with MPR, 3D angiography, and intravas-
cular ultrasound is found (Fig. 4). A pitfall is seen
when inappropriate window/level settings are used to
film or review the study, especially when the region
of interest, such as aneurysm neck and fundus, is
artifactually narrow (Fig. 5).
Always of concern is radiation dosage (skin dose)
to patients. Radiation dose for a 14-second acquisi-
tion is similar to that of a biplane digital subtraction
acquisition during a routine cerebral arteriogram.
The parameters used are 3 frames/second for the first
4 seconds, 2 frames/second for the next 4 seconds,
and 1 frame/second until the venous phase is visual-
ized. An 8-second acquisition approximates a single-
plane acquisition of a cerebral angiogram. A 5-second
acquisition has a radiation dose less than a single-plane

Fig. 11. Two posterior communicating artery aneurysms are illustrated. Both aneurysms are large in size, making it difficult to
identify the origin of the posterior communicating artery itself. From the routine angiographic runs, the necks of both aneurysms
seem patulous (A,C). In the first aneurysm (A,B), the actual size of the aneurysm neck is very small and the aneurysm has an
overall heart-shaped appearance, easily treated via an endovascular approach. The second aneurysm (C,D) has a somewhat larger
neck, but when the 3D images are rotated posteriorly, the origin of the posterior communicating artery clearly is identified. This
patient also was treated successfully using endovascular techniques.
 R.P. Klucznik / Radiol Clin N Am 40 (2002) 711–728 721

acquisition; therefore, the radiation dose to the patient
and the volume of contrast administered are well with-
in defined safety limits (Fig. 6).
Clinical use
Three-dimensional imaging has come to the fore-
front in the diagnosis and treatment of cerebral
aneurysms and arteriovenous malformations because
of the exquisite anatomic detail defined [7 – 13]. The
important factors necessary for treatment of a cerebral
aneurysm include neck size, morphology of the neck
and its relationship to surrounding vessels, and the
origin of vessels from the aneurysm base (Figs. 8 –
15), as seen with middle cerebral artery or posterior
communicating artery aneurysms. The 3D stereo-
scopic view and the surface shaded-display images
of the aneurysm are imperative for defining the
anatomy for all those practitioners involved in the
treatment of aneurysms [5,10]. From an endovascular
viewpoint, the true size of the neck determines
whether the patient is a candidate for Guglielmi
detachable coils (GDC) or a new liquid agent, such
as Onyx. If the neck is patulous in nature or if vessels
originate from the aneurysm base, surgical interven-

Fig. 12. An example of a carotid terminus aneurysm. The routine frontal projection of the angiogram (A) does not reflect the
nature of the aneurysm as well as the 3D image (B). This view is then used to treat the aneurysm with platinum coils. The post-
treatment single plane (C) view shows complete obliteration with preservation of the carotid terminus.
722 R.P. Klucznik / Radiol Clin N Am 40 (2002) 711–728

tion is then required (Fig. 13). The 3D imaging then used. Because the patient is in isocenter and a true
becomes important for a surgeon to plan not only the isotrophic volume is obtained, direct measurements
surgical approach, but also what type of clip may be are obtained on the screen. Therefore, the true size of

Fig. 13. Two anterior communicating artery aneurysms. The lateral view of a digital subtraction run (A) shows a large aneurysm
that seems to have a small neck. Three successive views from the 3D images (B – D), however, show that the aneurysm has a
wide, patulous neck that encompasses the entire anterior communicating artery complex. The patient underwent successful
surgical clipping. Having knowledge of the precise anatomy of the aneurysm was invaluable to the neurosurgeon for surgical
planning. The anatomic findings at the time of the surgery correlated exactly to those on the 3D images. A second anterior
communicating artery aneurysm (E,F) also is seen and can be treated either with endovascular techniques or surgically. The
angiographic planes used for the endovascular treatment (E) matches the best image from the 3D acquisition (F).
 R.P. Klucznik / Radiol Clin N Am 40 (2002) 711–728 723

Fig. 13 (continued ).

an aneurysm or arteriovenous malformation is deter- stenosis and vessel size also can be directly obtained
mined. An accurate measurement of the degree of in preparation for stenting or carotid endarterectomy

Fig. 14. Superior hypophyseal artery aneurysms are difficult to approach surgically, because the treatment involves drilling through
the anterior clinoid process. These aneurysms, however, usually are easily accessible via an endovascular approach. (A) This
superior hypophyseal aneurysm has a relatively narrow neck (B) and is more easily discernible with the 3D study than with the
routine biplane acquisitions. This also illustrates one of the features of the 3D imaging called ‘‘surface shading,’’ which may not
increase any specific information, but does allow the images to have a more realistic appearance by adding a shaded-light appearance
to the vessel.
724 R.P. Klucznik / Radiol Clin N Am 40 (2002) 711–728

(Fig. 16). In those patients who have multiple aneu-
rysms on a single vessel, 3D imaging supplants the
innumerable views that may be required to obtain the
relationship of all the aneurysms (Fig. 10). In this
case, a single-shot 3D study would involve a lower
contrast dose and radiation exposure.
In the evaluation and treatment of cerebral and
spinal arteriovenous malformations, 3D imaging is
imperative in the definition of aneurysms and its
feeding vessels, intranidal fistula, and relationship
of the nidus to the draining veins [6]. The amount
of information available in 3D and 3D stereo vastly
overshadows a biplane DSA (Fig. 17). Whether
planning endovascular, surgical, or radiation treat-
ment of the malformation, information as to the size
of the nidus, the entrance of feeding pedicles, and the
presence of intranidal draining veins, venous aneur-
ysms, or fistulae is extremely important. With endo-
vascular treatment, the feeding pedicles that may
harbor intranidal fistula can be approached first, with
subsequent treatment of the remaining or residual
nidus. Any high-flow fistula, such as carotid-cavern-
ous, dural, or spinal fistula may also be evaluated
using 3D techniques (see Fig. 18).
In abdominal-pelvic imaging, abdominal aortic
aneurysms are easily demonstrated (Fig. 19), but
the definition of anatomy sometimes may be limited
because of patient motion and breathing artifacts.

Fig. 15. Dissections and dissecting aneurysms are some of the most difficult disease processes to evaluate and treat. The routine
angiogram (A) shows a large fusiform dilatation of the basilar artery with a large pseudoaneurysm. The 3D images (B,C) better
delineate the nature of the dissection and dissecting aneurysm. There were no surgical options once the true nature of the disease
was identified. The patient underwent coiling of the pseudoaneurysm with parent vessel occlusion of both vertebral arteries,
allowing retrograde flow to fill the basilar artery.
 R.P. Klucznik / Radiol Clin N Am 40 (2002) 711–728 725

Fig. 16. Because the 3D acquisition is isotropic in nature, true measurements are identified, which are useful in the evaluation of
a stenosis for possible stenting. These are two separate patients with significant stenosis of the vertebrobasilar system. The first
patient (A,B) shows a significant stenosis of the proximal basilar artery. The 3D pictures allow exact measurements so that a stent
size is chosen accurately for placement across the area of stenosis. The second patient shows a significant stenosis of the distal
vertebral artery, with poststenotic dilatation (C).

There is, however, the potential that with one injec-
tion of contrast, all the information necessary for
treatment is obtained: the relationship of the aneur-
ysm to the renal arteries, the number of renal arteries,
the diameter and length of the aneurysm, the diameter
and length of the infrarenal aortic neck, the degree of
calcification or thrombus formation in the neck of the
aneurysm, stenoses of celiac artery, renal anterior
superior mesenteric artery (SMA), the patency of
the inferior mesenteric artery, and the degree of in-
volvement of the iliac arteries. In the future, with
the advancement of endovascular stent-grafting for
the treatment of aortic aneurysmal disease, 3D im-
aging may be invaluable for detecting the site and
significance of an endoleak and allow planning of
the treatment.
Future plans
Three-dimensional imaging is on the cusp of an
evolutionary development in the evaluation of vas-
cular lesions. The future will bring real-time 3D
imaging during the performance of endovascular
726 R.P. Klucznik / Radiol Clin N Am 40 (2002) 711–728

Fig. 17. The true microarchitecture of arteriovenous malformations can be delineated only on 3D imaging. This figure illustrates
a small vermial arteriovenous malformation with two principal feeding arteries on the superior and inferior surfaces. With
rotation, the entrance site is delineated. The venous drainage and fistula sites are delineated. The best method of evaluation,
however, is true steroscopic imaging, which is only available at the Virtuoso workstation with the use of the Crystal Eyes#
(Stereo Graphics Corp, San Raphael, CA) glasses, with which one perceives depth and identifies the architecture of the
malformation nidus.

Fig. 18. (A) Spinal arteriovenous malformation in a young patient with progressive leg weakness. From an L3 vertebral pedicle,
the single-plane spinal angiogram identifies the site of the fistula at the level of the conus. Because of the prolonged injection, the
3D imaging not only delineates the site of fistula, but also also identifies the nidus size and the venous drainage (B).
 R.P. Klucznik / Radiol Clin N Am 40 (2002) 711–728
Fig. 19. Abdominal aorta examination with a single image from the 3D run shows an abdominal aortic aneurysm in
different projections (A,B). Notice the exquisite anatomic delineation and relationship of the aneurysm to the rest of the
abdominal vasculature.
treatments. The use of glasses that have a ‘‘heads-up’’
display, similar to that used in modern-day fighter
jets, with real-time 3D road-mapping possibilities,
may become an integral component of the tech-
nology. Even now, functional MRI examinations that
evaluate language and motor skills are combined with
the 3D angiographic data for cerebral arteriovenous
malformations in order to locate the specific site of
motor and language function when planning surgical
or radiation therapy.
In the evaluation of stenosis, 3D flythrough tech-
niques may allow an interventionalist a view of the
vessel, as if from inside the blood vessel, providing
an additional perspective in the evaluation of an
aneurysm or an occlusive lesion.
The future will hold faster reconstruction times, so
that decision analysis is performed on a real-time basis.
References
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roentgenography. I. Evaluation of the technical proce-
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[2] Fahrig R, Fox AJ, Lownie S, Holdsworth DW. Use of a
C-arm system to generate true three-dimensional com-
puted rotational angiograms: preliminary in vitro and
in vivo results. AJNR Am J Neuroradiol 1997;18:
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 Radiol Clin N Am 40 (2002) 729 – 749
CT angiography of the arterial system
Lawrence C. Chow, MD*, Geoffrey D. Rubin, MD
Department of Radiology, Stanford University Medical Center, 300 Pasteur Drive, Room H-1307, Stanford, CA 94305, USA
Since its inception in the early 1990s, shortly after
the introduction of spiral-computed tomography (CT),
computed tomographic angiography (CTA) has ex-
perienced a dramatic rise in clinical indications, uni-
versal acceptance, and number of studies performed
worldwide. Although initially met with skepticism
regarding its ability to adequately image the arterial
system when compared to conventional angiography
(CA), CTA has rapidly become the imaging modality
of choice in many clinical situations, including the
evaluation of aortic aneurysm, dissection, trauma, and
penetrating atherosclerotic ulcer. CTA is clearly well-
suited for the pre- and post-procedural evaluation of
stent grafts. Other aortic abnormalities, including con-
genital anomalies, arteritides (such as Takayasu’s),
and intramural hematoma, are evaluated well by
CTA [1]. It also shows great promise in the imaging
of renal and visceral arteries and the peripheral arterial
system. Clear indications for CTA in the evaluation
of the cerebral, coronary, and pulmonary arterial sys-
tems are also evolving and are discussed elsewhere in
this isssue.
The explanation for the rapid development of CTA
is, of course, multifactorial. The technologic develop-
ments with slip-ring gantry design, faster gantry
rotation times, and, ultimately, multiple-row – detector
arrays have paved the way for CTA, rapidly overcom-
ing its major initial limitation—longitudinal anatomic
coverage. Additionally, when compared with other
imaging modalities, such as CA and magnetic res-
onance angiography (MRA), CTA is faster and gen-
erally more available with 24 – hour-a-day staffing of
CT scanners in many institutions. Few centers are able
to offer either MRA or CA as quickly as CT imaging.
* Corresponding author.
E-mail address: lchow@stanford.edu (L.C. Chow).
0033-8389/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 2 0 - 9
This feature of CTA is particularly salient in the
setting of trauma, where rapid diagnosis is critical
and where evaluation of other structures for traumatic
injury often requires the use of CT. Furthermore, CTA
combines the luminal information provided by CA
with the cross-sectional advantages conferred by tra-
ditional axial CT. Visualization of the wall of vessels,
extraluminal processes, and anatomic relationships
with adjacent structures is clearly a strength of CT
that cannot be matched by CA. Finally, CTA repre-
sents a noninvasive study with high diagnostic yield,
convenience, and speed at a substantial cost savings
when compared with CA [2]. It is easy to see why
CTA has seen such tremendous growth as a distinct
diagnostic modality in recent years.
Basic principles
Although imaging protocols for CTA vary from
institution to institution and should be tailored to the
available hardware, anatomic coverage needed, and
the clinical question to be answered, three basic scan
parameters need to be optimized to obtain the highest
quality study possible: longitudinal resolution, scan
speed, and luminal contrast enhancement.
Longitudinal resolution has typically been a lim-
iting factor in three-dimensional computed tomo-
graphy (3D CT), but with the advent of more rapid
gantry rotation times and multiple-row – detector
arrays, both of which allow more rapid coverage of
scan volumes, thinner nominal section thicknesses of
0.5 to 2.5 mm now can be routinely utilized, resulting
in nearly isotropic voxel dimensions. Such volu-
metric, near-isotropic datasets allow for 3D recon-
struction in arbitrary planes with virtually no loss of
image quality, when compared with axial source
images [3]. A more fundamental rationale for the
730 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749
use of thinner collimation is the improved spatial
resolution that it confers, which is particularly notice-
able when imaging structures lie in the plane of the
imaging section, such as the renal arteries. Thinner
collimation/section-width ultimately translates to
higher resolution along the longitudinal axis. By using
the thinnest possible section thickness in conjunction
with a pitch that allows coverage of the anatomic
region of interest within a reasonable amount of time,
z-axis resolution is maximized.
The obvious question that follows is: What con-
stitutes a reasonable scan time? For imaging of
structures within the thorax or abdomen, the patient’s
ability to hold his or her breath is often the limiting
factor. A 30- to 35-second breath hold is a fair
expectation for the majority of patients, particularly
when preceded by a few deep breaths to effect
hyperventilation [4,5]. When imaging continues into
the pelvis and lower extremities, the scan time can be
extended, as shallow respiration is unlikely to cause
motion artifact in these body regions. In situations
where patients are not able to hold their breath for the
entire scan duration, it is important to instruct them to
breathe quietly and slowly when they feel that they
can no longer hold their breath, rather than taking a
deep breath, or worse yet, gasping for air in the
middle of the acquisition.
In addition to reducing the likelihood of motion
artifacts, shorter scan times have an added benefit—a
decrease in the required contrast volume. Based on the
concept that the contrast bolus duration for a CTA
should be equivalent to the actual scan duration [6],
shorter scan times result in lower contrast doses. This
reduction in the volume of administered contrast has
implications for patient safety and comfort as well as
cost. Sometimes, the total volume of contrast deliv-
ered may limit the total acceptable scan time and is
more likely to occur with non – breath-held scans and
slower scanners, particularly single-detector – row
(SDCT) scanners. Improvements in the ability to scan
large anatomic regions with thin nominal section
thickness have been technology driven. The introduc-
tion of four-detector – row CT scanners in 1998, in
conjunction with 0.5-second gantry rotation periods,
improved scanning efficiency nearly eight-fold. Be-
cause eight-detector – row scanners are currently avail-
able and 16-detector – row scanners will soon become
available, the ability to scan faster and with thinner
section profile will continue to improve (Fig. 1).
Finally, proper evaluation of the arterial system
requires optimized, homogenous intraluminal contrast
enhancement. In general, brighter enhancement is bet-
ter, although in the strict sense, this rule can be taken to
excess and it is conceivable that too much intraluminal
enhancement could obscure subtle intimal or intra-
luminal abnormalities. In any case, it remains evident
that dense, homogenous intraluminal enhancement is
critical for high-quality, diagnostic studies.
Technique
Choosing scan parameters
The scan parameters for a given examination often
require tailoring to the particular clinical question at
hand and the technical capabilities of the available CT
scanner. An initial, precontrast scan with thicker col-
limation (5 mm is suitable for most applications) using
a low-dose (50 – 80 mA) technique often is useful to
determine the scan volume of interest, to map calcifi-
cations, to assess for potential artifacts, and, in some
circumstances, to evaluate precontrast attenuation val-
ues, such as the assessment of acute hemorrhage.
Along with the benefits of multidetector-row CT
comes a sometimes bewildering array of parameters
that needs to be considered when prescribing a CTA.
The scan parameters most important to consider are
the desired scan range (ie, the craniocaudal distance
the scan must cover), slice thickness, scan duration,
and pitch. Generally, one selects the desired scan
range and slice thickness depending on the anatomy
to be imaged. A pitch as high as possible that does
not introduce excessive reconstruction artifacts
should be selected in order to minimize scan duration
and radiation dose. Pitch (P) is defined as:
P ¼ TM=ST;
where TM = table movement during one gan-
try rotation period and ST = collimation width for
single-detector – row scanners or the width of a
single active-detector channel for multidetector-row
(MDCT) scanners. For single-detector – row scanners,
a pitch of 2.0 is the maximum. For four-detector – row
scanners, a pitch of approximately 6.0 to 7.0 is
suggested. Most manufacturers allow the user to freely
select an arbitrary pitch value of up to 8.0, although
pitches 8.0 are not recommended because of the
excessive artifacts that may be introduced. Lower
pitches of 3.0 or 4.0 provide marginally improved
image quality that is likely not worth the cost of
the concomitant increase in scan time and radiation
exposure. With four-detector – row scanners from
General Electric (GE Lightspeed, Milwaukee, WI),
there are only two choices of pitch: HiQ mode
(pitch = 3.0) and HiSpeed mode (pitch = 6.0), the latter
of which is suggested for virtually all CTA applica-
 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749
tions. One minor drawback of high pitch values is the
resultant increase in effective section thickness over
731
the selected nominal section thickness. Despite this
trade-off, the use of high-pitch values results in an
overall improvement in the relationship between effec-
tive section thickness and anatomic coverage for a
given scan duration. For example, an increase in pitch
from 1.0 to 2.0 results in a 30% increase in effective
section thickness [7], with either a 50% reduction in
scan duration or a chance to double the z-axis scan
coverage during the same imaging interval [8].
A source of some confusion is the existence of an
alternate definition of pitch. If pitch is defined as the
ratio of TM to the width of the collimated x-ray
beam rather than nominal section thickness, then it
can be generalized to all helical scanners, regardless
of the number of detectors. Using this definition, a
pitch between 1.5 and 2.0 should be used in all CTA
cases, and a pitch of 2.0 should always be used with
single-detector – row scanners [8]. Even though an
increase in pitch from 1.0 to 2.0 results in a 30%
increase in effective section thickness [7], one should
never sacrifice thinner slice width for lower pitch by
increasing slice thickness as this always adversely
affects the resultant z-axis spatial resolution when
compared with maintaining a thin slice width and
using a higher pitch [9,10]. Additionally, although it
is possible to retrospectively select reconstruction
interval and slice thickness with multidetector-row
CT scanners, it is never possible to reconstruct at a
slice thickness thinner than the width of a single
active-detector channel. For example, when scanning
in the 4  2.5 mm HiSpeed mode on a GE Light-
speed CT scanner, the thinnest section that can be
retrospectively reconstructed is a 3-mm effective
Fig. 1. Multidetector CT angiogram of a 62-year-old man
with bilateral leg claudication acquired from the aortic hiatus
of the diaphragm through the feet with 1.25-mm nominal
section thickness, pitch = 13.4, and table speed = 16.75 mm
per gantry rotation. The scan took 39 seconds and covered
1306 mm. Coronal maximum intensity projection image
after editing of osseous structures shows excellent arterial
depiction from the diaphragmatic hiatus to the foot. There is
occlusion of the distal abdominal aorta and common iliac
arteries bilaterally. Numerous collateral pathways, including
bilateral internal mammary to inferior epigastric and lumbar
to lateral circumflex iliac arteries (open arrows), supply the
legs, reconstituting the common femoral arteries. Addition-
ally, an enlarged inferior mesenteric artery with a stenotic
origin (white arrow) supplies collaterals to the lower
extremities via the superior hemorrhoidal arteries. A mild
stenosis of the distal left superficial femoral artery is present
(curved arrow). Single vessel runoff to the feet is present
bilaterally, with early termination of bilateral peroneal and
anterior tibial arteries (arrowheads).
732 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749
section width (this 0.5-mm discrepancy is accounted
for by the slice sensitivity profile broadening inherent
with spiral CT). In contrast, it is always possible to
reconstruct thicker images by combining detector
channels in the reconstruction process. Again, the
thinnest possible nominal section thickness should be
prospectively selected at the time of scanning which,
in conjunction with an appropriate pitch, yields a
reasonable scan duration for a given scan volume.
Once scan range, nominal section width, and pitch
have been selected, table speed is given by the pitch
equation shown above. The mA should be adjusted
according to the nominal section thickness to main-
tain an acceptable level of noise (as well as radiation
dose) [10 – 12]. Some scanners do not require manual
tube current adjustment and the mA is automatically
adjusted with changes in section thickness.
The final scan parameter that must be chosen is the
scan direction. Using the general example of a CTA of
the aorta, there are two choices: craniocaudal or
caudocranial scanning. Craniocaudal scanning makes
the most intuitive sense, because it follows the direc-
tion of the contrast bolus wave down the aorta. The
only real drawback to scanning in this direction is the
potential for excessive linear streak artifact arising
from dense intraluminal contrast within a brachioce-
phalic vein, assuming contrast is administered via an
upper extremity IV. When scanning the thoracic aorta,
avoiding a left upper extremity IV site can minimize
the risk of obscuration of key structures such as the
aortic arch branch vessel origins by artifact arising by
the left brachiocephalic vein [12]. Using an IV in a
lower extremity eliminates dense contrast within the
brachiocephalic veins when scanning the thorax, but
can lead to linear streak artifacts from the inferior vena
cava (IVC) or iliac veins when scanning the abdomen
and pelvis. Additionally, contrast administration sites
further from the heart, such as the lower extremities,
yield a poorer bolus effect and requires a larger timing
bolus volume. In day-to-day practice, placement of
the IV in the right upper extremity is most practical
and effective.
Caudocranial scan direction is a means of avoiding
the artifacts described previously, but scanning in this
direction is laden with its own difficulties. Because the
contrast bolus propagates down the aorta in cranio-
caudal direction, scanning in the opposite direction
can lead to greater variability in the degree of luminal
enhancement within different segments of the aorta.
Contrast timing and other contrast issues
An ideal CTA requires a combination of optimal
intraluminal enhancement and fine spatial resolution.
This combination of factors allows visualization of the
smallest structures possible, including small branch
vessels or subtle intimal abnormalities. To that end,
high-contrast flow rates of 4 to 5 ml/second of 300
to 350 mg I/ml contrast and a total bolus duration
equal to scan duration are suggested [10,13]. For a
20-second scan of the abdominal aortoiliac system
with a four-detector – row scanner, this yields a total
contrast dose of 80 to 120 cc. The exception to this
rule of thumb is in the imaging of the lower extremity
inflow and runoff, where such a practice requires
unnecessary large volumes of contrast. Because of
the prolonged circulation time through the lower
extremities, bolus durations of approximately 20 sec-
onds less than total scan time yield good results with
four-detector – row scanners [12].
The rapid scanning capabilities of multidetector-
row CT make imaging of large anatomic volumes
possible, without excessive doses of intravenous con-
trast. The short bolus durations associated with short
scan durations, however, require accurate timing of the
scan, lest the bolus be missed or only partially imaged.
Scanning too early can result in incomplete opacifica-
tion of the arterial system on early images and,
similarly, too long a scan delay can result in a drop-
off of luminal enhancement on images acquired
towards the end of the study. Such circumstances
create more serious problems than just visually unap-
pealing images, possibly resulting in nondiagnostic
studies or complicating the selection of thresholds for
3D rendering [14].
Optimizing intraluminal enhancement is perhaps
the most important of the three basic principles
required for optimizing a CTA study. Yet optimizing
contrast enhancement may be difficult to achieve
because it is affected by many variables including
cardiac output, patient positioning, injection rate, IV
location, scan direction, scan delay, body weight, and
pharmacokinetic properties of the contrast material
itself [14,15]. With more rapid scanners come shorter
contrast boluses and, thus, narrower temporal win-
dows with diminished tolerance for timing errors in
contrast administration [14]. It is clear that account-
ing for the various physiologic and morphologic
characteristics of the patients’ cardiovascular systems
and balancing them with the speed of available
hardware in order to achieve optimal CT angiograms
requires a careful, systematic approach.
There are currently three basic methods by which
scan delay times are selected: (1) empiric scan delay,
(2) timing bolus technique, and (3) automated bolus
detection and scan triggering [15]. Empiric selection
of a scan delay is unlikely to be reliable enough to
guarantee consistent results in any patient cohort
 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749
other than young, healthy individuals (eg, patients
being evaluated as potential living-related organ
donors) [16,17]. The timing bolus approach involves
injection of a 10- to 15-cc bolus of contrast at a rate
of 4 to 5 cc/second (a rate equivalent to that used for
the CT angiographic acquisition) followed by sequen-
tial dynamic scanning at 2-second intervals at a
specified level within the target vessel after a set
delay time. Serial region-of-interest attenuation meas-
urements within the target vessel on the dynamic
images can be graphically plotted against time, yield-
ing a time to peak enhancement, which represents the
contrast transit time from the site of administration to
the target vessel. Thus, the delay time after start of
contrast injection at which scanning should be ini-
tiated for the CTA acquisition can be accurately
predicted [18,19].
The drawbacks to using this approach include the
additional volume of contrast needed and the extra
radiation dose to the patient [15]. Another potential
problem with this method is the possibility that
the timing bolus yields no clear enhancement peak.
Troubleshooting in this situation should first include
careful examination of the IV site to exclude extra-
vasation as well as checking the injector setup and
contents. Assuming that the IV and injector are in
order, the most common cause for this dilemma, in
the authors’ experience, is the overhead positioning of
the arms, which may result in venous kinking and
prolonged contrast transit times. In this situation,
relaxing the position of the arms often yields a
normal-appearing enhancement curve on a successive
timing bolus acquisition. One relatively simple refine-
ment of the timing bolus technique, which could
reduce the likelihood of this event, is immediately
following the timing bolus with a 15- to 20-cc saline
‘‘chaser’’ bolus to prevent pooling of the contrast
bolus within the injector line and peripheral veins
[20]. This technique requires either a dual syringe
injector, such as those more commonly used in MRI,
or a stopcock and syringe setup with manual injection
of the saline chaser bolus. Finally, one should enter-
tain the possibility that the enhancement peak may be
missed on the timing acquisition, typically because of
too short an acquisition in patients with diminished
cardiac output and delayed contrast transit times.
Finally, several vendors offer bolus tracking with
automated or semi-automated scan triggering as
optional or standard software with their CT systems.
With this approach, a region-of-interest is selected
within the target vessel on a preliminary, unenhanced
image. After intravenous contrast administration is
initiated, sequential images (generally at 3 – 4 second
intervals) are obtained at the specified level and when
733
the attenuation within the selected region-of-interest
reaches a user-defined threshold value, the CTA
acquisition is either automatically or manually trig-
gered. The major benefits to this approach include
improved efficiency and a theoretical reduction in the
amount of contrast by eliminating a separate timing
bolus. As with the timing bolus approach, however,
additional radiation dose is imparted to the patient for
the acquisition of nondiagnostic images used only for
determining contrast arrival.
The most important limitation of this automated
technique is the possibility of a significant time delay
between the arrival of contrast and the start of the CTA
acquisition. This time lag results from a summation of
the interscan time, image reconstruction time, time for
the scan operator to review the image and initiate the
CT angiographic acquisition, and, finally, the time
required for movement of the table to the start position
for the CTA and breathing instructions to be given.
This time lag is typically on the order of 8 to 10 sec-
onds and would result in an additional 40 to 50 cc of
administered contrast (if injecting at 5 cc/second) not
imaged. To some degree, this slight delay can be
countered by selecting a slightly lower threshold;
however, selection of an appropriate threshold at this
time remains a somewhat arbitrary process that may
not optimally account for interindividual variation in
luminal enhancement characteristics. Whereas use of a
threshold that is too low could result in suboptimal
opacification of the arterial system, a threshold set too
high may never be attained and require rapid judgment
and intervention by the operator in order to initiate the
scan before the contrast bolus has passed. Whereas this
approach usually yields acceptable images, validation
of this technique has not yet been fully established.
Early studies evaluating the efficacy of automated
bolus tracking have been encouraging, but the current
literature is focused on solid organ imaging where
precise timing is less critical [21 – 30]. We are unaware
of any studies validating this method for CTA, perhaps
because of the limitations outlined previously.
One final issue regarding the optimization of
intraluminal contrast enhancement in CTA pertains
to the homogeneity of the enhancement during the
duration of the acquisition. Several authors observe
nonuniformity in the degree of luminal enhancement
during CTA with standard contrast injection tech-
niques [31 – 34]. Fleischmann et al show that by
using a biphasic contrast material injection protocol
according to a mathematical model based on discrete
Fourier transform, a substantially more uniform
enhancement profile can be obtained [14]. Again, this
technique does not account for interindividual vari-
ation in enhancement characteristics, but the same
734 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749

group is investigating methods of doing so [35]. of 3D reconstructions by reducing stair-step arti-

Whereas this approach shows great promise in opti-
mizing the luminal enhancement on CTAs, further
refinement in the mathematical modeling [35], as well
as integration of the modeling software into CT
systems by manufacturers, is required before it can
become widely used.
As new technology with more detector rows and
shorter gantry rotation periods continue to fuel the
speed capabilities of new scanners, the issues sur-
rounding optimal contrast delivery are of incremen-
tally increasing importance [14]. Additionally, short
scan durations would yield small total bolus sizes if
one adheres to the rule of setting bolus duration equal
to scan duration. Whereas this may be an advantage
of faster scanners, such small bolus volumes may
prove to be insufficient for proper arterial opacifica-
tion. These and other issues need to be addressed as
CTA continues to evolve.
Image reconstruction and postprocessing
The second step in CTA, that of image recon-
struction, is nearly as critical as the technique by
which data is acquired in determining the diagnostic
quality of the final product. Image reconstruction
begins with the choice of a desired section thickness,
which is generally the thinnest possible for a given
acquisition in order to optimize 3D reconstruction and
provide the best chance at visualizing small struc-
tures or abnormalities. The section thickness is deter-
mined by the width of a single active detector channel
for multidetector-row scanners and by the slice col-
limation for single-detector – row scanners. General-
izing from experience with single-detector – row spiral
CT in the evaluation of pulmonary and hepatic nod-
ules, a 50% overlapping reconstruction interval pro-
vides greater diagnostic confidence and accuracy in
the depiction of lesions [36,37]. Furthermore, over-
lapping reconstruction also improves image quality
fact. For these reasons, a reconstruction interval equal
to half the effective section thickness is suggested
[9,13,38,39].
When using 1- or 1.25-mm nominal section thick-
ness, the resulting 0.5- or 0.6-mm reconstruction
interval can result in many hundreds of axial images,
depending on the length of the scan volume. An
important consideration when interpreting CTA stud-
ies is that all the diagnostic information contained
within the study is present on the axial source images,
whereas the same cannot be said for the various 3D
reconstructions that may be generated [15]. For this
reason, it is imperative that the axial source images be
carefully reviewed in all cases in order to detect
vascular pathology and incidental, nonvascular ab-
normalities [40]. To improve the efficiency of CTA
interpretation, thicker axial slices (eg, 5- to 7-mm
thick) can be reconstructed from the CT data for the
purpose of evaluating the nonvascular structures.
Various 3D reformatting techniques are currently
used in practice to aid in the visualization of vascular
structures and their anatomic relationships. The most
commonly used reformatting techniques include mul-
tiplanar reformation (MPR), curved planar refor-
mation (CPR), maximum intensity projection (MIP),
shaded-surface display (SSD) and volume rendering
(VR). Each of these techniques has its strengths,
weaknesses, and particular utility (Table 1). Since all
these techniques rely on contrast differences between
the enhanced vascular lumen and surrounding struc-
tures, it is important that oral contrast not be given
prior to the CT examination.
Multiplanar reformation represents reconstruction
of source data into sections in any arbitrarily defined
plane. All commercially available spiral CT scanners
have the capability of acquiring data for the genera-
tion of MPR images quickly and easily. Whereas
viewing in a user-selected plane is useful for evalu-
ating structures that do not conform to an axial plane,

Table 1
3D reconstruction techniques
Reconstruction Interpretation Luminal, intimal and Vascular Adjacent nonvascular Stenosis grading
efficiency efficiency mural information contour structures accuracy
Stack of axial +++ + +++ + +++ ++
or MPR images
CPR ++ ++ +++ ++ ++ +++
MIP + to +++a +++ + ++ + ++
SSD ++ +++ + +++ + +
VR ++ +++ ++ +++ ++ +
Abbreviations: CPR = curved planar reformation; MIP = maximum intensity projection; SSD = shaded-surface display; VR =
volume rendering.
a
Depending on degree of prerendering editing of osseous structures.
 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749
it generally is not possible to define a single plane,
which includes an entire vessel of interest. Thus, the
user must scroll through a stack of MPR images,
leaving the task of 3D reconstruction to the inter-
preter, similar to paging through a stack of axial
images. The major clinical utility of MPR images
results from the rapidity with which these images can
be obtained, making it most useful in acute situations,
such as the evaluation for traumatic aortic injury.
Curved planar reformations display the entire
course of a vessel through a 3D volume in a collapsed
2D image. Points are designated in the center of the
structure of interest on each of a stack of transverse
images. This collection of points defines a curved line,
containing the vessel of interest, from which various
curved planes can be defined. This curved plane is
then projected onto a flat 2D image. CPR images are
useful for the evaluation of vessel lumina, vessel walls,
and immediately adjacent structures, thus making
them useful for evaluating vessels for stenoses [41]
and for quick communication of information regarding
the extent of other processes such as aneurysms,
intramural hematoma, vasculitides, and dissections.
There are two major potential pitfalls, however, in
the interpretation of CPR images. First, CPR images
are highly operator dependent in that any inaccuracy in
the selection of points that define a vessel may result in
artifactual pseudostenoses [42]. Second, CPR images
are only one voxel thick; thus, small or thin structures
such as a dissection flap may not be included in a given
CPR image, making it important to always generate at
least two CPR images of a given structure in orthog-
onal planes. This task is simple and quick to perform
once the points defining the plane have been selected
(ie, the orthogonal CPR image does not require a
second set of points to be designated).
Maximum intensity projection is a technique first
described in the MRA literature [43]. It is a simple
technique in concept. A specific projection angle is
selected and parallel rays are then ‘‘cast’’ through the
image volume with the maximum attenuation value
encountered along the path of each ray being dis-
played on the resultant 2D image. Only the brightest
pixel along the path of each ray is displayed; there-
fore, overlapping structures obscuring the vessel of
interest are limited to only those structures with
attenuation values greater than the enhanced blood
(ie, bones, calcium, and metal). The presence of such
structures often requires extensive manual editing of
the dataset prior to MIP rendering, a process that can
turn a theoretically simple process into a tedious one,
particularly in regions of complex vascular and bony
anatomy such as the extremities. This attribute of
MIP images can be used to advantage in preoperative
735
evaluation of patients with atherosclerotic occlusive
disease by mapping the global distribution of arterial
calcification (Fig. 2A).
Not surprisingly, the weaknesses of MIP images
parallel those of CA with its lack of depth information
resulting in ambiguity in interpreting overlapping
vessels. Since the virtual rays used to generate MIP
images are parallel, a MIP generated in an antero-
posterior direction is identical to that generated in a
posterior to anterior direction. Fortunately, just as
with CA, this issue is overcome by obtaining images
in multiple projections. Since CTA data is volumetric
in nature, MIP images in any projection can be
generated from the original dataset without additional
radiation exposure to the patient. As a routine at the
authors’ institution, 12 MIP images at 15-degree
intervals are generated from each volumetric dataset.
Another method of dealing with overlying bones
that requires no manual editing is that of sliding thin-
slab MIP [44], where MIP images are generated from
overlapping slabs within the volumetric dataset rather
than from the entire dataset at once. The result is a
stack of MIP images with minimal obscuration by
overlying structures. As with MPR images, however,
the entire extent of a vessel is no longer included on
a single image and requires paging through a stack
of images.
The SSD technique results in visually appealing
3D renderings of vessels by displaying a surface
between voxels at an arbitrarily determined threshold
value (Fig. 2B). A virtual light source is used to
generate reflections that are represented with gray-
scale, resulting in dramatic lighting effects. Unfortu-
nately, whereas SSD images are visually appealing
and can be useful for conveying information regard-
ing the overall anatomic relationships of vessels and
other structures, the arbitrary nature of threshold
selection can result in misrepresentation of the true
anatomy. For example, pseudostenoses can result if
too high a threshold is selected, resulting in ‘‘clip-
ping’’ of the edges of vessels, which may have lower
attenuation values as a result of partial volume
averaging. On the contrary, masking of stenoses
represents another potential pitfall and arises when
calcified plaque along the vessel wall falls into the
same threshold range as contrast within the vessel
lumen, thereby giving the false impression of a wider
lumen than actually exists. From this discussion, it
should be clear that whereas SSD is a useful tool for
giving an overall picture of the course and shape of a
vessel, it should never be used when accurate meas-
ures of luminal dimension are required.
VR is probably the most complex of the 3D re-
construction techniques in widespread use. In general,
736 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749

the voxels within a dataset are assigned both a degree
of opacity and a color as a function of their attenuation
values. By changing this function, which is repre-
sented by a user-defined curve where either color or
opacity is plotted against attenuation, structures of
different attenuation can either be emphasized or de-
emphasized (even to the point of invisibility). Some
VR software also allows the user to define degrees of
transparency depending on attenuation. Additionally,
much like SSD, VR allows the application of a virtual
external light source to yield lighting and shading
effects, resulting in an image with greater depth infor-
mation. The ability of VR to selectively depict struc-
tures of different attenuation values makes it useful
for assessing the anatomic relationships of vessels
with bones, calcium (including calcified plaque), and
other structures such as metallic stents. As with SSD,
however, the arbitrary nature of opacity and color

Fig. 2. (A) Maximum intensity projection image from an aortic CTA shows both the distribution of calcification throughout the
thoracoabdominal aorta and diffuse ectasia and aneurysm of this vessel. (B) The overall contour of the aorta and its relationships
to branch vessels are better depicted with shaded-surface display.
 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749 737

curve selection precludes accurate measurements of
vessel diameter.
Clinical applications
The aorta
With its longitudinal axis perpendicular to the
imaging plane of CT and its large luminal diameter,
the aorta is ideally suited for imaging by CTA.
Currently accepted indications for evaluation of the
aorta with CTA include congenital anomalies, aneu-
rysm, dissection, Takayasu’s arteritis, penetrating
atherosclerotic ulcer, and traumatic injury [1].
Perhaps the most common use of CTA in the aorta
is for evaluation of aneurysmal disease (Fig. 3). By
providing an overall map of the full extent of the
aneurysm including depiction of its relationship to
branch vessels and other anatomic structures, provid-

Fig. 3. CT scan of a patient with poorly controlled hypertension and two-day history of low, midline back pain is shown. (A)
Axial CTA images of the abdominal aorta demonstrate extensive irregular atherosclerotic plaque (long arrows) and an 8-cm
aneurysm (short arrows) with eccentric thrombus (*), but no evidence of aneurysm rupture. (B) Coronal maximum intensity
projection image of the contrast-enhanced acquisition shows the aneurysm (short arrows) with distinction between the flow
lumen and nonenhancing thrombus. A severe stenosis of the left renal artery (curved arrow) is present.
738 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749

ing accurate dimensions, and defining the presence
and extent of mural thrombus and extraluminal pathol-
ogy, CTA represents a single diagnostic test which is
capable of providing all the imaging information
necessary for the initial evaluation, treatment plan-
ning, and follow-up of aortic aneurysms. In the evalu-
ation of abdominal aortic aneurysms, coverage should
include the celiac axis down to the femoral bifurca-
tions. Current four-detector – row scanners are capable
of acquiring this data with 2.5-mm nominal section

Fig. 4. CTA of a 53-year-old man with a history of coronary artery disease and hypertension who presented with epigastric and
back pain. (A) Axial CTA image shows extension of the dissection flap (curved arrows) into the left common carotid (black
arrow) and left subclavian (white arrows) arteries. (B) Axial image at the level of the aortic arch reveals differential enhancement
of the true (*) and false lumina indicating substantially slower flow in the false lumen. Thrombus (white arrows) is present within
the false lumen. The intimal tear (curved arrow) with communication between true and false lumina is visualized. (C) Axial
image in the lower thorax shows compression of the true lumen (arrows) by the relatively larger false lumen (*) and dilatation of
the aorta overall. (D) Curved planar reformation through the renal arteries shows delayed enhancement of the right renal artery
(black arrows) and right kidney compared with the normal left renal artery (white arrows) as a result of renal artery ostial
obstruction by the intimal flap. Contrast from the timing bolus is seen in both renal collecting systems.
 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749 739

thickness, 1.25-mm reconstruction interval, pitch =
6.0, and table speed of 18.75 mm/second in approx-
imately 40 to 50 seconds in the majority of patients.
Imaging limited to the thorax can be performed with
even shorter scan durations.
Recently, there has been considerable debate re-
garding the best test for the evaluation of aortic dis-
section. CTA, as well as MRA, ultrasound, and CA, all
have their proponents, but, as a result of its rapid
accessibility, CTA remains the predominant modality

Fig. 5. A 96-year-old man with hypertension who presented with acute, severe chest pain radiating to the back. Myocardial
infarction was ruled-out by cardiac enzymes and electro-cardiogram. (A) A precontrast axial CT image demonstrates high
attenuation material adjacent to the aorta (circle) measuring 60 HU. (B,C) Axial CTA images show two intercostal arteries (black
arrows) whose origins have been sheared away from the aorta by intramural hematoma, resulting in small pools of intramural
contrast (curved arrows) between the aortic intima and adventitia. (D) Curved planar reformation image of the aorta shows a
hematoma (arrowheads) surrounding the aortic arch and proximal descending aorta.
740 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749

for this application. Because of the extensive coverage
required to insure definition and characterization of the
full extent of disease, this application can pose a
challenge for single-detector – row scanners. The
imaging volume should begin above the origins of
the aortic arch branch vessels and include the entire
aortoiliac system into the pelvis. A great strength of
CTA is its ability to clearly image the anatomic extent
of a dissection flap, as well as characterize its physio-
logic consequences (Fig. 4). For example, the dynamic
temporal nature of the intimal flap, as it varies in
location between systole and diastole, results in a
stair-step appearance on CTA. Its effect on end-organ
perfusion can best be appreciated in the kidneys where
flap occlusion of the renal arteries can lead to delayed
renal enhancement. The visualization of entry and exit
tears remains a difficult task, as it is with all current
imaging modalities.
Several pitfalls in the diagnosis and evaluation of
aortic dissections with CTA deserve mention. A diag-
nostic CTA is dependent on an optimal technique for
the diagnosis of dissection, perhaps more than for any
other application of CTA. Improper timing of the
contrast bolus or too slow an injection rate can result
in a failure to fully opacify a false lumen. In such
circumstances, it may be beneficial to increase the scan
delay accordingly to allow optimal visualization of
both the true and false lumen. One must also be aware
of the potential shortcomings of CTA in the evaluation
of Type A dissections in particular, where the presence
and severity of aortic regurgitation and coronary artery
involvement is not well evaluated [45].
Several CT artifacts may simulate the appearance
of an aortic dissection. The most common culprit is a
linear streak artifact, arising from medical devices,
clips, staples, lines, and catheters either within or
external to the patient, calcifications, or dense con-
trast within the brachiocephalic veins. Another com-
mon scenario is streak artifact arising from a patient’s
arms if they are kept at their side, rather than being
positioned overhead. In all these cases, however, the
artifact is easily recognizable by its failure to conform
to the aortic lumen. Finally, normal periaortic struc-
tures such as the left brachiocephalic vein, left
superior intercostal vein, left inferior pulmonary vein,
right atrial appendage, or even motion artifact from
the aorta itself can mimic a dissection flap [46].
Penetrating atherosclerotic aortic ulcer (PAAU)
with intramural hematoma (IMH) is a separate patho-
logic entity that may also mimic aortic dissection,

Fig. 6. Axial CT image at the level of the aortic arch in a 67-year-old male smoker with a 50-pack/year history and quadruple
coronary artery bypass surgery in 1991 shows a typical penetrating ulcer (arrow) along the lateral aspect of the arch.
 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749 741

clinically and on CTA images. Ulceration of an ather-
omatous plaque disrupts the internal elastic lamina of
the aortic wall and can ultimately result in an IMH
within the media [47,48]. This contrasts with a
spontaneous IMH (Fig. 5), which is thought to occur
with rupture of the vasa vasorum [49]. Whatever the
etiology, an IMH can simulate the appearance of
aortic dissection as it tracks along the long axis of
the aorta between the layers of its wall. In fact, the
complications of IMH include dissection, as well as
aortic rupture and pseudoaneurysm formation. PAAU
commonly occurs in the mid- to distal-descending
thoracic aorta, but can also occur elsewhere (Fig. 6).
Whereas CTA and DSA are capable of imaging the
ulcer in PAAU, only CTA depicts the full extent of
coexistent IMH and the extraluminal complications
such as pseudoaneurysm [50,51]. Although IMH and
PAAU may be closely associated, either may be
present independent of the other.
Because of its ready access, fast examination time,
and in many institutions, proximity to emergency
departments, CTA is well-suited for the evaluation

Fig. 7. CTA of a 19-year-old unrestrained passenger ejected from a vehicle during a rollover accident. (A) Axial CT images
demonstrate contained traumatic rupture (straight arrows) of the descending thoracic aorta and an intimal flap (curved arrow).
Mediastinal hematoma and bilateral pleural effusions are noted. (B) Curved planar reformation of the descending aorta again
shows mediastinal hematoma (arrowheads) and aortic pseudoaneurysm (arrows). Left pulmonary contusion (*) also is depicted.
742 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749

Fig. 7 (continued ).

of traumatic aortic injury (TAI) and is evolving into
the study of choice in the urgent evaluation of acute
aortic processes [52]. TAI is the primary cause of
death in 10% to 20% of fatalities related to decelera-
tion trauma [53]. Of the 10% to20% of patients with
TAI who survive to reach medical care, there is a 30%
mortality rate in the first six hours and 40% within
24 hours if not promptly diagnosed [54]. Only 2% to
5% of patients with TAI survive without treatment.
Whereas CT has been used for some time in the
setting of trauma, suspicion of TAI was based on only
secondary CT findings, such as periaortic mediastinal
hematoma. It was not until the advent of CTA that
direct visualization of aortic trauma with CT became
possible, thus greatly improving its diagnostic accu-
racy (Fig. 7). In one study of 382 patients evaluated
with single-detector – row CTA who had follow-up
aortography, CTA had 100% sensitivity, 96% specifi-
city, and 100% negative predictive value for TAI
using direct signs [55]. Direct signs of TAI include
an aortic contour abnormality, focal aortic caliber
change (pseudocoarctation or pseudoaneurysm), inti-
mal flap, or actual contrast extravasation [55,56].
In the authors’ institution, trauma patients with
abnormal or equivocal chest radiographs and those
with normal chest radiographs, but an appropriate
mechanism for traumatic aortic injury, undergo
MDCTA if hemodynamically stable. Those patients
with direct evidence of TAI with CTA go immedi-
ately to surgery. Patients with equivocal CTA or
indirect signs of TAI (such as periaortic hematoma)
proceed to traditional catheter-based angiography.

Fig. 8. A 69-year-old man presented with chronic tibial osteomyelitis after open tibia-fibula fracture. CTA examination (4 
1.25-mm effective section thickness, 0.6-mm reconstruction interval, pitch = 6.0, gantry rotation period = 0.5 seconds, 924 images
in 37 seconds, 55.5-cm coverage, 150-cc IV [300 mgI/L] contrast at 4 cc/second) was performed for preoperative planning.
(A) Oblique maximum intensity projection image of the left leg after manual editing of osseous elements shows early termination of
the peroneal artery (open arrow) and dorsalis pedis artery (curved arrow) with metatarsal arteries primarily supplied by the
posterior tibial artery via the plantar pedal arch. Regional soft tissue hyperemia is visualized (arrowheads). (B) Oblique volume
rendering image shows the relationship of vessels and soft tissue hyperemia (arrowheads) to the underlying bony deformities
(white arrows). The patient subsequently underwent successful soft tissue debridement, excision of osteomyelitic bone, and
placement of a vascularized free rectus flap anastamosed to the anterior tibial artery.
L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749 743
744 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749
Patients with a negative CTA or isolated nonperi-
aortic hematoma have short-interval follow-up CTA.
Aortitis is a recent addition to the list of indications
for CTA and represents a group of abnormalities for
which Takayasu’s aortitis (TA) is the prototypical
example. TA is a systemic vasculitis characterized by
intimal proliferation and fibrosis, ultimately leading to
luminal narrowing or even occlusion. Various large
arteries have been described to be involved with TA:
the aortic arch and its major branches, the abdominal
aorta, the entire aorta, and the pulmonary arteries. On
imaging, smooth, long-segment stenoses with vessel
wall-thickening are the hallmark findings. Aneurysms
are an uncommon manisfestation of TA. Whereas both
CA and CTA are capable of imaging the luminal
narrowing characteristic of TA, CTA also allows for
the assessment of mural thickening and persistent de-
layed enhancement of the wall [57]. A more important
benefit of CTA over DSA is its noninvasive nature.
The peripheral vascular system
The most common indication for CTA imaging of
the lower extremity arterial system is in the evaluation
of peripheral vascular occlusive disease (PVOD), for
the detection and characterization of stenoses and
occlusions, and, just as importantly, for the character-
ization of inflow and runoff vessels as an aid to
therapeutic planning. Other applications under current
investigation include preoperative evaluation prior to
microsurgical reconstruction procedures (Fig. 8) and
postoperative evaluation after angioplasty, stent place-
ment, or bypass procedures. In order to accomplish
this task, a single acquisition with coverage extending
from the supraceliac abdominal aorta down to the feet
is ideal. Because of the combined need for tremendous
longitudinal anatomic coverage and fine spatial res-
olution to visualize small-diameter vessels, evaluation
of the lower extremity arterial system is probably the
most technically demanding clinical application for
CTA, and a careful compromise must be made in order
to balance these opposing demands.
Imaging of the arterial inflow and runoff from the
celiac axis to the feet can be performed in under a
minute with current four-detector – row scanners using
2.5- to 3-mm nominal section thickness, pitch = 6.0 to
8.0, and half-second gantry rotation time, yielding
approximately 900 to 1000 images. A brief review
of the progress made in CTA of the lower extremities
reveals dramatic incremental improvements in scan
efficiency from single-detector – row to four-detector –
row and now eight-detector – row CT. In 1996, Rieker
et al reported CTA of the legs using a single-detector –
row scanner with 5 mm collimation, pitch = 2.0 with
approximately 700 mm of coverage (groin to inferior
calf ) in 70 seconds [32]. In 2001, Rubin et al reported
a technique using four-detector – row CT, which
imaged the entire lower extremity inflow and runoff
from the supraceliac aorta to the feet, which repre-
sents nearly twice the longitudinal coverage (mean
1233 mm), in less time (mean 66 seconds) with near-
ly twice the longitudinal resolution (3.2 mm effec-
tive section thickness) [33]. Not surprisingly, current
eight-detector – row scanners are approximately twice
as fast as those with four detector rows. It is possible
to image the entire arterial system from the neck to the
feet with 2.5-mm nominal section thickness in a single
breath hold. Clearly, longitudinal coverage is no
longer a limitation of CTA (see Fig. 1).
The rapid rate at which new technology has
allowed CTA to progress has not allowed validation
studies of these new techniques to keep pace. There
have been only two prospective studies comparing
CTA of the lower extremities with catheter angiog-
raphy [32,58]. These studies were conducted with
single-detector – row scanners, which were state-of-
the-art at the time. The first report is a more technical
note, with only six patients studied. The authors report
on the use of SDCT with 5-mm collimation and a
1-second gantry rotation, imaging from the inguinal
ligament to the proximal calf in two successive
60-second acquisitions at a pitch of 1.0. The results
yield 92.9% sensitivity and 96.2% specificity in the
depiction of arterial stenoses and occlusions [58].
Rieker et al report sensitivities of 94% to 100% and
73% to 88% and specificities of 98% to100% and
94% to100% for the diagnosis and grading of lower
extremity arterial occlusions and stenoses (75% to
99%), respectively, using SDCT with a 1-second
gantry rotation time, 5-mm collimation, pitch = 2.0,
and a total scan time of 70 seconds in a study of
50 patients [32]. One would expect that the major
technological advances in four- and eight-detector –
row scanners with gantry rotation periods of 0.5 sec-
onds would yield even better results, although this has
not yet been proved.
The most recent study of CTA of the lower
extremities evaluates the degree of vascular opacifi-
cation in 16 arterial and 16 venous segments in 24
patients and the detectability and degree of stenosis in
18 patients who had CTA and CA. Whereas this is
not a blinded study, and direct comparison is made
between CA and CTA images, there is 100% con-
cordance with CTA for all arterial segments visual-
ized on CA. Additionally, the 27 arterial segments not
visualized on CA are depicted on CTA; in each case,
these segments were distal to occlusions and supplied
by collateral flow. An additional important finding of
 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749 745

this study is that with CTA, there is adequate opaci-
fication of arterial segments in all instances of very
asymmetric occlusive disease, such that interpretation
and lesion detectability is not compromised [33].
Renal arteries
Whereas CTA can be used to depict normal ana-
tomy and evaluate various abnormalities involving
the renal vasculature, the three most common indica-
tions for renal CTA are for the evaluation of renal
transplant donors, renal artery stenosis, and ureter-
opelvic junction stenosis prior to surgical repair. In the
setting of potential living renal donors, it is increas-
ingly common for kidneys to be harvested using
laparoscopic techniques. Even when an open proced-
ure is performed for the purposes of surgical planning,
it is critical to be aware of the presence of occult
lesions and anatomic anomalies, such as accessory
renal arteries (Fig. 9), prehilar renal arterial branching,

Fig. 9. A patient presenting for potential kidney donor evaluation. (A) A coronal curved planar reformation (CPR) shows normal
bilateral renal arteries (arrowheads). (B) The shaded-surface display image shows that there are actually two right renal arteries
(arrowheads) originating from the abdominal aorta approximately equal in caliber. Main left renal artery (arrow) is depicted, but
a small left upper pole accessory renal artery is not seen, highlighting one of the weaknesses of thresholding techniques. (C)
A CPR reveals the lower of two right renal arteries (arrowheads). (D) The CPR shows a small left upper pole accessory renal
artery (arrowheads). The origin of the main left renal artery (arrow) is visualized, but the remainder of this vessel is not included
in this CPR.
746 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749

Fig. 9 (continued ).

multiple renal veins, renal artery aneurysms or oc-
clusive disease, and duplicated renal collecting sys-
tems. Traditionally, this information was garnered
from the combination of excretory urography and
conventional angiography, but CTA represents a sin-
gle, noninvasive examination capable of providing
this information [59 – 61]. Assessment of patients with
ureteropelvic junction obstruction with CTA for the
presence of crossing vessels can be helpful to deter-
mine whether endopyelotomy or pyeloplasty should
be performed and to help prevent procedure-related
complications [62]. In this particular setting, cysto-
scopic placement of a ureteral stent prior to CT can be
helpful in clearly defining the relationship of the
ureters to any crossing vessels [12].
Because the ultimate goal of imaging in each of
these clinical indications is the exquisite depiction of
vascular anatomy, a similar acquisition protocol can
be employed for each situation. The scan coverage
must include the entirety of both kidneys and inferi-
 L.C. Chow, G.D. Rubin / Radiol Clin N Am 40 (2002) 729–749
orly should encompass the bifurcation of the common
iliac artery such that accessory renal arteries origi-
nating from these vessels are completely imaged.
Because of the small diameter of the vessels of
interest, and their parallel or nearly parallel course
to the imaging plane, thin nominal section thickness
of 1 to 1.25 mm and overlapping reconstruction is
imperative. Additionally, as shown by Rubin et al in a
study where the sensitivities for the detection of
accessory renal arteries with MIPs and SSDs versus
axial images were 13% and 93%, respectively, 3D
reformations can improve the detection of accessory
renal arteries [60]. Whereas complete nonvisualiza-
tion of vascular anomalies using the approach out-
lined previously is unlikely, a systematic approach to
reviewing all the source and reconstructed images is
necessary in order to make a confident statement
regarding the presence or absence of such anomalies.
It is important that all vessels emanating from the
kidneys be traced back to their origin and, similarly,
all vessels arising from the abdominal aorta between
the SMA and the common iliac bifurcation should be
followed to their terminus. This evaluation process is
ideally performed at a workstation with the capability
of scrolling through images in a cine display mode.
In specific situations, additional acquisitions may
be indicated. For example, low-dose, precontrast
imaging of the kidneys can evaluate for calculi,
information that is particularly pertinent in the evalu-
ation of potential renal donors. An additional post-
contrast acquisition during nephrographic phase is
necessary when a thorough evaluation of the renal
parenchyma is desired.
Summary
CTA has become an important diagnostic tool in
the evaluation of vascular diseases in virtually all
parts of the body. Whereas CTA is able to provide
images depicting exquisite anatomic detail, careful
scanning technique and selection of scan parameters
are critical for high quality studies. The choices to be
made when prescribing a scan can seem daunting at
first, but if one applies the principles outlined pre-
viously, CTA can be a relatively easy, fast, and safe
diagnostic technique that is effective in the majority
of patients with vascular disease.
Acknowledgments
We acknowledge Laura Logan, Marc Sofilos, and
Linda Novello at the Stanford 3D Laboratory for
747
their efforts in generating the 3D images shown in
this manuscript.
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 Radiol Clin N Am 40 (2002) 751 – 771

CT for thromboembolic disease

Lacey Washington, MD*, Lawrence R. Goodman, MD,
Mary Beth Gonyo, MD
Department of Diagnostic Radiology, Medical College of Wisconsin, 9200 West Wisconsin Avenue,
Milwaukee, WI 53226-3596, USA

Pulmonary thromboembolism—more commonly
known as pulmonary embolism (PE) — and deep-
venous thrombosis (DVT) are different clinical
manifestations of a single disease entity, venous
thromboembolic disease. Pulmonary embolism is con-
sidered the ‘‘third most common acute cardiovascular
disease after ischemic heart disease and stroke’’
[1]. Unlike ischemic heart disease and stroke, how-
ever, venous thromboembolic disease has traditionally
been diagnosed with imaging techniques that have
limited sensitivity and specificity. Because it has been
difficult to make a diagnosis of venous thromboem-
bolic disease, understanding of its epidemiology and
natural history has been limited. The development of
helical computed tomographic pulmonary angiogra-
phy (CTPA) for PE has rapidly changed the workup of
patients with suspected thromboembolic disease,
while posing new treatment dilemmas.
The pathogenesis of venous thromboembolic dis-
ease begins with the development of DVT. DVT
usually arises in the deep-venous system of the lower
extremities. Risk factors for the development of DVT
include malignancy and other hypercoagulable states,
immobility, and venous injury.
DVT becomes a potentially life-threatening entity
when clots detach from their points of origin and
embolize to the lungs. Diagnosis of thromboembolic
disease, therefore, has two arms: the diagnosis of PE
and the diagnosis of DVT. Both are important, but it
can be argued that, in patients who have survived an
initial embolic event, the diagnosis of DVT is more
* Corresponding author.
E-mail address: lwash@mcw.edu (L. Washington).
important than the diagnosis of PE, as the next em-
bolus may have devastating consequences.
Diagnosis of the two entities historically has been
approached separately. The recent innovation, how-
ever, of delayed venous imaging (CT venography
[CTV]) after CTPA has resulted in the development
of a single diagnostic tool that can be used for a com-
plete evaluation of thromboembolic disease.
This article briefly reviews the range of diagnostic
tests other than CT that are used in evaluating pa-
tients with suspected thromboembolic disease. The
sensitivity and specificity of CTPA is compared with
other techniques. In addition, CTV is discussed. The
authors review the design of protocols for performing
CTPA and CTV. Findings of acute and chronic
thromboembolic disease are discussed as well as pit-
falls in interpretation.
Diagnostic tests other than CT
Diagnostic tests for PE
Chest radiography, the least invasive and lowest
risk diagnostic test used in imaging algorithms for
PE, is both nonspecific and insensitive for the diag-
nosis. The most common findings on chest radio-
graphs in patients with PE are atelectasis and small
pleural effusions. The more specific signs of PE,
the Westermark sign and the Hampton’s hump, are
not very specific, and they also are very insensitive.
Chest radiography is nevertheless usually the first
diagnostic test obtained, as it is a necessary adjunct to
ventilation-perfusion imaging and also may identify
unrelated causes of chest pain and shortness of

0033-8389/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 1 8 - 0
752 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771
breath, such as pneumothorax. It is the first imaging
test obtained at the authors’ institution in patients
with symptoms suggestive of PE.
Pulmonary arteriography is still considered the
gold standard diagnostic test for PE. It is, however,
time-consuming and invasive. Although it is asso-
ciated with some morbidity and mortality, there is
an exaggerated perception of moderate-to-high mor-
bidity and mortality with pulmonary angiography.
For this reason, it has been used less often than
most imaging algorithms would require [2,3]. It
should be noted that recent studies have called into
question the validity of arteriography as a gold
standard because of its unreliable evaluation of
subsegmental emboli [4]; nonetheless, it maintains
its position as a gold standard because anticoagula-
tion can be safely withheld in patients with negative
arteriograms [5].
Ventilation-perfusion imaging (lung scintigraphy
or V/Q scanning) was developed in response to the
need for a noninvasive test for pulmonary emboli. This
test has been validated in the multi-institutional Pro-
spective Investigation of Pulmonary Embolism Diag-
nosis (PIOPED) study [6]. When the findings on
ventilation-perfusion imaging fit into high-probability
or completely normal categories, then the study can
safely guide treatment. According to the PIOPED
data, a normal V/Q scan nearly excludes PE. Sim-
ilarly, in patients with clinical high probability for
PE, a high-probability V/Q scan has a 96% positive
predictive value for PE [6]. A large number of studies,
however, are rated as intermediate or low probability
for PE [7]. A recent meta-analysis concludes that
scintigraphy gives a definitive positive or negative
answer in only approximately 50% of patients [8].
Some studies show much lower rates of definitive
answers, including the PIOPED trial, in which only
27% of V/Q scans had near-normal/normal or high-
probability readings.
Diagnostic tests for DVT
Contrast venography of the lower extremities was
for many years the standard test for DVT. This tech-
nique had the advantage of completely imaging the
calf, thigh, and pelvic veins. Contrast venography,
however, is time-consuming and somewhat invasive,
irradiates the lower extremities and pelvis, and re-
quires the administration of intravenous contrast.
Lower-extremity ultrasound has largely supplanted
contrast venography in imaging the deep-venous sys-
tem of the thighs for thrombosis. Ultrasound, with a
sensitivity of 97%, is an excellent test in patients
with symptoms of DVT [9]. Unfortunately, because
the most important sonographic sign of DVT is the
noncompressibility of a venous segment, the test loses
sensitivity in patients with nonocclusive DVT, usually
those who are asymptomatic [10 – 12]. Sonography
shows DVT in 30% to 50% of patients with PE
[13,14], and in these patients, the test may safely
guide treatment even when there is no definitive diag-
nosis of PE; however, patients with negative sono-
graphy and indeterminate V/Q scan results require
additional evaluation.
Potential studies for PE and DVT
A serum assay, the D-dimer test, which evaluates
for breakdown products of cross-linked fibrin, is one
promising addition to the armamentarium of tests for
thromboembolic disease. This test detects thrombosis
and should therefore be positive in patients with PE,
DVT, or both. Unfortunately, there are many ver-
sions of the test, which vary from a good screening
test with strong negative predictive value for throm-
boembolic disease to more specific tests that are
probably less sensitive [15]. A version of the test
with a strong negative predictive value may become
an important step in the algorithm for assessing
outpatients and emergency room patients, helping
to reduce the number of patients who require addi-
tional testing. Some initial trials of these assays have
been performed, but larger studies are necessary.
Unfortunately, because these assays detect any
thrombosis, they are likely to be positive in most
trauma and post-surgical inpatients, and therefore
unlikely to be useful in excluding PE and DVT in
these patients.
MR venography is a test with excellent specificity
an sensitivity for DVT and with the capability of
imaging the pelvis. It is, however, expensive and
time-consuming and depends on equipment and a
level of expertise on the part of technologists and
interpreting physicians that may not always be read-
ily available. Additionally, the logistics of performing
a MR examination in a critically ill, monitored
patient may be prohibitive. MR imaging of the
pulmonary arteries can theoretically be performed
in conjunction with MR venography [16]; however,
MR imaging of the pulmonary arteries shares all the
drawbacks of MR venography and is not yet widely
clinically used or validated in large series. Some
studies (including some in animal models) suggest
that MR pulmonary arteriography is less sensitive
than CTPA for emboli, whereas others suggest that
newer MR techniques may be comparable to CT if
 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771
readers have sufficient experience with the tech-
niques [17 – 20].
CT for PE
History and development
In 1982, Sinner published the first report of CT
findings of PE [21]. Because of the extremely slow
scan speeds of CT scanners of the time, the primary use
of CT scans in that report was to improve the specific-
ity of concurrently performed lung perfusion scans.
Even with scan times of 2.5 minutes and 4.8 seconds
(on two different early CT scanners), however, CT was
able to visualize large pulmonary emboli directly as
nonenhancing regions in enhanced pulmonary arteries.
Whereas Sinner suggested that CT was a useful
adjunct to V/Q scans, the use of CT in this clinical
setting did not become popular over the course of the
next decade. This was partly a result of the stand-
ardized algorithm for the interpretation of V/Q scans
that was disseminated as a result of the PIOPED trial
and because the increased information acquired from
CT did not justify intravenous contrast administration
or increased expense and radiation dose.
The first milestone in the development of CTPA
occurred in 1992 when Remy-Jardin et al published
the first prospective randomized trial of helical CT to
evaluate for pulmonary emboli, not just as an
adjunct to V/Q scans, but as a competing diagnostic
technique [22]. The innovation that made this pos-
sible was the development of spiral or helical CT,
which enabled scanning of the central pulmonary
arteries in a single long breath hold (approximately
24 – 30 seconds).
A second breakthrough in the use of CT for
thromboembolic disease occurred in 1998, when
Loud et al published an article reporting that CT
could be used following CTPA to evaluate for DVT,
without administering any additional contrast [23].
This new technique is called ‘‘indirect’’ CT venog-
raphy. Before that publication, DVT had been fre-
quently suggested as an incidental finding on
abdominal and pelvic CT examinations, and ‘‘direct’’
CT venography using injections into the pedal veins
had been investigated [24]. With the introduction of
indirect CTV, however, CT became a single practical,
clinically available test for both DVT and PE.
Sensitivity and specificity
Despite many studies of the sensitivity and spe-
cificity of CT for the evaluation of pulmonary em-
753
boli, the subject remains controversial. Many studies
have reported sensitivities of helical CT for pulmo-
nary emboli in the range of 90% [25 – 30]. Occasion-
al studies, however, report much lower sensitivity
and specificity [31]. Usually these studies show a
decreased sensitivity for small subsegmental emboli
[27]. The overall clinical importance of these sub-
segmental emboli is controversial, and the prevalence
of isolated subsegmental emboli differs in various
studies, probably secondary to different patient pop-
ulations. In studies of large patient populations, iso-
lated subsegmental PEs seem to occur in less than
10% of patients [29,32,33].
Improvements in technology have brought about a
new clinical problem: the correct approach to isolated
subsegmental emboli. With newer, multidetector scan-
ners, small subsegmental emboli are easier to see.
Because some of these would have clearly been
undetected with previous imaging modalities, there
are no good historical data about the need to anti-
coagulate patients with isolated small emboli, in
particular those who have poor cardiopulmonary
reserve and who have no demonstrable lower extrem-
ity DVT.
Patients with good cardiopulmonary reserve and
indeterminate ventilation perfusion scans, who have
serial noninvasive negative studies of lower extrem-
ities for DVT, have clinically good outcomes [13,14].
Based on a recent meta-analysis, approximately 25%
of these patients can be assumed to have pulmonary
emboli [8]. It is therefore clear that in the absence of
DVT, patients with good cardiopulmonary reserve
tolerate subsegmental emboli. This result does not
apply to patients with a single negative lower extrem-
ity ultrasound [34].
A major cause of uncertainty over the sensitivity
and specificity of CTPA is the use of conventional
pulmonary arteriography as the gold standard. There
is a high rate of inter-reader disagreement for the
same small subsegmental vessels that are commonly
difficult to evaluate by CT [7,35,36]. In many studies,
interobserver agreement on subsegmental PE is not
much better than chance, yet angiography is the gold
standard to which CT is held accountable [4,33]. A
recent article in the Annals of Internal Medicine
concludes that large, prospective clinical trials are
needed to evaluate CT before it becomes a standard
part of a diagnostic algorithm [37]. The difficulty
with such large trials remains the problem of which
gold standard to use. The validity of pulmonary
arteriography has been challenged not only with
reference to inter-reader agreement, but also in ani-
mal models. In one study of PE, in an animal model,
truth was established by analyzing a methacrylate
754 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771
cast of pulmonary vessels and comparing the results
to both CT and angiography. CT was as sensitive as
angiography and had a comparable positive produc-
tive value [4].
At this time, a PIOPED II trial is being launched
in an attempt to meet the need for more large-scale
prospective studies of CTPA. In the meantime, sev-
eral small outcome studies show that patients with
negative CTPA who are not anticoagulated do not
experience significant morbidity and mortality from
subsequent PE [26,38 – 40].
Because CT venography is a newer technique,
there are fewer studies assessing its accuracy. Those
studies that have been published, however, show
moderately good interobserver agreement [41] with
good sensitivity and specificity when compared
with ultrasound [42 – 46]. A significant advantage of
CT venography, as compared with ultrasound, is
that the pelvic veins are also imaged. A recent MR
venography study shows a higher-than-previously-
suspected incidence of isolated pelvic vein throm-
bosis, suggesting that imaging these veins may have a
significant impact on patient care [47].
Diagnostic algorithm
At the authors’ institution, the following algo-
rithm is used in evaluating patients for suspected
thromboembolic disease. First, those patients who
present with signs and symptoms of DVT alone (with
no clinical suspicion of PE) undergo ultrasound
imaging because of the high sensitivity of lower
extremity ultrasound in this patient population.
Patients who present with signs and symptoms
suggestive of PE initially undergo chest radiography.
Those with normal chest radiographs undergo V/Q
scans. Patients with a normal chest radiograph are
more likely to have a definitive V/Q scan result (ie,
normal, very low probability, or high probability)
[48,49]. Patients with abnormal chest radiographs
have CT scans, which include evaluation both of the
pulmonary arteries and of the lower extremity veins.
Patients who have nondiagnostic results from
either the V/Q scan or the CT scan may be referred
for further testing as indicated. For example, if en-
hancement of the lower extremity veins is less than
optimal, and the clinical scenario suggests the pos-
sibility of DVT, or if there is significant mixing
artifact on the CT and the presence of DVT is ques-
tioned, the patient is referred for ultrasound. Patients
may undergo pulmonary arteriography in cases in
which poor pulmonary arterial enhancement or severe
motion artifact render CTPA nondiagnostic.
CT technique
CT for PE
The development of spiral CT was the technologic
breakthrough that allowed for CT arteriography,
including CT pulmonary arteriography. One of the
difficulties with evaluating studies of the sensitivity
and specificity of helical CT for pulmonary emboli
has been the rapid evolution of CT scanners with
increasingly short scan times, particularly since the
development of multidetector CT. This also makes it
difficult to comment on some aspects of protocol
design, because the technology changes by the time a
study is published. Multiple technical factors other
than scan speed, however, are also important in
designing a protocol for CTPA.
Scanning parameters
The portion of the lungs that can be imaged in a
reasonable breath hold depends on the speed of the CT
scanner. Earliest protocols were designed with scanner
speeds that only allowed imaging from the inferior
pulmonary veins to the aortic arch. More recent
protocols with faster single-detector and with multi-
detector CT scanners usually image from an area at the
level of the lower hemidiaphragm to the top of the
aortic arch. The apices and the bases are usually scan-
ned in a delayed fashion so that the lungs are com-
pletely imaged.
Although not all investigators agree, the authors
believe that caudal-to-cranial scanning improves the
quality of many studies. Respiratory motion image
degradation is usually most severe at the lung bases
and least severe at the apices. It is, therefore, desir-
able to image the lower lung early in the breath
hold, to minimize motion artifact. Occasionally, use
of nasal cannula oxygen may help to reduce mo-
tion artifact.
Theoretically, patients undergoing mechanical ven-
tilation can be held in apnea with chemical paralysis.
If this is performed, respiration should ideally be
suspended at high lung volumes, to increase pulmo-
nary resistance and improve opacification [50]. At the
authors’ institution, mechanical ventilation is almost
never suspended. Instead, patients on mechanical ven-
tilation and patients with severe dyspnea are imaged
during quiet respiration. Dyspneic patients are in-
structed to breathe as quietly as possible. Mechanical
ventilators are set to minimal tidal volume and rate for
the duration of the scan.
In general, thinner collimation CT yields better
depiction of peripheral vessels and greater sensitivity
for small subsegmental pulmonary emboli. The first
 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771 755

CTPA studies, which were performed on early single-
detector scanners, used 5-mm collimation with a pitch
of 1:1 and overlapping reconstructions at 3-mm inter-
vals [22, 27]. With newer single-detector scanners,
images with 3-mm collimation can easily be obtained
and reconstructed at 1.5-mm intervals [51]. On multi-
detector scanners, subsecond images can be obtained
with 1.25-mm collimation or less. This results in
better depiction of subsegmental vessels and beyond
[52] and diminishes motion artifacts [53]. The excep-
tion for single-detector scanners is with larger
patients, in whom decreasing the slice thickness may
yield unacceptable amounts of image noise; on multi-
detector scanners, the images can sometimes be retro-
spectively combined to provide for thicker sections if
there is excessive noise on initially acquired thin-
section images.
If the pitch is increased from 1 to 1.7 on single-
detector scanners, the image volume can be increased
within an acceptable breath-hold time. On the authors’
four-slice multidetector scanner, a pitch of 6 is used.
Decreasing scan times also allows for imaging of
larger volumes of the lungs within reasonable breath-
hold times.
Electron-beam scanners, which are relatively un-
commonly used, nevertheless can markedly increase
the speed of image acquisition and may consequently
improve the quality of CT pulmonary arteriography.

Fig. 1. Paddle-wheel reformations. (A) Scout film showing ‘‘batch rotation’’ or ‘‘paddle-wheel’’ multiplanar reformation with the
axis centered on the right pulmonary artery. (B,C) This results in images that lay out the arteries in longitudinal sections (arrows).
Occasionally, these reformations may help to separate perihilar lymphatic tissue (curved arrow) from mural thrombus (open arrow).
756 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771
Fig. 1 (continued).
Timing of imaging
At many institutions, fixed scan delays are found to
be adequate, with only a minority of patients having
poorly enhanced pulmonary arteries if imaging
is obtained at a delay of, for example, 28 seconds
from the start of contrast administration [54]. The
authors have found, however, that there are fewer
nondiagnostic studies when the timing of imaging
is tailored to the particular patient. Two approaches
may be used: a preliminary time-density curve or
bolus-tracking software such as SmartPrep (GE Med-
ical Systems, Waukegha, WI) or CareBolus (Siemens).
If a time-density curve is used, unenhanced images are
initially obtained to locate the pulmonary arteries, and
10 low-dose images are then obtained over the main
pulmonary artery during the injection of 18 ml of
contrast material. The time delay for the diagnostic
study is calculated using the time to peak enhancement
plus 5 seconds. With bolus-tracking software, initial
unenhanced scans are also obtained to locate the main
pulmonary artery. Contrast is then injected and low-
dose images are obtained over the pulmonary artery
until contrast appears, at which time diagnostic imag-
ing is initiated.
If a fixed delay is used, it is helpful to increase the
delay in patients who are thought to have cardiac
dysfunction, pulmonary arterial hypertension, or cen-
tral venous stenoses.
Contrast material
Nonionic intravenous contrast is almost exclu-
sively used for CTPA. Early in the experience of
CTPA, some authors recommended using low concen-
trations of contrast at high flow rates in order to reduce
streak artifact from high contrast density in the super-
ior vena cava [22]; however, the authors of this article
have not found this artifact to be particularly prob-
lematic. At the authors’ institution, 120 to 140 ml of
nonionic contrast (Omnipaque [iohexol] 300 mgI/ml)
is injected at 4 ml/second. Protocols ranging from
injection rates of 2 ml/second to 5 ml/second have
been advocated [54]; whereas with faster scanners,
smaller quantities of intravenous contrast may ade-
quately opacify the pulmonary arteries, at least 100 ml,
and probably 120 ml, must be administered to achieve
adequate enhancement of the lower extremity veins for
CT venography.
CT venography
Technique
As with CT pulmonary arteriography, many pro-
tocols have been used to image the lower extremity
veins. Some investigators advocate continuous helical
imaging from the level of the renal veins to the level
of the popliteal fossae [42]. Loud and colleagues,
who performed the first studies of CTV, obtain non-
contiguous axial images at 5-cm intervals [55].
The authors find that continuous helical imaging
creates artifacts in the pelvis secondary to the
obliquity of the iliac veins, which make these images
more difficult to read. For this reason, the authors
compromise between contiguous images and the
5-cm intervals of Loud et al. At this time, the
 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771 757

Fig. 2. Partial filling defects as a sign of pulmonary embolus. Low-attenuation clot is surrounded by contrast in several
subsegmental pulmonary arteries in the right upper lobe (arrows).

authors obtain 5-mm – thick axial CT images at 2-cm
intervals from the level of the iliac crests to the level
of the popliteal fossae.
Initial studies of indirect CT venography were per-
formed with imaging 3.5 or 3 minutes after the
initiation of contrast administration [23,45,46,55,56];
some authors advocate earlier imaging [57,58], where-
as others suggest that a delay of 4 minutes may be
preferable, at least in patients with suspected abnor-
mal hemodynamics or slow flow [45]. Timing for
CTV appears to be much less crucial than for CTPA.
The authors’ article in the Journal of Thoracic
Imaging discusses details of the normal anatomy of
the pelvic and lower extremity veins, as well as the
findings of DVT and pitfalls in interpretation of these
studies [59].

Fig. 3. Complete filling defect as a sign of pulmonary embolus. The artery to the anterior basal segment of the right lower lobe is
completely unopacified and filled with clot (arrow). There is good opacification of adjacent pulmonary arteries. (Clot also is seen
in a small subsegmental artery in the lingula [small arrow], and there is a small nodule in the anterior segment of the right lower
lobe. There also is a right rib metastasis.)
758 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771

Fig. 4. Complete filling defect in a right middle lobe artery with distention; ‘‘railroad track sign’’ in a lingular artery. The right
middle-lobe subsegmental artery (open arrow) appears larger than other vessels of a similar generation. On the left, linear
collections of contrast are seen on either side of a clot in an obliquely coursing vessel, appearing similar to a ‘‘railroad track.’’

Image viewing seldom necessary to resort to the multiplanar refor-

mations in actual practice. One group has advocated
The large number of images generated by CTPA
and CTV is most easily evaluated on a workstation; at
institutions that are filmless, all images can easily be
stored and recalled from a Picture Archiving and
Communications System (PACS). As discussed later,
the authors believe that workstation review is essen-
tial for accurate interpretation of these studies. At
the authors’ institution, every CTPA-CTV study is
reviewed on a workstation, but in addition, selected
images are filmed (every third image) at both lung
and mediastinal windows. If only small clots are
found, selected magnified demonstration images are
filmed as a record.
Despite the presence of a film record, the authors
find that when repeat imaging is performed in the
same patient to evaluate for resolution of previously
seen emboli or for development of new emboli, it
is most convenient to restore the original archived
study to the workstation and page through both stud-
ies side-by-side.

Post-processing techniques

Multiplanar reformations occasionally can be

used to clarify diagnoses on PE studies. This is most
commonly done when it is difficult to separate
perihilar lymphatic soft tissue from mural thrombus
or wall thickening in chronic PE. In the authors’
experience, although this is of theoretic utility, it is
Fig. 5. Acute embolus in larger pulmonary arteries. Clot
within two large caliber right lower lobe pulmonary arteries
appears as mural filling defects adherent to the vessel wall.
Note that in both vessels there is an acute angle between the
embolus and the vessel wall (arrows).
 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771 759

use of a ‘‘paddle-wheel’’ reformation technique,
which allows visualization of all the vessels in the
plane of section [60]; similarly, this is only occasion-
ally useful (Fig. 1).
CT findings
Acute PE
The fundamentals of CT visualization of pulmo-
nary emboli have not changed significantly since the
original descriptions appeared in articles by Sinner
and Remy Jardin et al [21,22]. Partial or complete
filling defects in pulmonary arteries may represent
acute pulmonary emboli; the emboli also may be seen
with a ‘‘railway track sign’’ or as mural defects.
A partial filling defect is a clot seen in the center
of a vessel surrounded by contrast (Fig. 2). When the
entire artery fails to opacify because of a central clot,
this is a ‘‘complete’’ filling defect. When completely
filled vessels are seen in the setting of acute PE, they
may be distended and often appear larger than vessels
of the same generation that are free of emboli. A
‘‘railway track sign’’ is a clot floating within a vessel,
surrounded by contrast (Figs. 3, 4). Mural defects are

Fig. 6. Pulmonary ‘‘infarct.’’ (A) A wedge-shaped area of ground-glass attenuation abuts the pleural surface (short arrows).
There is adjacent subsegmental atelectasis. (B) An embolus is seen in a more proximal subsegmental artery supplying this
portion of the lung (arrow).
760 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771

clots that adhere to the wall of the vessel. In larger
vessels, acute mural emboli commonly make acute
angles with the vessel walls (Fig. 5).
Secondary signs in acute pulmonary emboli
include visualization of the CT equivalent of a
Hampton’s hump, the pulmonary ‘‘infarct’’ (Fig. 6).
These represent areas of hemorrhage, frequently
without true tissue necrosis [61]. These wedge-
shaped peripheral opacities are the only parenchymal
signs in one recent series that are significantly asso-
ciated with PE, and seen in only a minority (7 of 28)
of patients [62]. Nonspecific findings in patients
with PE include atelectasis and pleural effusions;
these are commonly seen both in patients with and
without PE.
Artifacts and pitfalls
Multiple artifacts that could be confused with
emboli have been described. To help avoid confusion,
it is best to look for sharply demarcated areas of low
attenuation in vessels, and to diagnose emboli only
when these are seen on more than one sequential
image. (Acute emboli, at least, are unlikely to be so
small that they will be seen in cross section for a
distance of only 1 to 3 mm.) Additionally, many areas

Fig. 7. Mucoid impaction. (A) The mucus-filled bronchi are similar in appearance to thrombus-filled arteries when viewed at
soft-tissue window settings. (B) On lung window settings, it is clearer that they are the bronchi, running in parallel with the
arteries; no aerated bronchi are identified.
 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771 761

of confusion can be easily avoided by reviewing
scans on a workstation.
Anatomic pitfalls
Many anatomic causes of confusion are pre-
vented by the use of a workstation to review studies.
At least a minimal understanding of pulmonary
arterial anatomy is necessary in order to interpret
studies. There are many variants of pulmonary
arterial anatomy, and naming vessels is frequently
confusing. It helps to remember that an artery is
usually named according to the segmental bronchus
it accompanies. Pulmonary veins run independent of
the bronchi. A more complete discussion of pul-
monary arterial anatomy as identified on CT is
found in the literature [63 – 66].
If imaging is obtained early in the contrast bolus,
unopacified pulmonary veins can be confused with
arteries containing PE. This mistake can easily be
avoided by workstation review, which allows the
reader to trace vessels back either to their origins at
the pulmonary arteries or to their terminations at the
left atrium. It also is helpful to remember that, in
the lower lobes, pulmonary arteries are peripheral to

Fig. 8. ‘‘Fractured bolus.’’ (A) At the lung bases, the arteries are poorly enhanced (arrows); however, there is contrast in the
pulmonary veins and in the left ventricle, indicating that imaging is not too early. (Note incidental pericardial effusion.) (B) It is
possible based on the findings in Fig. 8A that the imaging is performed too late; however, the arteries at the lung apices, imaged
later, are well opacified (curved arrows). (Incidental intrafissural pleural fluid is noted on the left.)
762 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771
the accompanying bronchi, whereas veins are central.
In the upper lobes, the arteries run central to the cor-
responding bronchi.
Another misinterpretation that can be avoided by
the use of workstation review is mistaking mucoid
impaction of a bronchus for a PE. Mucoid impaction
of the bronchus causes central lower attenuation with
peripheral higher attenuation, which on a single
image can look very much like a PE. Following the
bronchi to a section on which they appear aerated
helps make this distinction, in particular while chan-
ging to lung window settings (Fig. 7). Hilar lymph
nodes can also potentially be mistaken for emboli.
Again, workstation review helps avoid this interpret-
ive pitfall, as lymph nodes will not extend into
longitudinal vessels.
Imaging artifacts
The most common imaging artifacts that may be
mistaken for emboli are streak artifacts or motion
artifacts. Streak artifacts often arise from dense con-
trast opacification of the superior vena cava or may
arise from calcified nodes or metallic surgical clips.
They can cause focal areas of low attenuation in the
vessel. Streak artifacts are seldom sufficiently well-
defined to truly cause confusion with emboli and
usually continue beyond the vessel.
Motion artifacts, on the other hand, can cause
very convincing pseudo emboli. Partial volume
averaging of the lung surrounding vessels occurs
because of motion, causing an apparent embolus.
Fig. 9. Calcification in chronic pulmonary embolism. Calcification is seen in chronic mural emboli in the right and left interlobar
arteries (arrows).
The easiest way to avoid this confusion is to evalu-
ate scans on a workstation and switch window and
level settings from the soft-tissue windows used to
evaluate for pulmonary emboli to lung windows.
Motion artifacts are much more easily seen at lung
window settings. Additionally, workstation review
enables the reader to see that the vessel changes
position rapidly from one section to another, con-
firming that there is motion. The area most prone to
motion artifact is the portion of the left lower lobe
immediately behind the heart that receives transmit-
ted cardiac pulsations.
Other pitfalls
It is important to avoid interpreting poor
enhancement of vessels as emboli. This is usually
easy to avoid, as the degree of enhancement is
generally uniform throughout the images, or may
perhaps be uniformly low in the earliest images or
the latest images, suggesting imaging either too
early or too late in the contrast bolus. Recently, a
new artifact has been described, most commonly
seen in young patients. This is caused by rapid
inspiration, which causes marked negative intra-
thoracic pressures and an influx of unopacified
blood from the inferior vena cava to dilute the
contrast bolus [67]. This is particularly confusing
as the vessels are well enhanced more proximally,
and there may be good pulmonary venous enhance-
ment, indicating that the timing of imaging is
adequate. This is probably the cause of areas of
 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771 763

Fig. 10. Chronic PE. Mural thrombus in the right interlobar artery, making obtuse margins with the vessel wall (arrow). This
patient with known chronic pulmonary embolism presented with acute chest pain. No acute emboli are seen; however, a
pericardial effusion is identified.

poor enhancement when multiple vessels at the same
level appear inadequately enhanced to the same
degree (Fig. 8).
Another potential cause of confusion is the partial
volume averaging that occurs at vascular bifurcations
or in small vessels seen in the axial plane. Identifica-
tion that a low-attenuation region is at a vascular
bifurcation and does not continue on more than one
or two images helps to prevent misinterpretation of
these as pulmonary emboli. The ‘‘paddle-wheel’’ re-
constructions may be helpful in distinguishing these
from emboli.

Fig. 11. Vascular webs in chronic pulmonary embolism. There are linear low-attenuation structures in the right interlobar artery
and the artery to the medial segment of the right middle lobe.
764 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771

Chronic PE: findings
The most specific finding for chronic pulmonary
emboli is demonstration of calcification within a clot
(Fig. 9). This finding is insensitive, however, and
other findings (as well as clinical history) may be
more helpful in making this diagnosis. The clots of
chronic emboli are usually eccentric and contiguous
with the vessel wall (Fig. 10). The relationship of clot
to the vessel wall is easier to assess in large, central
vessels than in smaller vessels. Chronic mural emboli
tend to make obtuse angles with vessel walls (unlike
the acute angles commonly seen in acute mural PE).
Vascular webs can also be seen (Fig. 11). Areas of
stenosis may be evident, appearing as enhancing
vessels that are significantly smaller than the adjacent
bronchus and other vessels of a similar generation;
this finding alone is not diagnostic of chronic PE but
may be an adjunctive sign when other findings are
present. Abrupt cutoff of the contrast column in a
vessel may be seen. Vessels containing chronic
emboli are apt to be smaller than uninvolved vessels
of the same order, in contrast to the enlarged ves-
sels frequently seen with acute pulmonary emboli
(Fig. 12). Occasionally in the authors’ practice, find-
ings that suggest that a clot is ‘‘chronic’’ lead to

Fig. 12. Chronic pulmonary embolism. (A) The artery to the superior segment of the right lower lobe is diminutive, with a small
amount of mural thrombus (curved arrow). (B) Three years earlier, at the time of the patient’s acute pulmonary embolism to this
region, the artery appears normal in caliber, but filled with clot (straight arrow).
 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771 765

Fig. 13. Dilated bronchial arteries. Contrast-enhanced vessels along the margins of the right and left-main-stem bronchi (arrows)
are dilated bronchial arteries, which are often seen in patients with chronic pulmonary embolism. (There is incidental severe
coronary artery calcification.)

retrospective discovery of acute embolus on earlier
studies performed for other indications.
Dilation of the main pulmonary arteries is seen in
pulmonary arterial hypertension, including that
caused by chronic pulmonary emboli. There may be
prominent bronchial collateral arteries (Fig. 13). Mo-
saic attenuation in the lungs is frequently seen in
chronic pulmonary emboli (Fig. 14). The distinction
of mosaic attenuation from ground-glass opacity is
that vessels in the denser areas of the lung are larger
than in the low-attenuation (hypoperfused) areas.
This finding is not specific for chronic PE and also

Fig. 14. Mosaic perfusion in chronic pulmonary embolism. There are areas of higher and lower attenuation in the lungs at lung
window settings. Vessels in the high attenuation regions (straight arrows) are much larger than those in the lower attenuation
regions (curved arrows), indicating that the difference in attenuation is secondary to differences in perfusion.
766 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771

Fig. 15. Subpleural scar in chronic pulmonary embolism. A small subpleural triangular area of consolidation along the pleural
surface in the right lower lobe (arrow) is seen in a patient with known chronic pulmonary embolism.

is seen in small airways disease and in other causes of Findings of DVT

pulmonary arterial hypertension. Expiratory images
may distinguish small airways disease from diseases
with vascular obstruction. Small sub-pleural areas of
scar, which are probably sequelae of old areas of in-
farction, are also common in patients with chronic
PE (Fig. 15).
As with PE, DVT is directly visualized with CT
as an area of low density in an otherwise well-
enhanced vein. This may be a focal or partial filling
defect (Fig. 16) or the vein may be completely filled
with clot (Fig. 17). As with acute pulmonary emboli,

Fig. 16. Partial filling defect as a sign of deep-venous thrombosis. There is a focal area of low attenuation in the right popliteal vein
(curved arrow). The surrounding portion of the vein is well enhanced. Compare with normal left popliteal vein (straight arrow).
 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771 767

Fig. 17. Complete filling defect as a sign of deep-venous thrombosis. The right popliteal vein is completely filled with clot
(arrow). The vein appears enlarged in comparison with the left side, there is enhancement of the wall, and there is stranding in
the fat around the vein indicating perivenous edema.

when a vein is completely filled with thrombus, the
vessel is usually enlarged. There may be enhance-
ment of the wall. Small amounts of stranding in the
fat around the vein may be seen, caused by perive-
nous edema.
In patients with chronic DVT, the vein is usually
smaller than the accompanying artery, in contrast to the
normal state and to the distension seen with acute DVT.
There may be prominent collateral veins (Fig. 18).
Calcification of the vein may be seen (Fig. 19).

Fig. 18. Chronic deep-venous thrombosis. The left superficial femoral vein (open arrow) is smaller than the accompanying artery
and smaller than the right superficial femoral vein (curved arrow), a finding of chronic deep-venous thrombosis. There are
multiple dilated superficial collateral vessels in the left leg (straight arrows).
768 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771

Fig. 19. Calcification in chronic deep-venous thrombosis (DVT). The superficial veins are small bilaterally, suggesting chronic
DVT. On both sides, there is typical, peripheral arterial calcification (arrows). On the left, there is also a larger, round
calcification in the expected location of the superficial femoral vein, as is occasionally seen in chronic DVT (curved arrow).

Artifacts that may be seen in CTV are similar to
those seen in CTPA and include mixing artifacts and
streak artifacts (Fig. 20).
In patients in whom part of the reason for a PE
workup is symptomatology in the lower extremities,
incidental findings occasionally may be seen that
explain lower extremity pain or swelling. For example,
knee joint effusions or Baker’s cysts are sometimes
identified as well as muscle hematomas, fractures, and
venous aneurysms. In the authors’ practice, other
incidental findings include ruptured abdominal aortic
aneurysms and pelvic and abdominal tumors.

Fig. 20. Streak artifact. There is low attenuation in the right superficial femoral vein (arrow) arising from calcification in the right
superficial femoral artery. There also is mild motion artifact.
 L. Washington et al / Radiol Clin N Am 40 (2002) 751–771
Summary
CTPA has dramatically changed the diagnostic ap-
proach to PE in the last decade. The addition of CTV
has created a single diagnostic test that can evaluate
for both important components of venous thromboem-
bolic disease. Newer, multislice scanners will provide
thinner images and more complete anatomic cov-
erage. Shorter scan times will minimize motion arti-
facts. These improvements may continue to improve
the diagnostic yield of CTPA.
The availability of an accurate noninvasive diag-
nostic tool to evaluate for PE and DVT should lead to
a better understanding of the wide range of presenta-
tions of thromboembolic disease. The next decade
may produce improvements in understanding of the
epidemiology of PE and perhaps to a more tailored
approach to treatment for thromboembolic disease.
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 Radiol Clin N Am 40 (2002) 773 – 782
Assessment of coronary arteries with CT
Christoph R. Becker, MD
Department of Clinical Radiology, Ludwig-Maximilian-University of Munich, Klinikum Grosshadern,
Marchioninistrasse 15, 81377 Munich, Germany
This article is designed to provide the reader
information about the technical details of retrospec-
tive ECG-gated spiral 4SCT and its applications for
the detection and quantification of coronary artery
calcification, the detection of coronary artery steno-
ses, and the characterization of coronary atherosclero-
tic plaques.
Multidetector-row computed tomography (CT) is
the most recent development of third-generation
rotational CT scanners. The detector configuration
of most commercially available CT scanners currently
allows acquisition of four slices in a single gantry
rotation (4SCT). Combining this technology with
continuous gantry rotation and table feed results in
reduced scan time, greater scan coverage, and im-
proved spatial resolution.
The advantage of 4SCT acquisition has become
apparent for many different applications. Musculo-
skeletal investigations benefit most from improved
z-axis resolution by reconstruction of near isotropic
images in any projectional plane. The ability to per-
form a study of the abdominal aorta, and the iliac,
femoral, and crural arteries in a single acquisition
now can be achieved with 4SCT [1]. Imaging vessel
territories, such as the carotid, mesenteric, and renal
arteries, with high spatial resolution also provides
new diagnostic opportunities [2].
Investigation of the coronary arteries is a major
challenge for CT because of the small tortuous
vessels, which are subjected to continuous cardiac
movement. The overall reduction in scan and expo-
sure time with 4SCT now allows coverage of the
entire heart and coronary artery tree in the slow mo-
E-mail address: christoph.becker@ikra.med.
uni-muenchen.de (C.R. Becker).
0033-8389/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 1 5 - 5
tion phase with thin slices and within a reasonable
acquisition time.
This article is designed to provide the reader
information about the technical details of retrospec-
tive electrocardiogram (ECG)-gated spiral 4SCT and
its applications for the detection and quantification of
coronary artery calcification, the detection of cor-
onary artery stenoses, and the characterization of
coronary atherosclerotic plaques.
Electron-beam tomography
Electron-beam computed tomography (EBCT)
was developed in the mid-1980s and was the first
dedicated cardiac CT scanner designed to evaluate
myocardial perfusion [3] and cine imaging of the
ventricles [4]. With EBCT, electrons are accelerated
in a vacuum funnel and focused on four 210-tungsten
target rings underneath the patient. Emitted x-rays
pass through the patient and are detected by two 240°
detector rings above the patient. The technique avoids
any moving components and allows for scanning at
eight levels, with an exposure time of 50 milliseconds
per slice acquisition.
Morphological assessment of cardiac structures be-
came possible with EBCT by prospective ECG-trig-
gered slice-by-slice acquisition with 100 milliseconds
temporal resolution. To predict the mid-diastolic phase
of the next cardiac interval, prospective ECG trigger-
ing estimates the next cardiac interval based on the
median of the last seven cardiac intervals. Prospective
ECG triggering, however, is of limited use in patients
with arrhythmias and is also affected by the physio-
logic changes that may occur to the heart rate during a
breath hold [5].
774 C.R. Becker / Radiol Clin N Am 40 (2002) 773–782
Retrospective multislice ECG gating
Cardiac studies with 4SCT utilize a technique
called retrospective ECG gating: raw data are
acquired in the conventional spiral acquisition mode,
using a constant table-feed speed while simultane-
ously recording the ECG. The table – feed speed is
slow compared to routine spiral CT to allow for an
over-sampling of image data. On the basis of the
recorded ECG, only the data acquired during diastole
are used for image reconstruction. To further improve
temporal resolution, special postprocessing recon-
struction algorithms are used, and the fan beam angle
is reduced to a minimum to reduce the exposure time
to about 250 milliseconds [6].
Reconstruction methods have also been used to
further decrease the exposure time in retrospective
ECG-gated 4SCT. With the ‘‘multisector’’ approach,
the x-ray projections of more than one heartbeat are
used to reconstruct the images [7]. The more heart-
beats taken into account, the shorter the exposure
time. The disadvantage of this technique is that the
over-sampling rate must be increased, resulting in a
slower table feed and more radiation exposure for the
patient. In addition, the exposure time is no longer
constant, but changes with the gantry rotation time
and the heart rate of the patient. Because of the
inherent variability in the heart rate, motion artifacts
commonly degrade the image quality. Optimal scan
results, therefore, are best achieved with a reconstruc-
tion algorithm that uses the shortest gantry rotation
time and a single heart beat. In general, the slower the
heart rate, the better the image quality with 4SCT.
With the currently available 250-millisecond expo-
sure time, diagnostic image quality can be achieved
in patients with a heart rate of 60 beats per minute or
less [8]. To achieve this heart rate on a regular basis,
patient preparation with a beta-blocker (ie, 50 –
100 mg metoprolol orally one hour prior to the exam)
may become necessary.
Radiation dose
With retrospective ECG gating techniques, the
amount of radiation administered to the patient
becomes a concern. New techniques are being
developed to reduce the amount of redundant radia-
tion. In a patient with normal sinus rhythm, the x-ray
tube current can be modulated to a nominal and
minimal value in diastole and systole, respectively.
The image quality and signal-to-noise ratio in dia-
stole remains at a constant level, and the radiation
exposure can be reduced by 50%. [9]. Further
reduction of radiation to the patient is possible by
using the appropriate x-ray tube voltage. The absorp-
tion, and therefore the sensitivity, for the detection of
calcium is higher at 80 kV when compared to
images acquired at 120 kV [10]. Using a setting of
80 kV, radiation can be decreased by 70%, when
compared to a setting of 120 kV, for a given tube
current (mAs).
In summary, the radiation exposure to a patient
undergoing a coronary calcium screening scan with
4SCT is in the range of a conventional fluoroscopy
study (0.5 mSv), whereas the radiation exposure as-
sociated with a coronary CT angiogram is in the range
of a catheter-based coronary angiogram (4 – 5 mSv).
Coronary calcium screening
Coronary artery calcifications, such as plates of
calcium, are usually associated with the advanced
type of atherosclerosis associated with type VII
fibrocalcified lesions [11]. Other causes for coronary
calcifications, such as Mönckeberg calcific medial
sclerosis and hypervitaminosis D, are rarely seen
[12]. The ability to reliably quantify the amount of
calcium and characterize the morphology of plaque
will become more important as medical therapy is
shown to alter the natural history of plaque progres-
sion. Indeed, in a study using a rhesus monkey
model, therapeutic reduction of high levels of blood
cholesterol led to a reduction in extracelluar lipid
from advanced atherosclerotic lesions, although cal-
cium deposits remained in the arterial wall [13].
EBCT has been shown to be more sensitive than
fluoroscopy in the detection of coronary artery calci-
fications [14]. The question remains, however,
whether or not the presence of coronary artery
calcium detected with CT accurately predicts the
presence of significant coronary artery disease
(CAD). In a study that directly compared EBCT
calcium morphology with the findings on coronary
angiography, Kajinami et al found a positive predic-
tive value of 0.04 and 0.56 for spotty and diffuse
calcifications, respectively [15].
Coronary artery calcium is often present in
patients without symptoms. Whether the deposition
of calcium represents a preclinical stage of CAD or
whether coronary calcium in asymptomatic patients
has a predictive value for future cardiac events
(myocardial infarction or death) independent of the
other conventional cardiovascular risk factors, is not
clearly defined at this time. Three major trials [16 –
18] have been established to address this question and
are currently in the process of enrolling 12,000
 C.R. Becker / Radiol Clin N Am 40 (2002) 773–782 775

Table 1
Guidelines for quantification of coronary calcium in asymptomatic patients, accounting for age and gender
Mass mg CaHA Gender age Atherosclerotic burden CAD CV risk Recommendation
1 0 No Unlikely Very low Reassure patient
2 <5 M > 45 Minimal Minimal Low CV risk modification, ASS,
F > 55 LDL < 160 mg/dL
3 < 20 M > 55 Mild Low Moderate CV risk modification, ASS,
F > 65 LDL < 130 mg/dL
4 < 80 M > 65 Moderate High High CV risk modification, ASS,
LDL < 100 mg/dL, stress testing
5 >80 Extensive Stenoses Very high CV risk modification, ASS,
LDL < 100 mg/dl, stress testing,
invasive investigation
Patients presenting with too much calcium for age and gender are assigned the next higher CV risk group. ASS = aspirin, LDL =
low density lipoprotein, CV = cardiovascular.

patients with the hopes of delivering definite results
within the next five years.
As definite beneficial outcomes data for coronary
calcium screening and the methodology for inter-
preting such studies on asymptomatic and symp-
tomatic patients are currently lacking, many cardiac
screening centers are following the recommendations
of Rumberger et al (Table 1) [19]. Once objective
quantification of calcium in the coronary arteries of
asymptomatic patients is performed, patients are
stratified into cardiovascular risk groups. Diagnostic
and therapeutic algorithms for these patients are
recommended based on the cardiovascular risk group
assignment. In addition, according to the current
American Heart Association guidelines, screening pa-
tients with typical symptoms of angina for coronary
artery calcium is not recommended [20]. Screening
for coronary calcium, however, may be helpful in
excluding significant CAD in patients who present to
an emergency department with atypical chest pain
[21 – 25].
The quantification of coronary calcium with
EBCT is performed according to the method sug-
gested by Agatston et al [26]. This method, however,
is specific to EBCT and the acquisition parameters
for EBCT. Determination of the mass of coronary
calcium is an independent quantification method for
all cardiac CT scanners. Similar to bone densitom-
etry, coronary calcium mass is measured in milli-
grams of calcium hydroxyapatite (CaHA). The
volume (area  slice increment) and the density
(HU) of the identified calcified coronary lesions are
multiplied by a calibration factor. Calibration phan-
toms exist to determine the calibration factor for
each CT scanner and protocol. Using these specifi-
cations, the amount of calcium can be compared
from CT scanner to CT scanner, even with different
scan protocols [27].
With 4SCT, the sensitivity for the detection of
calcium is at least 1 mg of CaHA. In patients with
extensive coronary artery calcifications, the amount
of calcium may exceed 1000 mg or more of CaHA.

Table 2
Summary of contrast-enhanced CT studies for the detection of significant coronary-artery stenoses compared to conventional
coronary angiography
Author Journal Year Modality # Patients % excl. Segm. Accuracy NPV
Nakanishi JCAT 1997 EBCT 37 0 92 93
Achenbach NEJM 1998 EBCT 125 25 93 94
Schmermund AJC 1998 EBCT 28 28 87 96
Reddy Radiology 1998 EBCT 23 7 81 93
Budoff AJC 1999 EBCT 52 11 87 91
Niemann Lancet 2001 4SCT 35 30 95 97
Achenbach Circulation 2001 4SCT 64 32 86 98
Mean 19 89 95
Note the significant number of segments that were excluded from the evaluation process and the high negative predictive
value (NPV)
776 C.R. Becker / Radiol Clin N Am 40 (2002) 773–782

The Agatston score is approximately five times
higher than the mass of calcification [27] and, there-
fore, allows for cross-conversion of EBCT and 4SCT
calcium scores.
Coronary screening may also be used to follow
the progression of coronary atherosclerosis during
medical therapy [20]. Current literature indicates that
slower progression of atherosclerotic disease with
aggressive antilipid therapy may be observed when
compared to a patient population receiving no anti-
lipid therapy [28]. The question remains, however:
Does following the progression of coronary calcium
allow optimization of therapy and reduce cardiac
morbidity in patients identified to be at increased risk
for a cardiovascular event [29]?
The interscan variability of two calcium score
measurements should be less than 10% to reliably
determine the annual progression rate. With current
EBCT technology, only the progression rate in pa-
tients with at least a moderate atherosclerotic calcium

Fig. 1. Standard projection planes with conventional coronary angiography and four-slice CT angiography with 3D volume-
rendering postprocessing show the correlation between these two modalities. The left anterior descending coronary artery is seen
in the 60° left anterior oblique (A) and the 30° right anterior oblique (B) projection views. The right coronary artery (C) is
displayed in the 60° left anterior oblique projection.
 C.R. Becker / Radiol Clin N Am 40 (2002) 773–782 777

Fig. 1 (continued ).

plaque burden can be followed reliably [30]. In pa-
tients with mild and minimal calcium burden, the
partial volume effect seen with 3-mm slices makes
reproducible determination of progression and regres-
sion of tiny coronary calcifications difficult.
Further improvement in the scan technique (thin-
ner slices) and calcium measurement (mg CaHA) is
needed to allow for a reproducible calcium measure-
ment in the patients with minimal coronary calcifica-
tions. The reported regression rate of 7% in patients
receiving antilipid therapy [31] is difficult to assess,
given the poor reproducibility of the calcium score
measurements in mild to moderate lesions with the
EBCT [13].
Coronary CT angiography
For the past six years, contrast-enhanced EBCT
studies, in combination with three-dimensional post-
processing methods, were performed to specifically
visualize the vessel lumen and to achieve an angio-
graphic-like presentation of the coronary arteries
[32]. Investigators have tested this technique for the

Fig. 2. Characterization of atherosclerotic lesions on the basis of the components and the density of plaques. Type V atheromas
(V) may present with similar densities (40 HU) as thrombi (VI). With further plaque progression and healing, atheroma or
thrombi may progress to predominantly type VII calcified (VII) or type VIII fibrotic (VIII) lesions with a density of 100 HU.
778 C.R. Becker / Radiol Clin N Am 40 (2002) 773–782

Table 3
Guidelines for characterizing atherosclerotic coronary artery lesions by contrast-enhanced 4SCT on the basis of plaque
composition and density
AHA type Plaque entity Calcification Non calcified component Angiography
IV Atheroma No  40-HU Vessel-wall irregularities
V Fibroatheroma May be present  70-HU Vessel-wall irregularities
VI Thrombus May be present  40-HU High-grade stenosis or occlusion
VII Fibrocalcified plaque Extensive calcification  100-HU or absent Significant stenosis likely
VII – VIII Calcified nodule Small round nodule Absent Vessel-wall changes
VIII Fibrotic plaque No  100-HU Vesssel-wall changes or
stenosis possible

detection of coronary artery stenoses compared to contrast-enhanced EBCT is reliable in excluding

catheter-based coronary angiography [33 – 37]. The
overall conclusion from these studies is that a sig-
nificant number of coronary segments obtained with
EBCT must be excluded from the comparison evalu-
ation because of motion artifacts, small vessel size,
and severe calcifications. The mean negative predic-
tive value with EBCT for detecting coronary artery
stenoses is above 95%, indicating that a normal
significant CAD (Table 2).
With 4SCT, the exposure time is significantly
longer (250 milliseconds) than with EBCT (100 milli-
seconds); therefore, quality contrast-enhanced coro-
nary CT images with 4SCT can only be achieved in
patients with slow heart rates [8]. The clear advantage
of 4SCT, however, is the superior spatial resolution
(0.6  0.6  1 mm3) and signal-to-noise ratio when

Fig. 3. In early atherosclerosic stages (types I – III), plaques may develop to an atheroma (types IV and V) with compensatory
lumen widening (positive remodeling). Later, an atheroma may spontaneously calcify and develop to a calcified nodule (types
VII and VIII), causing vessel wall irregularities. An atheroma may rupture or erode because of inflammatory processes thinning
the fibrous cap. When plaque rupture occurs, the plaque may enter a cycle of bleeding and healing, followed by another episode
of rupturing. Following an episode of plaque rupture, the healing phase may lead to the development of scar tissue, causing a
more fixed narrowing of the vessel lumen (negative remodeling). This healing process often leads to the stenoses seen in patients
with chronic stable angina. In the event the plaque ruptures and bleeds with subsequent development of a thrombus, acute
coronary artery occlusion can occur leading to an acute myocardial infarction or unstable angina.
 C.R. Becker / Radiol Clin N Am 40 (2002) 773–782 779

compared to EBCT (0.8  0.8  2.5 mm3), allowing
4SCT to provide detailed assessment of coronary ar-
teries and cardiac structures (Fig. 1).
The feasibility [38] and accuracy [39,40] of 4SCT
in the detection of coronary artery stenoses has been
reported recently (Table 2). The authors of these
reports excluded a significant number of coronary
segments in the evaluation process because of motion
artifacts secondary to heart rate, extensive calcifica-
tions, small vessel size, adjacent contrast-filled struc-
tures such as the veins or ventricle, noncardiac
motion artifacts caused by breathing, and poor vessel
opacification [39].
Extensive calcifications also obscure the vessel
lumen with 4SCT because of the ‘‘blooming artifact’’
that occurs with dense materials such as stents or
calcifications evaluated with standard CT soft tissue
reconstruction algorithms. The detection of coronary
artery stenoses in the presence of dense calcifications
or stents, therefore, may be falsely negative when
compared to selective coronary angiography [35].
As a result of the blooming artifact caused by
dense calcifications and the limited spatial resolution
of 4SCT compared with conventional coronary
angiography (0.2  0.2 mm2), the assessment of
the degree of coronary artery stenoses with 4SCT
remains limited. Patients with known CAD, typical
angina, or obvious myocardial ischemia on exercise
testing are better served by cardiac catheterization,
because the option to perform percutaneous coronary
interventions in the same session is also made avail-
able [33].
As the negative predictive value for coronary
4SCT is at least as high as that with EBCT, there is
a chance to reliably rule out CAD with 4SCT in a
low- to moderate-prevalence population such as
asymptomatic patients with CV risk factors, symp-
tomatic patients with atypical chest pain, or patients
with nonspecific stress tests (ie, female patients). In
addition, 4SCT can be used to screen for anomalous
origins to the coronary arteries when selective cor-
onary angiography has been unsuccessful.
The limitations, however, of 4SCT in the evalu-
ation of the coronary arteries must be understood.
Anatomic details such as collateral vessels, contrast
run off, and direction of flow within the coronary
arteries are not visualized with 4SCT. Finally, the
hemodynamic relevance of coronary artery stenoses
that are detected with 4SCST can not be reliably
determined without a corresponding physiological
study such as a myocardial wall motion or per-
fusion analysis.
Atherosclerotic plaque characterization
In the early stages of atherosclerotic plaque for-
mation in the coronary arteries, a process called
positive remodeling [41] compensates for the athero-
sclerotic wall thickening and keeps the inner lumen

Fig. 4. A 62-year-old female with chronic stable angina. The volume-rendering image demonstrates a high-grade stenosis in the
middle segment of the left anterior descending coronary artery (arrow, left). The corresponding axial CT slice shows soft tissue
with a density of 110 HU, most likely corresponding to fibrotic plaque (type VIII).
780 C.R. Becker / Radiol Clin N Am 40 (2002) 773–782
of the vessel relatively unchanged. The pathophysi-
ology of this mechanism is unknown, but the specific
type of coronary artery plaque may be unstable and
have a predisposition for developing an intraplaque
hemorrhage and lead to a subsequent acute coronary
event [42].
The key feature of an unstable plaque, as some-
times seen in types IV and V atheromatous coronary
lesions [11], is the accumulation of a lipid core of
cholesterol in the basal intimal layer. With an inciting
inflammatory process, the fibrous cap of these plaques
becomes thinned, putting the plaques at risk for
rupture and subsequent thrombosis.
A number of different types of atherosclerotic
lesions in the coronary artery wall (Fig. 2) can be
differentiated with 4SCT [43]. In heart specimen
studies, atheromatous lesions are well-defined humps
of soft tissue with low (  40 HU) density. Further-
more, with 4SCT, attenuation values of noncalcified
plaques vary depending on the ratio between the lipid
and fibrous content of the lesion: type IV atheroma
(  40 HU), type V fibroatheroma (  70 HU), and
type VIII fibrous plaque (  100 HU) [12] (Table 3).
The most common coronary lesions observed with
CTA are small dots of calcium. These plaques form
‘‘calcified nodules’’ that are associated with minor
angiographic vessel wall irregularities [44], and only
in rare cases, are found to be associated with sudden
coronary death [42]. The type VII fibrocalcified
plaques may be the result of ongoing plaque rupture
and a healing process (Fig. 3) that may result in
excessive scar tissue, with resultant stenosis and
myocardial ischemia (Fig. 4) [12].
Acute coronary thrombosis has a characteristic
appearance on axial CT images. The coronary artery
has a low attenuation center (  40 HU) with a higher
attenuation rim. In any other stage of evaluation of
coronary thrombosis, an irregular border may be seen
[45], and the density of the vessel lumen varies
depending on its stage of fibrosis. The differentiation
between thrombosis and atheroma may be difficult
because of their similar densities on 4SCT (see
Table 2). The clinical presentation, however, of the
patient should direct the attention towards an acute
coronary thrombosis rather than an atheroma (Fig. 2).
Future perspective
Coronary CT with multirow detectors will continue
to evolve and improve in both spatial and temporal
resolution. From the technical point of view, more
than four detector rows with smaller elements and
faster gantry rotation soon will be available. These
types of scanners may be capable of near-isotropic
resolution with 0.5  0.5  0.6-mm3 spatial resolution
and less than 200-milliseconds temporal resolution.
With faster scanning and improved resolution,
fewer breathing artifacts will occur and less contrast
media will be needed. With thinner slices, smaller
vessels will be visualized more consistently, the
‘‘blooming artifact’’ associated with dense calcifica-
tions will be further reduced, and the quantification of
atherosclerotic coronary lesions will be improved by
the reduction in partial volume effects.
In the near future, the resolution associated with
conventional coronary angiography will not be
achieved with multidetector-row CT. The improve-
ments, however, with this technology will add
important information to the diagnosis and therapy
of CAD in many clinical situations.
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 Radiol Clin N Am 40 (2002) 783 – 798

CT angiography and MR angiography in the evaluation of

extracranial carotid vascular disease
C. Douglas Phillips, MDa,*, Lori A. Bubash, MDb
a
Division of Neuroradiology, Department of Radiology, University of Virginia Health Systems, Post Office Box 800170,
Charlottesville, VA 22908-0170, USA
b
Department of Radiology, University of Virginia Health Systems, Post Office Box 800170, Charlottesville, VA 22908, USA

The two major reasons for the interest in the effi-
cacious and noninvasive imaging of the extracranial
carotid vascular system are the relatively high inci-
dence of atherosclerotic disease in the US population
and the ease with which this disease can be treated
[1 – 5]. Strokes and stroke-related disability remain an
important public health problem in the United States.
Of the number of alternatives for vascular imaging of
the extracranial cerebral vasculature, the following
are the most common available modalities:
Computed tomographic angiography (CTA)
Digital subtraction angiography (DSA)
Magnetic resonance angiography (MRA) (three-
dimensional [3D] or two-dimensional [2D]
time-of-flight [TOF], phase-contrast, or gado-
linium-enhanced first-pass)
Radionuclide angiography
Ultrasound (US) (Doppler, B-mode, duplex, or
color-flow)
It is possible to further divide these imaging
modalities into ‘‘flow-dependent’’ and ‘‘filling’’ tech-
niques. ‘‘Filling’’ techniques depend on filling the
lumen of the vascular structures with a contrast media.
The available imaging modalities that use ‘‘filling’’
techniques include radionuclide angiography (used
for brain death evaluations in some locales), DSA or
conventional angiography, CTA, and gadolinium-
enhanced MRA (typically using a first-pass tech-
nique). These modalities require the passage of a
* Corresponding author.
E-mail address: cdp9m@virginia.edu (C.D. Phillips).
bolus of contrast media through the imaged volume
to allow depiction of the vessel lumen. When cross-
sectional imaging techniques are used, not only is the
lumen defined, but the surrounding arterial wall and
other soft tissues also are depicted.
Modalities that use ‘‘flow-dependent’’ techniques
include US (Doppler, duplex, or color-flow) and MRA
(TOF). For US and MRA to provide data for genera-
tion of images, blood must flow into the volume of
interest. Again, information about the vascular ana-
tomy and surrounding tissues can be obtained with US
and MRA. Although ‘‘flow-dependent’’ and ‘‘filling’’
imaging techniques are distinctly different, some over-
lap between the two techniques exists.
Each of these techniques has strengths and weak-
nesses, and any single modality will likely have
specific deficiencies or pitfalls in certain applications.
The most common pitfalls or problems related to
the available noninvasive vascular imaging modali-
ties include a flow-velocity threshold for evaluation
of flow-dependent techniques; contraindications to
MRA; costs and complications associated with the
use of invasive techniques as screening studies; contra-
indications to iodinated contrast media; and avoid-
ance of ionizing radiation, claustrophobia, and operator
dependence for some of the techniques, especially
US [6 – 8].
This article discusses two of the major noninvasive
modalities for evaluation of the extracranial cerebro-
vascular system: CTA and MRA. Catheter-based
angiography, however, still remains the ‘‘gold stand-
ard’’ for imaging the extra- and intracranial vascular
system, although it does not define the anatomy of the
vascular wall or surrounding soft tissues [9 – 11]. The
ability of catheter angiography to depict the vessel

0033-8389/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 1 7 - 9
784 C.D. Phillips, L.A. Bubash / Radiol Clin N Am 40 (2002) 783–798

lumen is usually excellent. Multiple angiographic
series in various projections, however, may be required
to completely understand or resolve a complex area of
luminal abnormality. Catheter angiography is repro-
ducible from institution to institution, is able to accur-
ately depict the morphology of the vessel lumen
regardless of blood flow rates, and can portray the
arterial anatomy from the aortic arch to the very small
intracranial vessels in a single examination. Important
information regarding cerebral hemodynamics may
also be obtained from the examination, including
the presence of important intracranial or extracranial
collateral circulation; therefore, any noninvasive tech-
nique used for evaluating the cerebrovascular bed must
be able to provide information similar to or better than
catheter angiography in order to stand as a reliable
replacement for this vascular imaging modality
[12,13].
CTA in the evaluation of cerebrovascular disease
CTA has always been a theoretic possibility with
computed tomography. It has been a combination of
factors that has allowed this technique to grow in use
and become a reasonable substitute for catheter
angiography. These factors include: (1) the advent of
powerful computers to allow multiplanar reconstruc-
tion of the image data; (2) x-ray tubes that can provide
adequate photon flux with narrow collimation and
exceptional cooling capacity; (3) detector technology
allowing the simultaneous gathering of multiple thin-
axial profile data sets; and (4) continuous rotating
x-ray tubes with continuous table travel (helical or
spiral technology). The current generation of CT
scanners with spiral capability and multirow detectors,
coupled with powerful stand-alone workstations, have
enabled the radiologist to acquire an exceptionally

Fig. 1. (A) Gadolinium-enhanced MRA of carotid bifurcation in a patient with a completed stroke and new transient ischemic
attacks. Oblique maximum intensity projection (MIP) image demonstrates a focal stenosis of proximal internal carotid artery
(arrows) with apparent complete interruption of the contrast column. A CTA was performed to evaluate the carotid bifurcations. (B)
Coronal MIP image demonstrates persistent lumen medially (arrow), and (C) axial MIP demonstrates the extent of exuberant
calcified plaque.
 C.D. Phillips, L.A. Bubash / Radiol Clin N Am 40 (2002) 783–798
Fig. 1 (continued ).
high quality volumetric data set to reprocess and
create detailed images of the vascular anatomy and
surrounding soft tissue for evaluation.
CTA
The inherent high spatial resolution of CT is a
significant advantage for this modality. The contrast
data necessary to resolve the vessel lumen comes from
the administration of intravenous (IV) contrast, which
is timed either by a timing bolus technique or by
monitoring the inferior aspect of the volume to be
imaged as the injection proceeds. The authors use the
second technique for contrast bolus timing with excel-
lent results. The technique for contrast administration
is to use 120 cc of 300mg/mL contrast injected at
3 to 5 cc/second. With the authors’ current multi-
detector CT (GE Lightspeed, General Electric, Mil-
waukee, WI), the image data is acquired at 1.25-mm
thickness and reconstructed with a 50% overlap. The
patient is allowed to quietly breathe during the
acquisition. Proper patient preparation includes an
adequately sized IV catheter (20 gauge or larger) that
is confirmed to be intraluminal, patient coaching to
785
avoid swallowing, and use of a shoulder harness (if
necessary, to depress the shoulders to avoid difficulty
in penetrating larger patients without significant
quantum mottle or scatter artifact). Elevating the jaw
can also aid in moving dental amalgam out of the
area of interest to allow better evaluation of the
cervical internal carotid. The scan is best interpreted
on a workstation by reviewing the source images in a
stack mode and the maximum intensity projection
(MIP) images in both the sagittal and coronal planes,
and occasionally, creating volume-rendered (VR) or
shaded-surface display (SSD) images for evaluation
[14,15]. Complex curvature of the carotid artery at its
extracranial bifurcation may require curvilinear refor-
matting and evaluation at the time of interpretation.
The authors believe it is essential to review each
technique of image postprocessing to adequately
interpret these studies.
CTA advantages and disadvantages
CTA images (source, MIP, and VR) are easy to
interpret and are understood by most clinicians. This
visual correlation adds to the acceptance of the
786 C.D. Phillips, L.A. Bubash / Radiol Clin N Am 40 (2002) 783–798

technique of CTA. The authors also are able to depict
plaque morphology, with calcified plaque easily dis-
tinguished from ‘‘soft’’ or lipid-laden plaque (Fig. 1).
There are also relatively few contraindications to
CTA—the images can be acquired very rapidly
(usually in less than 30 seconds), and the technology
to acquire these images is readily available. Claus-
trophobic and large patients are less of a concern than
with MR imaging, given the typical short bore of a
CT scanner.
There are, however, some disadvantages to CTA.
A high-quality CTA study requires the injection of
iodinated contrast at a relatively rapid rate (3 – 5 cc/
second). Even with current CT technology, because of
the acquisition speed and time limitations, it is rela-
tively difficult to scan from the aortic arch to the
intracranial circulation at appropriate slice thickness in
one setting. The intracranial scan data will be accom-
panied by significant venous opacification, which
can interfere with the image reconstructions and
interpretation. A practical disadvantage is the sig-
nificant amount of physician time for post-processing
spent at a workstation, generating MIP, VR, and SSD
images, and calculating stenoses [16]. Some practices
have dedicated technologists performing this post-
processing task, but some physician time is almost
always necessary. There are now current procedural
terminology (CPT) codes for CTA of the intracranial
circulation, as well as of the neck. In the setting of
marked vessel tortuosity, however, and extensively
calcified vasculature, the reimbursement for the time
spent by the physician for the reconstruction pro-
cesses remains relatively small.
Overall, in comparison with MRA, US, or catheter
angiography, CTA is evaluated infrequently in the
scientific literature [17 – 19]. This lack of referenced
information is changing with time, and the growing
body of literature is very supportive of CTA as an
effective and accurate modality [20,21]. In the
authors’ experience, the adoption of CTA by the
clinical staff parallels the acquisition of a multidetec-
tor CT scanner. High-quality CTA images of the ex-
tracranial circulation produced with this technology
are readily understood by nonradiologists, and the
quantum leap in the reconstruction quality on stand-
alone workstations, in addition to the avoidance of a

Fig. 2. (A) Oblique maximum intensity projection (MIP) image from a gadolinium-enhanced MRA of the carotid bifurcation in a
patient with a carotid bruit demonstrates a focal stenosis of proximal internal carotid artery (arrow), which was interpreted as
being severe on the MIP image, but determined to be approximately 70% on review of the source images. (B) Digital subtraction
angiography image demonstrates a focal > 65% stenosis (arrow), correlating with the MRA image.
 C.D. Phillips, L.A. Bubash / Radiol Clin N Am 40 (2002) 783–798 787

potentially risky intravascular procedure (catheter use in diagnosing and following carotid artery ath-
angiography), will likely lead to a significant increase erosclerosis, stenoses, dissection and arteritides, as
in the use of CTA as a vascular imaging modality for well as being widely applied in the intracranial cir-
evaluating cerebrovascular disease [22]. culation [26 – 28].

MRA in the evaluation of cerebrovascular disease MRA

MRA has been available as an imaging technique The acquisition style of MRA has undergone
for the human body for more than a decade [23 – 25] extensive change, with one technique becoming the
and a considerable body of literature has accompa- most widely accepted technique in recent years.
nied its development. MRA has been investigated for Three-dimensional TOF sequences have remained

Fig. 3. (A) Two-dimensional time-of-flight MRA image (oblique maximum intensity projection [MIP]) demonstrates significant
misregistration artifact as a result of respiratory motion and swallowing at the level of the carotid bifurcations (arrows). The
image gives the impression that there is a moderate stenosis of the left internal carotid. (B) Gadolinium-enhanced MR (oblique
MIP) of the left internal carotid demonstrates a severe >90% stenosis with a very diminutive lumen (arrow) based on a review of
MIP and source images. (C) Digital subtraction angiography image of left carotid demonstrates the approximately 60% irregular
stenosis (arrow). MRA overestimated the degree of stenosis.
788 C.D. Phillips, L.A. Bubash / Radiol Clin N Am 40 (2002) 783–798
Fig. 3 (continued ).
the dominant imaging method for evaluating the
intracranial circulation, with some users continuing
to use the technique for the extracranial circulation as
well. There has also been considerable interest in
phase-contrast MRA as another technique for vas-
cular imaging. Phase-contrast MRA relies on the
change in spin phase of blood flowing into a mag-
netic field gradient to provide contrast relative to a
stationary vessel wall. The potential advantages of
this technique include the flow direction and velocity
information acquired during the study. In contrast, the
TOF technique requires the inflow of unsaturated
spins (carried by water within the blood in a vessel)
into an imaged volume examined by a flow-compen-
sated, gradient-recalled echo technique. This tech-
nique is optimized to minimize the signal from
stationary tissue, thereby increasing the relative sig-
nal from the fresh spins delivered into the volume by
blood flow from outside of the imaging volume.
Two-dimensional and three-dimensional varia-
tions of TOF imaging exist, and many articles are
available to detail the technical factors of these
techniques [29 – 31]. The 2D TOF method is more
sensitive to slower flow, while the 3D TOF method
depicts a wide range of flow velocities and has shown
greater accuracy in defining internal and external
lumen morphology [7]. The 3D techniques are more
sensitive to any form of patient motion during the
acquisition. The limitation of both TOF methods is
some distortion of carotid artery anatomy and a
tendency to overestimate the degree of stenosis in
the presence of turbulent flow. The 2D and 3D TOF
methods have remained the mainstay in the evalua-
tion of the intracranial carotid and vertebral circula-
tion. The volume acquisition is reviewed as both
axial-source images and postprocessed MIP images,
which provide an anatomically correct depiction of
the entirety of the vessel and which can be manipu-
lated to review multiple projections of the vessel
lumen [32,33].
Contrast-enhanced MRA
More recently, there has been considerable interest
and ongoing development in contrast-enhanced MRA
(CEMRA). While there are several forms of
CEMRA, the technique used most often at present
is a rapid 3D gradient-echo (GRE) sequence first-pass
MRA, using a relatively large bolus of gadolinium-
based contrast [34,35]. This technique provides flow-
independent anatomic information, has a short
acquisition time, and minimal dephasing effects that
help minimize the difficulty in differentiating severe
stenosis and occlusion. This acquisition sequence
allows identification of slow flow in nearly occluded
vessels by decreasing the saturation effects and reduc-
ing intravoxel dephasing (which is responsible for the
lack of morphologic detail in high-grade stenoses)
[36 – 38]. It also allows more accurate assessment
of stenoses and visualization of ulcerated plaques
(Fig. 2). Challenges with CEMRA include trying to
balance the resolution with imaging time and volume
imaged and increasing the accuracy of the timing of
the contrast bolus. More accurate timing of the
contrast bolus will allow for a shorter imaging time,
with a corresponding decreased risk of motion
artifact, and a greater area of imaging, while allowing
for better differentiation of arteries and veins [39].
The shorter acquisition time, however, creates a
problem by restricting the number of slices and
voxels that can be obtained. Elliptic-centric phase
encoding and the TRICKS (time resolved imaging of
contrast kinetics) are methods designed to improve
evaluation of the carotid bifurcation by minimizing
 C.D. Phillips, L.A. Bubash / Radiol Clin N Am 40 (2002) 783–798 789

venous enhancement [39,40]. SENSE (sensitivity MRA advantages and disadvantages

encoding) is another technique to improve imaging
speed by use of multiple-surface coils, each with its
own receiver unit, to decrease imaging time while
maintaining image resolution [29]. Regardless of the
acquisition technique, the high contrast and resolu-
tion achieved with this CEMRA ‘‘fill’’ technique has
led to its recent position as the mainstay of arch and
extracranial carotid and vertebral artery evaluation.
There are a number of advantages to the use of
MRA as an imaging modality to evaluate the extra-
cranial cerebral vasculature. The techniques currently
used allow for the evaluation of the near-entirety of
the cerebral circulation in one setting. The absence
of ionizing radiation is also an advantage of MRA.
Studies support the sensitivity and specificity of

Fig. 4. (A) Elderly patient presents with a carotid bruit and transient ischemic attacks. Gadolinium-enhanced MRA image (lateral
maximum intensity projection [MIP]) demonstrates tandem, < 20% stenoses of distal common carotid and proximal internal carotid
artery (arrows) based on review of the MIP and source images. Strong clinical suspicion of disease led the patient to angiographic
evaluation. (B) Digital subtraction angiography (DSA) image in the lateral projection demonstrates excellent correlation of the
MRA and DSA study. Mild stenoses (arrows as in Fig. 4A) were noted and the patient was treated medically.
790 C.D. Phillips, L.A. Bubash / Radiol Clin N Am 40 (2002) 783–798

MRA, and the technique has been extensively and MRA also has a number of relative disadvantages
favorably compared to the other existing vascular to its use. The length of a study can be significant,
imaging modalities [41]. particularly for the TOF techniques, requiring the

Fig. 5. (A) An elderly vasculopathic patient presents with multiple transient ischemic attack symptoms. Gadolinium-enhanced
MRA image (oblique maximum intensity projection [MIP]) of the vertebral system demonstrates a severe stenosis of the
proximal cervical vertebral artery (arrow) based on MIP and source-image review. (B) Digital subtraction angiography (DSA)
image demonstrates a mild ( < 50%) vertebral stenosis (arrow). The degree of stenosis was overestimated on MRA. (C) Oblique
MIP image from the acquisition used in Fig. 5A demonstrates tandem severe stenoses of left distal common carotid (arrow) and
proximal internal carotid artery (arrowhead) based on MIP and source-image review. (D) DSA image demonstrates tandem
stenoses (arrow and arrowhead as in Fig. 5C). MRA overestimated proximal stenosis more so than the distal stenosis, but the
morphology of the stenoses and relative surgical importance of the lesions were correct.
 C.D. Phillips, L.A. Bubash / Radiol Clin N Am 40 (2002) 783–798
Fig. 5 (continued ).
patient to remain relatively motionless for an extended
period of time. Patient motion can lead to slice
misrepresentation artifact in 2D TOF angiography
and image blurring in all studies [37] (Fig. 3A). This
problem is of less concern with the relatively rapid
first-pass techniques. The acquisition of ‘‘arch- to
skull-base’’ studies using a large field-of-view
(FOV) results in a decrease in resolution for the
intracranial circulation. There is obvious difficulty in
visualizing a 2- to 3-mm lumen with a technique
resulting in 2-mm voxels [30]. Use of a smaller
FOV, however, will not allow complete evaluation
of the aortic arch and intracranial vessels in one study.
Another problem with MRA is the difficulty in
evaluating the true size of the lumen of the vessel in
the face of turbulent flow [7,26,44] (Fig. 3B,C). The
evaluation of the carotid bifurcation is often an area of
concern, as the application of the North American
Symptomatic Carotid Endarterectomy Trial criteria
791
requires an accurate depiction and measurement of
this lumen [45 – 48]. With TOF techniques, spins may
remain within the imaging volume for a long enough
period of time to see numerous pulses and become
saturated, thereby leading to a loss of signal within the
vessel lumen and the inability to depict the vessel
contiguous to a lesion. This effect may also lead to the
apparent depiction of a stenosis within a tortuous
vascular segment where no lesion exists [49].
Although spatial resolution may also be a limitation
with gadolinium-enhanced MRA, gadolinium short-
ens the T1 of the blood and the technique does not
depend on blood motion or the inflow of unsaturated
protons, allowing for more accurate assessment of
stenoses [37] (Fig. 4). Motion artifacts, such as
swallowing or exaggerated respiration, can cause a
loss of image quality and lead to incorrect diagnoses
or suboptimal studies. Surgical clips adjacent to the
arteries being studied may create artifacts, leading to a
792 C.D. Phillips, L.A. Bubash / Radiol Clin N Am 40 (2002) 783–798

false-positive diagnosis of stenosis [50]. In a cost-
conscious world, the relative expense of MRA also is a
concern for routine use of MRA as a general screening
tool. Lastly, approximately 5% of patients will not tol-
erate the claustraphobic confines of current MR units.
Reliance on MIP images and data alone is to be
cautioned against. MIP image sets are extensively
post-processed, with alteration of the data that is pre-
sent within the acquisition that can alter the appear-
ance of the vessel. Post-processing, which includes
numerous algorithms to smooth or ‘‘clean up’’ the
data, can result in the vessel size being reduced, both
the normal segment of a vessel or the diseased
segment [51]. For this reason, interpretation of the
source images, multiplanar reformatted images, and
the MIP images is necessary to provide an accurate
diagnosis, particularly when the quantification of a
stenosis is performed [52] (Fig. 5).

Fig. 6. (A) An incidental carotid bruit was detected on physical examination. A CTA was ordered to evaluate the extracranial
vasculature. A volume-rendered anterior-posterior oblique image demonstrates a persistent hypoglossal artery (PHA). Note the
PHA entering hypoglossal canal (arrow) to form the basilar artery. (B) Lateral projection of CTA study demonstrates the origin of
the PHA. (Courtesy of Dr. Andrew Wagner, Department of Radiology, Rockingham Memorial Hospital, Harrisonberg, VA.)
 C.D. Phillips, L.A. Bubash / Radiol Clin N Am 40 (2002) 783–798 793

CTA, MRA, and their competitors
Both CTA and MRA techniques provide a useful,
noninvasive, reproducible, and accurate method of
evaluating the extracranial circulation. Local expertise
is increasingly a consideration in the choice of the
imaging modality used. This local expertise, as well as
the quality of imaging technology available, can be an
important factor in the choice of an imaging test [42].
Some vascular surgeons operate on the findings of an
ultrasound exam alone. Ultrasound is a good test, with
extensive validation and widespread acceptance. It
is, however, operator dependent and not without its
own limitations. Often CTA or MRA is performed to
confirm the findings on an US exam and to provide the
surgeon more detailed vascular morphology of a larger
segment of the vascular system prior to revasculari-
zation [43,44,46]. There is little difficulty in being
reimbursed for alternative noninvasive imaging stud-
ies, such as CTA or MRA, to reinforce the findings of
an US examination, although with concordant find-
ings of the two studies, a third exam will likely not
be reimbursable.
plaques elsewhere. Dangerous carotid plaques, termed
‘‘high-risk,’’ are heterogeneous, very fibrous and not
necessarily lipid-rich [53]. Less common are athero-
sclerotic changes of the carotid origin and of intracra-
nial medium- and small-sized vessels. A complete
evaluation of an atherosclerotic lesion requires assess-
ing the vascular stenoses and evaluating the plaque
morphology [47].
Nonatheromatous disease
Nonatheromatous disease of the cerebral circula-
tion is less frequently seen than atherosclerotic disease,
but remains an important cause of cebrovascular
disease. Nonatheromatous processes are always sus-
pect in patients with the appropriate clinical histories
or in younger people with stroke symptoms. Carotid

Diseases of the extracranial carotid and

vertebral circulation

Two major categories of diseases of the cerebral

circulation are most often seen in clinical practice—
atheromatous disease (atherosclerotic disease) and the
nonatheromatous diseases. In the United States popu-
lation, atherosclerotic disease is the major cause of
clinically significant vascular disease [4].

Atheromatous disease

The most common area of atherosclerotic involve-

ment in the cerebrovascular system is at the carotid
bifurcation, located typically at or near the superior
border of the thyroid cartilage or near the C4-5 inter-
vertebral disk space. A basic histologic feature of ather-
osclerosis is the deposition of fatty compounds in the
intima. The atheromatous plaque (cells, fibrous con-
nective tissue, and lipids) and the occasional compli-
cation associated with the plaque itself (intraplaque
hemorrhage, ulceration, and so forth) are responsible Fig. 7. A 37-year-old woman with no vascular risk factors
presents with transient ischemic attack symptoms and asym-
for the development of significant stenoses of the ves-
metric arm-blood pressures. Gadolinium-enhanced MRA
sel [47]. In some instances, significant luminal irregu- image (oblique maximum intensity projection [MIP]) dem-
larity without a flow-limiting stenosis leads to platelet onstrates multiple stenoses of arch vessels: left subclavian
aggregation and, ultimately, artery to artery embolic artery (arrow), left common carotid artery (arrowhead), and
phenomena to the brain. The composition of danger- left internal carotid artery occlusion (small arrow). The
ous plaques in the carotid arteries is different from presumed diagnosis was Takayasu’s arteritis.
794 C.D. Phillips, L.A. Bubash / Radiol Clin N Am 40 (2002) 783–798

Fig. 8. (A) A young patient presents following a penetrating injury to neck (shotgun blast). Digital subtraction angiography
image at time of injury demonstrates through-and-through injury of vertebral artery with mirror pseudoaneurysms (arrows). The
authors followed the course of the pseudoaneurysms with serial CTA studies to determine if endovascular therapy was indicated.
(B) Follow-up CTA study at one month (shaded surface display) demonstrates a stable appearance of medial pseudoaneurysm
but an increase in size of lateral pseudoaneurysm (arrows). (C) Following endovascular treatment and coil obliteration, both
pseudoaneurysms have been excluded from the circulation.
 C.D. Phillips, L.A. Bubash / Radiol Clin N Am 40 (2002) 783–798
Fig. 8 (continued ).
dissection is a particularly important cause of strokes
in the young patient [54,55]. Dissections result from
hemorrhage into the wall of a vessel. Most com-
monly, the vessel responds to the hemorrhage in two
ways—the lumen is compromised, but the overall
vessel diameter is increased. By MRA, the signal in-
tensity of the mural hematoma in the acute phase (1 –
4 days) is low on both T1- and T2-weighted images.
The hematoma becomes hyperintense during the sub-
acute phase, secondary to the methemoglobin. Flow
within the true lumen, however, usually gives an even
higher intensity signal, which helps distinguish the
hematoma from the vessel lumen. In addition, the
morphology of the hematoma is characteristically
crescent-shaped, adjacent to the vessel wall and may
have a spiral configuration [56 – 58]. Dissection may
be either traumatic or spontaneous, with an increasing
recognition that spontaneous dissection may result
from minor and perhaps unrecognized trauma [59 –
61]. Suspected carotid dissections traditionally have
795
been evaluated using angiography, but MRA and
CTA are increasingly used with good accuracy [62 –
64]. The authors use a combination of MRA and MRI
in the evaluation of a potential carotid dissection. The
authors’ experience with first-pass gadolinium studies
is good, and the vessels are also imaged in the axial
plane with a fat-suppressed T1 technique, with an
inferior presaturation slab producing a uniform low-
signal – intensity vascular lumen [65].
Fibromuscular dysplasia (FMD) is another cause
of vascular disease in younger patients, resulting from
a vasculopathy of unknown cause that typically
affects medium-sized arteries. FMD is more common
in women, and involvement of the vessels of the head
and neck is second only to the renal arteries in overall
frequency [66]. Uncommon congenital abnormalities,
postoperative anastomotic strictures, and postangio-
plasty and poststent stenoses can also be visualized
with CTA [67] (Fig. 6). Other non-specific and un-
common vasculopathies may also be diagnosed [68]
(Fig. 7). Radiation-induced arteritis may be seen in
patients with prior history of significant radiation
therapy, often to head and neck primary cancers. This
vascular disease is most commonly seen more than
10 years after the radiation therapy, and results in
long-segment stenoses of the common carotid arter-
ies [69,70].
Trauma is another common reason for investi-
gating the cerebral circulation and for the increasing
importance of the evaluation of patients with high-
speed motor vehicle accidents. These vascular injuries
often involve the intima with or without associated
thrombosis and occlusion or the development of trau-
matic pseudoaneurysms and dissections [59,61,63,64]
(Fig. 8).
Summary
CTA and MRA techniques likely will continue to
increase in use in the evaluation of the extracranial
cerebrovascular system. The increasing reliance on
noninvasive tests mirrors an overall concern with the
risks and costs of more invasive examinations. Given
the rapid development of the computer technology,
data acquisition, and reconstruction algorithms in the
past few years, it is apparent that CTA and MRA also
will continue to improve.
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 Radiol Clin N Am 40 (2002) 799 – 833

Imaging of aortic stent-grafts and endoleaks

Siegfried Thurnher, MD*, Manfred Cejna, MD
Division of Angiography and Interventional Radiology, Department of Radiology, University Hospital Vienna,
Währinger Gürtel 18-20, A-1097 Vienna, Austria

The substantially high morbidity and mortality
rates for graft replacement of aortic aneurysms, par-
ticularly in high-risk patients, have encouraged the
development of an endoluminal approach to treat-
ment. The introduction of endovascular stent-graft
repair for aortic aneurysms has engendered consid-
erable enthusiasm and interest from vascular special-
ists [1]. With progressive improvement in imaging,
clinical experience, and stent-graft design, and the
use of adjuvant procedures, a substantial number of
patients are now candidates for endovascular repair of
an aortic aneurysm [2]. Endoluminal aneurysm repair,
however, currently is at a critical point [3,4]. Unques-
tionably, endoluminal aneurysm repair can reduce
substantially the need for intensive care and length
of hospital stay, and survival is reportedly improved
when compared with open repair. Although the use of
stent-grafts for the treatment of thoracic and abdom-
inal aneurysms has increased dramatically, there is
little midterm or long-term proof of its efficacy [1].
With longer follow-up, complications are reported
with increasing frequency [3 – 5]. The majority of
failures may be asymptomatic initially, but, if
untreated, can result in fatal aneurysm rupture [6 –
8]. Such complications may not appear until months
or years after apparently successful endoluminal
repair; therefore, although endovascular stent-grafting
of aortic aneurysms is less invasive and potentially
effective in the long term, it often is not a definitive
procedure [6,9]. The need for lifetime surveillance,
the probability of graft failure, and the need for
reintervention negate some of the advantages. The
* Corresponding author.
E-mail address: siegfried.thurnher@univie.ac.at
(S. Thurnher).
small incidence of unpredictable rupture following
endoluminal aortic aneurysm repair is a timely
reminder of the need for caution and continued
careful follow-up. In addition, the need for life-long
surveillance substantially adds to the overall cost of
the procedure.
Rationale and goals for postprocedural imaging
In addition to preoperative imaging, adequate
surveillance after endovascular aneurysm repair
requires imaging modalities capable of detecting
complications and treatment effects. Follow-up
imaging is directed toward repeated assessment of
the aneurysm size, detection of endoleaks, and
monitoring of the structural and positional integrity
of the stent-graft. Late-stent deformation is noted in
abdominal and thoracic applications, and deforma-
tion ultimately can lead to graft thrombosis, graft
migration, endoleak, and aneurysm rupture. Because
the presence or absence of an endoleak alone is not
considered indicative of failure or of successful
rupture prevention, accurate means to ascertain treat-
ment success are needed. Theoretically, an obvious
indicator would be provided by pressure measure-
ments inside the excluded aneurysmal sac using
remote pressure transducers. It is not unlikely, how-
ever, that the aneurysm might harbor both high- and
low-pressure segments, which would seriously limit
the reliability of local pressure measurements. In-
deed, pressure measurements in closed aneurysmal
sacs during open abdominal aortic aneurysm (AAA)
repair reveal a high variability of intrasac pressure
regardless of the number of patent lumbar arteries
[10]. The second-best parameter seems to be changes
in the size of the aortic aneurysm. Unfortunately,

0033-8389/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 2 4 - 6
800 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833

shrinkage of the aneurysm sac after stent-graft noninvasive modalities of plain radiography and
placement may take several months to become ultrasound can be performed at the same time or on
visible, which means that a patient with an endoleak alternate dates.
that is not visualized may be at risk during this
interval [11,12]. Although the measurement of the
maximum diameter is accomplished easily and
quickly and does not necessitate advanced measuring
equipment, it suffers from poor reproducibility.
Thus, there is evidence that estimation of entire
sac volume using computed tomographic (CT)
angiography is a more accurate indicator of such
expansion [13]. CT angiography allows complete
assessment of the aneurysm, including visualization
of morphologic changes within the aneurysm sac.
According to the imaging guidelines for AAA repair
with endovascular stent-grafts from the Society
of Cardiovascular and Interventional Radiology
(SCVIR), the goals of postprocedural imaging are
as follows (available at: www.guidelines.org; ac-
cessed January 28, 2000):

 To confirm and redocument the appropriate

placement of the stent graft
 To assess better the effectiveness of the stent-
graft in initially excluding the AAA (detecting
flow in the sac)
 To follow the long-term fate and size of the
AAA sac and ensure its stability
 To detect remote stent-graft failure (structural
or functional)
 To better characterize and possibly treat
any endoleaks

As with the entire field of endovascular surgery,

imaging techniques and recommendations regarding
their use are changing rapidly. Only long-term fol-
low-up data determine which methods will become
standard. Endovascular aneurysm repair has the
potential to involve most, if not all, of the facilities
of the diagnostic imaging department. Patient follow-
up should be individualized to meet individual patient
needs. At present, the imaging modalities best suited
to achieve the above goals are plain film radiographs
of the abdomen (chest) and CT angiography with
specialized 3D reconstruction protocols. In centers of
excellence, color- or power-Doppler ultrasound is a
useful adjunctive modality and ultimately may Fig. 1. Plain radiograph (left column), coronal planar
reformation of a CT scan (middle column), and coronal T1-
decrease the required frequency of more expensive
weighted FFE MR image (right column) showing radiologic
studies such as CT [14]. These imaging techniques
features of Zenith (Cook) (upper row), Endologix (Bard)
are performed prior to discharge to confirm satis- (middle row) stent-graft, and Vanguard (Boston) (lower row)
factory deployment and provide baseline studies. endoprosthesis. Note difference in metallic MR artifacts
Subsequently, major imaging (eg, helical CT) is induced by the stainless-steel Zenith device compared with
performed at less frequent intervals, such as at 3 the stainless-steel Endologix and Nitinol-based Vanguard
and 12 months and yearly thereafter. The cheaper, stent-graft.
 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833 801

Follow-up imaging may also include magnetic res-
onance (MR) angiography, but intra-arterial digital
subtraction angiography (DSA) is reserved for
selected circumstances.
Imaging evaluation should be able to show:
 Aneurysmal size
 Changes in aneurysm size
 Position of the stent-graft
 Evidence of change in position of the endopros-
thesis
 Structural integrity of the device
 Endoleak
 Change in the characteristics of the endoleak, ie,
new endoleaks
No single one of these modalities addresses
adequately all the questions that must be answered
when caring for the patient. Each modality has its
own strengths and weaknesses. In general, a com-
bination of examinations is superior to any single test.
The preferential use of these modalities in any given
case should be based on issues of relative cost,
radiation exposure risk, invasiveness, contrast neces-
sity and tolerance, availability, reproducibility, ease
of interpretation, and performance in all patients. In
addition, the imaging modalities should be applicable
to all current device designs.
Imaging techniques
Plain films of the abdomen (chest)
Plain films (four views, anterior-posterior (AP),
lateral, and oblique) are most helpful for evaluating
the metallic components of endovascular stent-graft
devices (Fig. 1) [15]. Plain radiography is easy to
obtain and inexpensive. As the aneurysm shrinks,
there are structural changes that may occur in these
components (the significance of which is as yet un-
known). Migration, angulation, kinking, and fractures

Fig. 2. Material fatigue. Lateral (A) and anteroposterior (B) plain abdominal radiographs showing separation of the top ring
(arrow) of a bifurcated Vanguard (A) stent-graft and complete fracture (arrow) of a tubular Vanguard prosthesis (B).
802 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833

of the stent mesh are significant findings (Fig. 2) [15].
According to SCVIR guidelines, a baseline series of
plain films should be obtained after discharge and
then every six months for at least two years.
Ultrasound
Ultrasound scanning is used widely for routine
surveillance of AAA [16 – 20]. It offers the advan-
tages of wide availability, low cost, and lack of
radiation exposure or nephrotoxicity. Although the
value of Duplex ultrasound scanning for routine
follow-up of AAA is well accepted, its accuracy
and reliability in evaluating aneurysms after endo-
vascular repair is not well defined [21]. Whereas
high-quality color (contrast-enhanced)-Doppler ultra-
sound is capable of demonstrating endoleaks and
graft patency, the assessment of endograft abnormal-
ities, such as stent distortion or fracture, is not readily
visible and the examination can be rendered inad-
equate by bowel gas (Fig. 3) [14,22,23]. Measure-
ments of pulsatile wall motion and intrasac blood
pressure by means of ultrasound scans are of great
theoretic value in patients who undergo endovascular

Fig. 3. Color-Doppler unltrasound: transverse section showing both iliac limbs (arrows) of a patent, bifurcated stent-graft within
an abdominal aortic aneurysm (A). Levovist-enhanced ultrasound shows flow within the endoprosthesis to better advantage
(B). Levovist-enhanced ultrasound reveals a large type 3 endoleak (arrow) in another patient after dislocation of the second
iliac limb (C).
 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833 803

aneurysm repair; however, this method seems to be
unreliable in a clinical setting [24].
Heilberger et al studied the reliability of Duplex
ultrasound scanning for follow-up imaging in 113
patients with aortic stent-grafts, most of which were
tube grafts [25]. They claim that Duplex ultrasound
scanning is almost as sensitive as CT in the detection or
exclusion of endoleaks, but inferior to CT in the
assessment of graft integrity. Zannetti et al validated
the role of Duplex sonography in 103 patients after
endovascular repair of AAA (Table 1) [23]. They find a
tendency toward overestimation of endoleaks (positive
predictive value, 78.6%) and a low ability of Duplex
scanning to identify the source of the endoleak [23].
Although CT and MR angiography are accurate in the
assessment of aortic dimensions, interobserver vari-
ability in measuring the diameter of AAA from CT
images is significant and is reported to differ by 5 mm
or more in 17% of cases [26]. The difference in
measurements between ultrasound scanning and CT
is reported to be even greater, with 33% of cases
different by more than 5 mm and ultrasound scan
measurements, on average, smaller than those ob-
tained with CT [26]. Although discrepancies between
Duplex scanning and CT do occur, differences be-
tween Duplex scans from different laboratories may be
even greater. Thus, it is crucial to compare Duplex
scans from the same laboratory. CT and Duplex
ultrasound scans may be interchangeable for routine
uneventful surveillance, but in cases of significant
change in size or a clinical change or uncertainty,
confirmation using the alternative study is prudent.
In addition, the rate of inadequate Duplex scans varies
from 7% to 81% [19,22]. Because ultrasound scanning
of deep intraabdominal structures, such as the aorta, is
highly operator dependent, close cooperation between
laboratory staff and physicians and internal validation
with other imaging modalities, in particular CT, are
vital to achieve optimal results [21]. A study by
McWilliams et al raises caution about the diagnostic
relevance of unenhanced Duplex sonography (see
Table 1) [27]. The investigators conclude that Levov-
ist-enhanced vascular ultrasound increases confidence
for detecting relevant endoleaks [27]. Follow-up using
Duplex ultrasound scanning or a protocol consisting of
the alternate use of both modalities may result in
substantial cost reduction, reduced radiation exposure,
and avoidance of nephrotoxicity associated with the
use of iodinated contrast materials—all without com-
promising patient care [22].

Table 1
Results of prospective comparisons of ultrasound and computed tomography
20 examinations
166 examinations 198 examinations (unhanced vs
Patients in 76 patients 100 examinations 122 examinations in 103 patients enhanced [Levovist])
Technically adequate 93% 93% Not given 99% 100%
Sensitivity 81% 97% 96% 91.7% 33% (unenhanced)
100% (enhanced)
Specificity 95% 74% 94% 98.4% 94% (unenhanced)
65% (enhanced)
+ predictive value 94% 66% 89% 78.6% 50% (unenhanced)
33% (enhanced)
predictive value 90% 98% 98% 99.4% 88% (unhanced)
100% (enhanced)
Type 1/3 leak detection 14 (one — —
false-positive
type-1 leak)
Type 2 leak detection 19 (3 false
positive, 1
false negative)
Endoleaks (overall) 54 (11 false 33 (17 false 12 endoleaks 6 endoleaks,
negative, 3 positive, 1 3 not confirmed
false positive) false negative)
Diameter correlation r = 0.93 (92% Not done r = 0.88 (with Not done Not done
within 5 mm, variations from
P < 0.001) 7 mm
to + 13.5 mm)
CT mode Biphasic Biphasic Uniphasic Uniphasic
804 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833

Computed tomographic arteriography
Computed tomographic arteriography is widely
available, easily accessible, and well tolerated by the
patient. Helical/spiral CT angiography is preferable to
nonhelical CT and is considered capable of providing
all the necessary information for the assessment of
endoluminal aneurysm repair [28 – 32]. Helical CT
angiography clearly and consistently demonstrates
important details, such as size of the aneurysm and
integrity of the implanted stent-graft device. For the
EUROSTAR registry, CT angiography is considered
the gold standard for evaluation after stent-graft
implantation, regardless of the acquisition protocol
or type of scanner [33,34]. CT angiography with
three-dimensional (3D) rendering clearly depicts the
position of the stent-graft relative to the renal or
subclavian artery and aneurysm (Figs. 1, 4 – 6)
[2,35,36]. CT angiography offers a useful means of
serially evaluating patients with stent-grafts to confirm

Fig. 4. Axial arterial-phase CT scans of a Talent (Medtronic) (A), Excluder (Gore) (B), Vanguard II (Boston Scientific) (C), and
Zenith (Cook) (D) endoprostheses. Note partially-supported iliac limb in the Talent stent-graft (arrow). Mild circular thrombus
formation in the Zenith device (arrowheads).
 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833 805

progressive thrombosis of the sac. The focus of post-
procedural CT angiography, however, primarily is to
document aortic and aneurysmal size and to search for
the presence of endoleaks. The fate of early and late
endoleaks constitutes one of the major reasons to
perform contiguous postoperative surveillance by
imaging studies, in particular CT scanning [37 – 39].
In light of the desire to detect all types of endoleak, an
additional delayed series, obtained more than one
minute after the dynamic contrast scan, is recommen-
ded (Fig. 7) [40]. Recently, it has been demonstrated
that delayed CT scanning increases the sensitivity for
the detection of reperfusion endoleaks significantly
but as a result, doubles the radiation dosage per exam-
ination [41]. According to the EUROSTAR registry,
the incidence of type 2 endoleaks decreases within the
first year of follow-up, but the clinical sequela of type 2
endoleaks remains to be clarified [42,43].
The protocols for CT angiography are similar to
those for preprocedural imaging. An initial baseline
(less than one month) CT angiography should be
obtained. If no complications associated with the
device are apparent, then scans should be repeated
every six months for two years and yearly thereafter.
If a problem is apparent (migration, kinking, endo-
leaks, or increase of AAA size) or symptoms occur,
more frequent imaging may be required.
According to SCVIR guidelines, helical CT angi-
ography with multiplanar reconstruction is recom-
mended. Alternatively, thin-cut (less than 3 mm)

Fig. 5. Curved planar reformations (CPR) (A,B) of CT data set shows patent iliac limbs of an Excluder stent-graft. Maximum-
intensity projection (MIP) image shows position of the stent-graft in relation to the renal arteries but precludes assessment of
device integrity and patency (C). Axial CT scan shows normal air bubbles (arrowhead) in the excluded left iliac aneurysm stent-
graft two days after implantation (D).
806 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833

Fig. 5 (continued ).
 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833 807

conventional dynamic CT scanning may be adequate. This allows localization of the celiac trunk and
Different CT scan manufacturers recommend slightly femoral bifurcations and is useful for assessing cal-
different protocols to achieve the same result. cification and parenchymal organs.

1. First, a localizing precontrast scan should be
performed from the diaphragm to the mid-
intertrochanteric region.
 Helical/spiral mode: 10-mm collimation; 2.0
pitch; 80 – 100 KiloVolt (KV); 90 – 100
milliAmpere (MA).
2. Then, two CT angiographic scans employing
a double breath-hold technique from the
celiac origin to the femoral bifurcation should
be performed.
 Helical/spiral mode: 3-mm (or less) collima-
tion; 2.0 pitch; 120 KV; 280 MA; 750-milli-

Fig. 6. Thoracic aortic aneurysm. Axial CT scan (A) prior and after (B) successful endoluminal exclusion of the aneurysm.
Completion arteriography (C) and curved planar reformations of CT data (D) show Excluder (Gore) stent-graft covering the
stenotic left subclavian artery (arrow).
808 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833
Fig. 6 (continued ).
second gantry rotation, total scan time less
than 40 seconds.
 Volume of 120 to 200 mL of low osmo-
lar contrast administered via large-bore
(18-gauge) antecubital vein at 2 to 5 mL/
second. Data acquisition should coincide with
peak contrast enhancement of the aorta, which
can be achieved with a standard 30-second
scan delay. Greater reliability is gained,
however, by first measuring the delay with a
small volume of contrast or by triggering data
acquisition when aortic opacification reaches
a predetermined level.
 A delayed CT angiographic scan is per-
formed using a scan delay of 60 to
120 seconds to allow slow-filling side
branches to opacify.
3. Then, axial slices (reconstruction interval, 2 mm
or less) are constructed from the raw data set of
both the arterial and delayed CT angiographic
scan including the total table travel distance
(usually 33 – 42 cm) and smaller field-of-view
(FOV) centered on the aorta (18 – 20 cm).
Choosing a reconstruction interval smaller than
the collimation results in a slice overlap. This
series should be evaluated on a workstation ca-
pable of multiplanar reformation using a spe-
cific window setting for distinguishing calcium
from contrast medium and structural compo-
nents of the stent-graft device. In contrast to
preprocedural scans, multiplanar reformatting
generally is not required. The cine-mode view is
an excellent means for detecting endoleaks.
For follow-up, CT angiography provides accurate
and reproducible measurements of aneurysm diameter
and volume. It shows structural failure, distortion, or
displacement of the endograft. For the detection of
endoleaks, CT angiography is shown to be superior to
intra-arterial DSA [41,44]. As new devices are
developed for endovascular aortic aneurysm repair,
spiral CT angiography will play an important role in
the assessment of the adequacy of these devices, both
immediately after treatment and long term.
The limitations of CT angiography are few. When
compared with plain radiography and DSA, CT
angiography has a lower spatial resolution. For
optimization of signal-to-noise ratios and coverage,
radiograph tubes with high-heat capacities and
detector efficiency are required. The substantial
 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833 809

Fig. 7. Proximal type 1 endoleak. Two consecutive CT scans (A) and axial reformations of a MR angiographic data set (B)
demonstrate a proximal perigraft endoleak (arrow). The endoleak (arrow) is also visible on the maximum intensity projection-MR
angiogram (C) and is confirmed by catheter angiography (D).

amount of iodinated contrast agents necessary for
adequate postprocedural imaging may be unac-
ceptable in severly azotemic patients.
Magnetic resonance angiography
Magnetic resonance angiography is a noninva-
sive technique that is competitive with invasive
conventional angiography and CT as a diagnostic
modality for the preprocedural work-up for endolu-
minal treatment of aortic aneurysms [31,45,46]. MR
offers certain advantages; one in particular is that
large volumes of potentially nephrotoxic, iodinated
contrast medium are not required. Thus, MR angiog-
raphy serves as an attractive alternative to CT
angiography in patients who should not receive
810 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833

iodinated contrast medium. The introduction of mization that results in angiographic acquisition with
high-gradient systems allows pulse sequence opti- impressive imaging quality. Compared with noncon-

Fig. 8. Maximum intensity projection reconstruction of a contrast-enhanced MR angiography after successful implantation of a
Talent (A) and Vanguard (B) stent-graft for endoluminal abdominal aortic aneurysm repair. Note platinum markers used for better
radiopacity and easier identification of stent-grafts cause only minimal MR artifacts (arrows). Axial reformations (C – E) of the
3D MR angiographic data set show full patency of the stent-graft limbs and complete exclusion of the aneurysm sac from
systemic circulation.
 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833
trast techniques, dynamic contrast-enhanced MR
angiography essentially is independent of flow.
High-quality angiographic images of the aorta and
accessory vessels can be obtained during a single
breath-hold. Sequential acquisitions enable visualiza-
tion of the distal aorta and iliac vessels even in the
presence of very slow flow. The low sensitivity of
MR imaging to bone and calcification facilitates
postprocessing because it eliminates the need for
segmentation. Both patient selection and aortic
measurement based on MR assessment are similar
to helical CT [31].
Three-dimensional contrast-enhanced MR angiog-
raphy is a reliable and noninvasive diagnostic
modality for follow-up after endovascular stent or
stent-graft placement in patients with aortic aneur-
ysms or peripheral arterial occlusive disease (Fig. 8)
[47 – 50]. In the postprocedural imaging of peripheral
arterial disease using stents or stent-grafts, the focus is
demonstration of perivascular changes induced by the
cover material or depiction of restenosis or occlusion
[47,51 – 55]. Stainless-steel and nonferromagnetic
nitinol-based endoprostheses have proved their bio-
compatibility and are expected to be suitable for MR
evaluation [48,56 – 62]. In previous in-vitro and in-
vivo reports, nitinol stent-grafts for endoluminal
treatment of aortic aneurysms were shown to be
suitable for two-dimensional and 3D MR angiogra-
phy, and MR imaging was regarded as a safe proce-
dure (Fig. 1) [57,58,63,64]. MR angiography is the
modality of choice in patients with impaired renal
function or known allergic reactions to iodinated
contrast media, because gadolinium-based contrast
media have a more favorable safety profile [49,65].
The lack of radiation is a considerable issue in
younger patients with a life expectancy of more than
20 years, because contiguous follow-up after endolu-
minal treatment of aortic aneurysm may result in
numerous radiation exposures.
Table 2
Commercially available aortic stent-grafts used in 2493 patients in the EUROSTAR registry [33]
Stent-graft
Stentor (Mintec, La Ciotat, France)
Vanguard (Boston Scientific/Meadox Medical, Oakland, NJ)
AneuRx (Medtronic, Sunnyvale, CA)
Talent (World Medical, Sunrise, FL/Medtronic, Sunnyvale, CA)
Ancure (Endovascular Technologies, Menlo Park, CA)
Excluder (WL Gore, Flagstaff, AZ)
Zenith (Cook, Indianapolis, IN)
Other
Endologix (Bard, Covington, GA)
811
The MR angiographic protocol used in the authors’
institution is as follows. First, an axial T2-weighted
ultrashort turbo – spin-echo (UTSE) sequence and a
T1-weighted fast – field-echo (FFE) or Flash-2D
sequence (eg, TR/TE/FA 80 milliseconds/6.9 milli-
seconds/60°) is obtained through the abdominal (tho-
racic) aorta and iliac arteries. Klemm et al show that the
optimal strategy for visualization of vascular and peri-
vascular regions outside the stents is fast – spin-echo
imaging with the stent axis and read direction parallel
to the static field [52]. The scan delay for contrast-
enhanced MR angiography is determined after admin-
istration of 2 mL of a paramagnetic contrast medium
in the cubital vein, followed by a saline flush of 20 ml
with a flow rate of 2.0 ml/second injected by an auto-
matic power injector. Contrast-enhanced MR angiog-
raphy is performed using a 3D FFE or 3D spoiled
gradient-recalled – echo sequence in a coronal orienta-
tion during breath-hold (eg, TR/TE/FA 6.3 milli-
seconds/1.8 milliseconds/40° or 4.0 milliseconds/1.6
milliseconds/40°) in both the arterial and late phase
(delay, 60 seconds). Finally, an axial postcontrast
T1-FFE or Flash-2D sequence again is employed.
Postprocessing of MR angiographic data sets
consists of image subtraction of both the arterial
and the venous phase from the precontrast 3D MR
angiograms. In addition, multiplanar reformations
(MPRs) of the MR angiography images are calculated
in the axial plane with a slice thickness of 2 mm on
a workstation.
Visualization of stent-grafts and artifacts
Ideal depiction and visualization of the stent-graft
is of utmost importance for follow-up examinations. It
is mandatory to identify the relative position of the
stent-graft to anatomic landmarks (eg, the renal artery
in case of abdominal aneurysms or the subclavian
artery for thoracic aneurysms) to ensure nonmigration
of the stent-graft device. The stent-graft is easily
Material Patients
Nickel titanium 267
Nickel titanium 823
Nickel titanium 607
Nickel titanium 315
Nickel titanium 108
Nickel titanium 104
Stainless steel 192
47
Stainless steel
812 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833

identified on T2-weighted spin-echo, and T2*- or T1-
weighted gradient-echo images (see Fig. 1). MR
visualization of stents and stent-grafts (artifacts) is
related to geometry and metallic composition of the
implant [52,56] and nitinol stents and stent-grafts
cause only minor distortions during MR angiographic
examinations. Platinum or gold markers used for better
radiopacity and easier identification of stent-grafts
cause only minimal MR artifacts, but sometimes result
in severe beam hardening artifacts at CT angiography
(Fig. 8) [58]. Three-dimensional MR angiograms
permit a comprehensive assessment of the arterial
lumen, perivascular tissues, and the aneurysm sac.
Hilfiker et al and Engellau et al, however, demonstrate
an underestimation of the luminal diameter of nitinol-
based abdominal aortic stent-grafts on 3D contrast-
enhanced MR angiography, whereas the wall thickness
is overestimated [57,63,66]. The degree of stent-

Fig. 9. Distal type 1 endoleak. CT scan (A) and catheter angiography (C,D) reveal a large endoleak (arrow) as a result of
upward migration of the left iliac limb into the sac. After distal overstenting, CT image (B) and digital subtraction angiography
(E) confirm complete seal of the endoleak.
 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833
Fig. 9 (continued ).
related susceptibility artifacts depends on the magnetic
field strength employed and the length of echo time
(TE); with lower field strength and shorter TE, sus-
ceptibility artifacts are reduced [56 – 58,62,67]. Over-
all, the visualization of nitinol-based stent-graft
devices is sufficient on 3D MR angiography, and this
technique helps to answer all clinically relevant issues
[47]. Visualization of stainless steel-based stent-grafts,
however, is impossible, based on the authors’ experi-
ence. Artifacts generated by the steel meshwork and
struts result in a substantial signal loss compose the
complete interior of the stent-graft and a radius of at
least 5 mm surrounding the stent-graft device.
Detection of endoleaks
Currently, two prospective studies comparing CT
angiography and MR angiography in the evaluation
of endoleaks are available [64,66]. Haulon et al
correlate 3D contrast-enhanced MR angiography with
dual-phase CT angiography and conventional angiog-
raphy in a series of 31 patients [64]. Arteriography
demonstrates an endoleak in 19 patients (18 type 2
and 1 type 1 endoleak). MR imaging detects 18 of 19
endoleaks on postcontrast T1-weighted sequences
including 2 false-positive findings. Delayed CT
angiography detects 10 of 19 endoleaks, one of which
is false positive. The sensitivity of contrast-enhanced
MR imaging and helical CT angiography for the
detection of type 2 endoleaks is 94% and 50%,
respectively [64]. The authors conclude that con-
trast-enhanced MR angiography is substantially
superior to helical CT in the detection of type 2
813
endoleaks. Engellau et al assess the success of
endoluminal stent-graft deployment in 11 patients
with the use of uniphasic CT (n = 20), contrast-
enhanced MR angiography (n = 20), and catheter
angiography (n = 13) [66]. In this report, MR
angiography detects contrast enhancement within
the aneurysmal sac (suggestive of a type 2 endoleak)
not confirmed by uniphasic CT or angiography in 10
cases. Large type 1 or type 3 endoleaks are identified
by all three modalities in four patients.
In the authors’ unpublished series of 32 patients,
MR angiography is confirmed superior to CT angiog-
raphy in the detection of type 2 endoleaks. Forty MR
angiograms correlate with arterial phase (n = 22) or
biphasic CT angiography (n = 18). In this series,
uniphasic CT angiography demonstrates three type 1
or type 3 endoleaks and four type 2 endoleaks. In
addition, MR angiography depicts two type 2 endo-
leaks missed by CT angiography. Using biphasic CT
angiography, two type 1 or type 3 endoleaks and three
type 2 endoleaks are detected. Delayed CT scanning
detected five type 2 endoleaks, of which two are
missed during arterial phase CT angiography. In addi-
tion to the findings with CT angiography, MR angiog-
raphy depicts another type 2 reperfusion endoleak.
One of the major weaknesses of published pro-
spective comparisons between CT and MR angiog-
raphy is the lack of a clearly defined gold standard.
Thus, it is impossible to confirm superiority of MR
angiography in detection of type 2 endoleaks if the
leak is not demonstrated on CT angiography on
arterial or delayed imaging.
Ferromagnetism (deflection)
A major safety concern is the occurence of stent
deflection or stent displacement during MR angiog-
raphy. In two in-vitro studies using a nitinol-based
Vanguard stent-graft, the degree of deflection meas-
ured is zero, and no displacement of the stent-graft on
application of a static magnetic field is noted [56 –
58,63]. According to these findings, any displace-
ment during in-vivo studies is extremely unlikely.
Consequently, MR angiography of nitinol stent-grafts
is considered a safe procedure. There are no reports
currently available that address MR safety concerns
about endoprostheses containing stainless-steel fer-
romagnetic materials (eg, Zenith or Endologix).
Heating
In in-vitro studies, heating of a nonferromagnetic
stent-graft device does not pose a biologically rel-
evant problem for MR imaging [63]. Studies with
increasing specific absorption rate (SAR) levels for
up to 18 minutes’ imaging-time do not show any
814 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833

increase in temperature of the stent-graft. Only meas-
urements at maximum SAR levels for 35 minutes
reveal a temperature increase of 1°C (2°F), which is a
minimal effect if the permanent cooling by constant
blood flow is considered [63]. It generally is accepted
that bioimplants tested for heating with a temperature
increase of less than 1°C do not create relevant
physiological effects [49,61,65]. Unfortunately, there
currently are no reports available that address the
heating effects of stainless-steel stent-grafts.
holding. In addition, claustrophobia is a doubtful
contraindication for MR angiography, because patients
can be examined after intravenous administration of
sedatives. MR image quality is severely hampered in
patients with metallic orthopedic implants or after
steel-coil embolization of branch vessels. Other im-
portant disadvantages of MR angiography are limited
availibility and economic considerations.
Catheter angiography

Limitations In light of the excellent results of CT and MR

MR imaging of several stainless-steel stents and
stent-grafts (eg, Zenith stent-graft) currently is not
recommended (see Fig. 1). The creation of severe
metallic artifacts limits the assessment of both stent
integrity and patency. For these types of stent-
grafts—unlike nitinol stent-grafts—potential hazards,
such as heating or deflection effects, are yet eval-
uated. The role of MR imaging after implantation of
stainless-steel stent-grafts still must be clarified in in-
vitro studies.
In general, contraindications for MR angiography
include patients with implanted cardiac pacemakers or
the inability of the patient to cooperate with breath-
angiography, the role of catheter angiography in
the preprocedural assessment is limited. Rarely, spiral
CT during selective accessory renal artery angiogra-
phy to measure the volume of the vascular territory of
each renal artery is useful before stent-graft implan-
tation [68]. According to SCVIR guidelines, angiog-
raphy may be helpful in better characterizing (inflow
and outflow channels) and treating any endoleaks that
are detected (Figs. 6, 7). There is no need for a catheter
angiogram in those patients with satisfactory outcomes
suggested by CT angiography. Angiography remains
the gold standard for demonstration of vessel anat-
omy and endoleaks. Because of its invasive nature,

Fig. 10. Type 2 endoleak. Arterial-phase (A) and delayed-phase (B) CT images after implantation of a Vanguard endoprosthesis
demonstrate a faint enhancement (arrow) within the aneurysm sac. Intra-arterial aortography (C) shows a retrograde flow to the
lumbar arteries via both iliolumbar arteries (arrows). Selective arteriography of the right hypogastric artery (D) after glue
enbolization of the iliolumbar artery shows glue/lipiodol-filled lumbar artery and aneurysm sac (arrow) with complete seal of
the endoleak.
 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833
Fig. 10 (continued ).
high cost, and operator dependence, however, intra-
arterial angiography normally is reserved for specific
cases where concern is raised, as in the assessment
of branch vessel endoleaks with a view to treatment
with embolotherapy.
A catheter angiogram should encompass the
abdominal aorta from the celiac axis to the femoral
bifurcations. The abdominal aorta and the stent-graft
should be imaged in at least two views (AP and
lateral). Selective catheterization of the superior
mesenteric artery should be performed to rule out
retrograde flow into the main trunk of the inferior
mesenteric artery and aneurysm sac via the Riolan
arch. The pelvic (iliofemoral) segment should be
imaged in at least three views (AP, right anterior
oblique [RAO], and left anterior oblique [LAO])
with the catheter positioned in each of the iliac limbs
of the stent-graft. In addition, selective arteriograms
of the hypogastric artery are mandatory to exclude
retrograde bleeding into the aneurymal sac via the
iliolumbar, lumbar, or median sacral arteries. Digital
815
imaging with subtraction should be employed to
ensure adequate visualization of branch vessels.
Imaging of stent-grafts
Currently available stent-grafts are made of an
external or internal stent skeleton (Nitinol, stainless
steel, or Elgiloy) covered with a graft material
(Dacron or polytetrafluoroethylene [PTFE]) inside
or outside the stent frame (see Fig. 1).
The brand names and features of devices that are
commercially available include (see Fig. 4) (Table 2)
[34,69]:
 The Ancure device (EVT/Guidant, Menlo Park,
CA), a bifurcated or tube endograft with hook-
like fixation devices made of elgiloy alloy. The
graft is made of Dacron with crimped legs. The
polyester fabric is supported only at both ends
by self-expandable, zigzag attachments.
816 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833

Fig. 11. Type 2 endoleak after endoluminal treatment of an abdominal aortic aneurysm. Curved planar reformations of a CT data
set (A,B) reveals a patent accessory right renal artery (arrow) via the left lumbar artery L4 (arrowheads).

 The AneuRx stent-graft (Medtronic, Sunnyvale,  The Quantum LP device (Cordis/Johnson &
CA), a modular endoprosthesis made of thin- Johnson, Warren, NJ), a bifurcated stent-graft
wall Dacron fully supported by self-expand- with a Nitinol gasket and two iliac extension
able Nitinol. legs, covered with thin Dacron.

Fig. 12. Type 2 endoleak. Aortography (A) and selective arteriography of a prominent left lumbar artery L1 (B) show a
retrograde flow into the proximal portion of the abdominal aortic aneurysm (arrows).
 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833 817

 The Endologix device (Bard, Covington, GA),
a one-piece self-expandable device with
a frame made of elgiloy and a graft of thin
e-PTFE.
 The Excluder device (Gore and Ass, Flagstaff,
AZ), a tube or bifurcated modular ePTFE stent-
graft fully supported by a self-expandable frame
of Nitinol.
 The Lifepath endoprosthesis (Baxter, Morton
Grove, IL), a modular device made with a metal
frame of elgiloy and stainless steel, covered
with standard polyester Dacron. The device is
fully supported by internal-external elgiloy wire
hoops interwoven to graft fabric and combined
with a balloon expandable stainless-steel stent.
 The Talent stent-graft (Medtronic, Sunnyvale,
CA) is a supported, self-expandable, tubular or
bifurcated modular device with a metal frame
made of Nitinol covered with a thin-wall
Dacron graft material.
 The Vanguard stent-graft (Boston Scientific,
Natick, MA), a supported, bifurcated self-
expandable device, made of a frame of Nitinol
and a thin Dacron.

Fig. 13. Failed endovascular treatment of a thoracic aortic aneurysm. CT scan prior (A) and after (B) placement of a total of four
tubular Talent stent-grafts demonstrate incomplete overlap of the devices, resulting in a large type 3 endoleak. Patient refused
further treatment and was submitted two years later for follow-up. CT scans (C,D) reveal a substantial growth of the aneurysm
sac and complete separation of the modular segments of the endoprostheses.
818 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833

 The Zenith stent-graft (Cook Inc., Bloomington,
IN), a fully-supported, bifurcated, modular self-
expandable device with stainless-steel Z-stents,
covered with standard Dacron.
Plain radiography depicts all metallic components
of the devices and is used preferentially to Âdemon-
rate any changes in structural integrity (see Fig. 1).
An application perfectly suited to CT angiography
is the evaluation of metallic stents and stent-grafts for
the treatement of aneurysmal disease. Regardless of
their metallic components, vascular stents and stent-
grafts typically result in few artifacts on spiral CT
scans. As a result, CT provides exquisite depiction of
the metallic frame and lumen of stent-grafts and of
thesurrounding structures.
On MR imaging and MR angiography, the stent-
graft is identified easily on T2-weighted spin-echo
and T2*- or T1-weighted gradient-echo images. Niti-
nol stents and stent-grafts cause only minor artifacts
during MR angiographic examinations. Platinum or
gold markers used for better radiopacity and easier
identification of stent-grafts cause only minimal MR
artifacts, but sometimes result in severe beam hard-
ening artifacts at CT angiography (Fig. 8). In contrast,
the metallic structure of certain stainless-steel stent-
grafts (eg, the Zenith endoprosthesis) may preclude
their evaluation with current MR-imaging techniques
(see Fig. 1).
Endoleaks and endotension
The classic complication of endoluminal aneurysm
repair is an endoleak, which continues to pose a
challange for stent-graft technology. Endoleaks,
defined as persistence of blood flow within the aneu-
rysmal sac outside the lumen of the endoprosthesis, are
a major limitation to the success of endoluminal
treatment of aortic aneurysms [39,70]. White et al
propose a classification system for endoleaks [71].
Type 1 endoleaks are related to inadequate seals at

Fig. 14. Type 3 endoleak. Contrast-enhanced maximum intensity projection-MR angiogram (A) demonstrates a large endoleak
(arrow) at the proximal attachment zone of the left iliac limb. Coronal T1-weighted gradient-echo MR image (B) shows the
dislocated left iliac limb (arrow) of the Vanguard device. CT images and digital subtraction angiography prior (C,E) confirm the
endoleak (arrow), and, after oeverstenting (D,F), the complete seal.
 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833 819

Fig. 14 (continued ).

the proximal (1A) or distal (1B) attachment sites (see
Figs. 7, 9). Type 2 endoleaks result from retrograde
perfusion of patent aortic branch vessels (eg, lumbar
arteries, inferior mesenteric artery, median sacral
artery, or accessory renal arteries) (Figs. 10 – 12).
Type 3 endoleaks are graft-related failures, resulting
from component disconnections of modular devices,
fabric tears, and disintegration (Figs. 13, 14). Type 4
endoleaks result from transgraft flow due to graft wall
porosity. Absence of a patent endoleak is no guarantee
that a rupture will not occur and continued expansion
of the apparently excluded sac is a better indicator that
820 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833

the aneurysm is at risk for rupture [72,73]. Indeed, a the absence of an endoleak as ‘‘endotension’’ (Fig. 15)
limited number of aneurysms enlarge without an [74 – 76]. Currently, it is unknown how much flow
apparent endoleak after endovascular aortic aneurysm through the endoleak or how much contrast agent is
repair [73,74]. Several reports refer to sac expansion in required to visualize an endoleak. The Laplace law

Fig. 15. Endotension. CT scan three days after implantation of an Excluder stent-graft seems normal with complete exclusion of
the aneurysm sac (A). Five-month follow-up CT scan (B) demonstrates enlargement of the sac without evidence of an endoleak.
Subsequently performed T2-weighted MR images (C) show a high-signal-intensity thrombus formation and extra-aneurysmal
fluid collection. Coronal contrast-enhanced MR angiography (source images) in arterial phase (D) and delayed phase (E) reveals
a delayed faint perigraft enhancement (arrows) within the sac, which was missed on CT images. Selective arteriography (F) of
the left iliolumbar artery confirms patent lumbar arteries; however, a retrograde flow into the sac was lacking. (G) CT scan
employed five months after glue embolization of these arteries demonstratres shrinkage of the aneurysm sac and thus confirms
the hyppothesis of successful treatment of endotension.
 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833 821

Fig. 15 (continued ).

suggests that it is pressure (or endotension), rather
than flow within the aneurysm sac, that causes
expansion and rupture [75,76]. Endotension may be
present in the absence of detectable flow because of
fenestration or leaks in the stent-graft membrane [77]
or transmission of pulsatile pressure into the aneur-
ysm sac [78]. Thus, it is possible to have systemic sac
pressures without evidence of endoleaks on CT or
angiography. Although direct routine measurement of
endotension is not yet possible, continued postoper-
ative expansion or re-expansion of the sac defini-
tively implies the presence of an endotension, and,
therefore, is a strong indication for secondary inter-
vention. Measurements of the sac diameter suffer
822 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833
from poor reproducibility, and there is evidence that
estimation of sac volume using spiral CT angiography
is a more accurate indicator of such expansion. The
most important advantage of sac-volume measure-
ment is that volume measurements provide a good
description of precision with an intra- and interob-
server repeatability coefficient (5.6 mL and 10.3 mL,
respectively), compared with diameter measurements
(3.8 mm and 3.9 mm, respectively) [79]. Wever et al
show that aneurysm size changes after endovascular
repair remain unchanged using maximum diameter
measurements in 37% of cases [80]. Thus, volume
measurements allow for earlier definition of success-
ful exclusion of an aneurysm [70].
According to the literature and the EUROSTAR
registry, endoleaks occur in 2.4% to 45.5% of patients
with endovascular repair of thoracic and AAAs during
follow-up [33,39,44,70,71,81 – 83]. The EUROSTAR
registry proposes survival, free from persistent endo-
leaks, as a possible outcome measure. The rationale
for using an endoleak as an indicator of treatment
failure is based on the assumption that in the presence
of an endoleak, aneurysms continue to expand and
eventually rupture [73]. The course of endoleaks,
however, varies, including disappearance with or
without subsequent shrinkage of the aneurysmal sac
or persistence with or without further expansion of the
sac [72]. If there is no perigraft flow after stent-graft
placement or successful treatment of endoleaks, the
natural history should be a decrease in aneurysm size
[2,38,83,84]. Malina et al observe that even minor
endoleaks or collateral perfusion inhibit the reduction
of sac diameter in patients after aortic stent-graft
implantation [83]. It is evident that incomplete depres-
surization of the aneurysmal sac allows the aneurysm
to continue to grow, and rupture may occur in this
situation [12,85,86].
Misplacement of the endoprosthesis may result in
a type 1 endoleak (Figs. 7, 16) [71]. Another reason
for type 1 endoleaks is a mismatch in the diameter of
the stent-graft and the diameter of the attachment
zone. Albertini et al find a significant correlation
between proximal neck angulation and both endoleak
and graft migration, whereas the conical shape,
thrombus lining, and calcifications of the proximal
neck do not increase the complication rate [87,88]. In
contrast, others find no correlation between proximal
type 1 endoleaks and neck angulation or form of the
aortic neck [70,89]. In the EUROSTAR registry,
proximal type 1 endoleaks are observed in 2.7% of
patients [33,34]. In the multicenter AneuRx trial, the
rate of proximal type 1 endoleaks is 4% of patients
[73]. If a modular device is used, endoleaks at the
junction site, because of incomplete expansion or
displacement, may occur (type 3 endoleaks). Aneu-
rysms with large type 1 and type 3 endoleaks are
associated with a significant risk of aneurysm rupture
if untreated [6,12,33,82,90,91]. Therefore, patients
with type 1 or type 3 endoleaks cannot be considered
successfully treated and these procedures must be
considered technical failures.
The occurrence of a type 2 endoleak with persistent
flow outside the endograft was initially considered a
failure of endovascular aortic repair, but this condition
is unpredictable [43,92]. The clinical importance of
retrograde perfusion of the aneurysmal sac still is a
subject of debate [72,89,93]. Approximately 40% to
67% of the inflow and outflow aortic branches that are
patent prior to stent-graft implantation occlude sponta-
neously after successful endovascular aortic repair
[94,95]. Rarely, endoleaks seal spontaneously after
more than six months [96]. Type 2 endoleaks seem
to occur more readily when there is little thrombus in
the aneurysm sac and when there are obvious patent
branch vessels, such as lumbar arteries or the inferior
mesenteric artery, communicating within the sac
[97,98]. An ex-vivo model demonstrates that, in the
absence of thrombus, pressure transmitted via an
endoleak to the sac is unchanged regardless of length
or diameter [99]. There is evidence that embolization
of lumbar and inferior mesenteric vessels prior to stent-
graft implantation has little influence on the incidence
of type 2 endoleak during follow-up [100].
Criado et al create aortic aneurysms with full-
thickness jejunal patches, which, in contrast to pros-
thetic patches, are susceptible to rupture [101]. After
endovascular stent-graft treatment of these aneurysms,
the sac pressure differential is measured. In dogs
without endoleaks, the pressure differential is high
and there is no evidence of aneurysm rupture. In dogs
with endoleaks, there is no significant pressure differ-
ential and all aneurysms ruptured within 5 days of
surgery [101]. Baum et al measure blood pressures
within the aneurysmal sac in patients, and find sys-
temic or near-systemic pressure in the presence of type
2 endoleaks [42,78]. Enhancing flow channels within
the sac are found at imaging, and further expansion of
aneurysms is considered a consequence of this per-
sistent sac pressure [6,71]. Other studies show, how-
ever, a poor correlation between the presence or
absence of type 2 endoleaks and postoperative
changes in the morphology of the aneurysmal sac [12].
Tears in the fabric material (type 4 endoleaks) are
observed in the early phase of commercial stent-grafts
[11,91]. Because the graft component of the devices
is improved, however, fabric tears rarely are seen.
All types of endoleaks are conditions unrecog-
nized in the era of conventional opensurgical repair,
 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833 823

Fig. 16. Distal migration as a result of severe kink of the proximal neck, resulting in a type 1 endoleak. Intravenous digital
subtraction angiography at discharge (A) three months (B) and one year (C) after implantation of a bifurcated Vanguard device
show progressive distal migration of the stent-graft (arrows) with development of a proximal type 1 endoleak. Axial CT scan (D)
and maximum intensity projection (MIP)-CT reconstruction (E) confirm migration and perigraft endoleak (arrowheads).
Subsequently, a tubular stent-graft was implanted proximally to seal the endoleak. Axial CT scan (F) and MIP-CT reconstruction
(G) show a satisfactory result. Two years later, however, the patient was admitted to the authors’ institution because of sign of
peripheral occlusive disease. Plain lateral radiograph (H) and aortography (I) reveal complete separation of the bifurcated and
tubular stent-graft because of further distal migration of the bifurcated device and severe kink of both iliac limbs. Finally, access
to the lumen of the devices was achieved (J) and an Excluder stent-graft was successfully placed. Aortography (K) and axial CT
scan (L) demonstrate patency of the endovascular devices (arrowheads) and complete exclusion of the aneurysm.
824 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833

Fig. 16 (continued ).

in which a prosthetic graft replaces the aneurysmal
segment and side branches are sutured. Thus, unlike
open repair, follow-up remains vital for endovascular
aortic aneurysm repair.
Imaging of major complications
Endovascular repair of aortic aneurysms is ac-
cepted as an alternative to conventional open surgery,
but various complications may occur after treat-
ment [3,34,102 – 104]. Apart from aneurysm rupture,
failure of the repair is implied by patent endoleak,
by contiguous expansion of the aneurysmal sac, or
by thrombotic occlusion of the stent-graft device
[105 – 107]. In the absence of such evidence, im-
pending failure may be suggested by distortion,
displacement, or any form of structural disintegration
of the endoprosthesis.
Imaging of endoleaks
The success of endovascular aneurysm repair
depends on ensuring that the aneurysm is completely
excluded. The most common complication of these
procedures is persistent flow within the aneurysm
 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833 825

Fig. 16 (continued ).

[39]. Perigraft flow can be very slow and thus patency of endoleaks [43,109]. In addition, selective
undetected during aortography [41,108]. Selective placement of microcatheters into branch vessels of
catheter angiography, however, may be used to dis- the aorta may facilitate direct depiction and treatment
play inflow and outflow arteries that contribute to the of type 2 endoleaks [42]. CT angiography is used
826 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833
commonly for the detection of endoleaks and is
superior to color-Doppler ultrasound [20,37,94,110];
although evidence is emerging that contrast-enhanced
MR angiography is more sensitive [64,66,111]. In
contrast to catheter angiography, helical CT angiog-
raphy relies on generalized arterial enhancement from
an intravenous injection; thus, opacification of peri-
graft channels is improved. To increase further the
sensitivity of CT angiography to slow endoleaks, a
biphasic protocol is advocated, incorporating a sec-
ond, delayed acquisition.
Goerich et al propose a classification system
for endoleaks based on findings at CT, DSA, and
radiography [44]. According to this classification,
four areas most affected by the endoleaks (leakages)
are observed:
1) Broad-based leakages directly adjacent to the
prosthesis, the result of leakage at the sites of
the terminal end of the stent-graft (see Fig. 14);
2) Ventral leakages without direct connection to
the stent-graft, supplied by the inferior mes-
enteric artery;
3) Leakages that have a base dorsolateral to the
margin of the aneurysm sac supplied either by
the lumbar arteries or the median sacral artery
(see Figs. 10, 11);
4) Huge circumferential perigraft leakages indic-
ative of dislocation of the stent-graft or a too-
short endoprosthesis (see Figs. 9, 13).
In series comparing CT and MR angiography,
stent-graft disconnection, limb retraction, or prox-
imal migration of the stent-graft body resulting in
type 1 and type 3 endoleaks, respectively, are equally
well detected with both techniques (see Figs. 7, 9,
13, 14) [64,66,111]. MRA has an advantage in the
detection of small reperfusion type 2 endoleaks in
several studies. Neither arterial-phase CT nor MR
angiography is likely to diagnose small type 2 endo-
leaks. In our series, delayed T1-weighted MR scans
after gadolinium injection or delayed CT scans are
mandatory to increase detection confidence (see
Fig. 15). Delayed T1-weighted images are of the
utmost importance in detecting small type 2 endo-
leaks, but readers must be careful not to misinterpret
hyperintense thrombus formation on precontrast
images, particularly in recently implanted or revised
stent-grafts, because thrombus signal intensity may
vary according to age [54,109]. Consequently, false-
positive identification of an endoleak is likely to
occur if no precontrast T1-weighted sequence or a
delayed T1-weighted MR scan is included in the
scanning protocol.
In the detection of type 4 endoleaks, all imaging
modalities (Duplex ultrasound, CT scans with
delayed series, or contrast-enhanced MR angiogra-
phy) may visualize the endoleak only indirectly.
Device-related failures
Successful insertion of the stent-graft device is
possible in 97% to100% of cases [2,9,34,73]. Device-
related failure may include migration, distortion,
structural disintegration, or any combination of these
and can result in either an endoleak or occlusion [93,
104,112,113].
Plain radiographs are an important method for
assessing the integrity of the stent-graft and for
detecting rupture of the stent mesh at long-term
follow-up [15]. This seems to be particularly true in
patients in whom the rupture is the result of material
fatigue, which may be an issue in older prostheses
(see Fig. 2). The diagnosis of such ruptures often
is more difficult to make with DSA, CT, or MR
angiography, because the only finding may be a
large endoleak.
Migration is an important risk factor for sub-
sequent rupture or late conversion to open repair
(Fig. 16) [33]. In addition to inappropriate small
sizing of the stent-graft, dilatation of the aneurysm
neck after endoluminal repair is a cause of graft
migration in up to 50% of cases [38,70,104,114].
Dilatation of the proximal neck does not seem to be
related to the stent-graft diameter or the degree to
which it is oversized to the neck [114].
Mild changes in the shape of the endograft over
time are common, but severe distortion or kinking
can lead to failure of the repair [33,113]. The rela-
tionship of stent-graft distortion and the reduction in
size of the aneurysm sac that can follow successful
exclusion is unknown. A highly significant associa-
tion between reduction of sac dimensions, device dis-
tortion, and limb complications is reported [33,112].
In contrast, others find a nonsignificant reduction
in length of the aneurysm sac in the majority of
cases [115].
Material fatigue, including failure of the structural
intergrity of stent-grafts, is noted increasingly
[91,112,113,116]. Plain radiographs clearly can dem-
onstrate fracture, distortion, or separation of parts of
the metallic framework but will miss tears of the graft
fabric along with subsequent endoleaks.
Graft thrombosis
Semicircular thrombotic wall appositions are
observed on follow-up CT scans in up to 19% of
 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833 827

cases (see Fig. 4D) [102,116]. These thrombotic
wall appositions are not usually flow-limiting and
have no clinical relevance. Late occlusion of all or
part of the stent-graft occurs in 1.5% to 10% of
cases (Fig. 17) [73,81,113]. In the majority of cases,
distortion of the device by kinking or twisting or a
stenosis of the distal iliac artery is responsible for
limb thrombosis. The completion angiogram at the
end of the procedure should be carefully evaluated
for any stenotic lesion. An uncommon complication

Fig. 17. Graft-limb thrombosis. Follow-up CT scan (A,B) shows an occluded left iliac limb (arrow) one year after endovascular
treatment of an abdominal aortic aneurysm. Catheter angiography (C) confirms complete thrombotic occlusion of the left iliac
limb of the Vanguard I prosthesis.
828 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833
Fig. 18. Infection of an endoluminal stent-graft. Initial axial CT image (A) prior to placement of an Excluder endoprosthesis is
unremarkable. Three months after implantation, CT scan (B) shows gas (arrowhead) within the aneurysm sac and enhancing
irregular posterior aneurysm wall (arrow).
is a complete acute thrombosis of the stent-graft
[102], which necessitates local fibrinolysis or urgent
surgery [107].
Graft infection
Although graft infection is considered a serious
complication with high morbidity and mortality in
open surgical repair, stent-grafts are rarely prone to
infections. A postimplantation syndrome including
low-grade pyrexia, leukocytosis, and elevation of
C-reactive protein is a common, self-limiting phenom-
enon [11,117]. In the early postprocedural period, CT
angiography frequently shows air within the sac,
introduced during the procedure (see Fig. 5D) [117].
Late appearance of gas within the sac, however, is an
ominous sign of stent-graft infection (Fig. 18).
Summary
Although the technical success of stent-graft
implantation is established and relatively safe, data
on the long-term safety and efficacy of endovascular
repair are just emerging. Because several late com-
plications of aortic stent-graft placement have been
observed, life-long follow-up remains essential.
Imaging methods form an integral part of every
stage of endovascular aortic aneurysm repair. The
current imaging strategy should include initial plain
films, CT angiography, and color-coded Duplex
sonography. Plain films are an excellent means to
detect migration, angulation, kinking, and structural
changes of the stent mesh, including material fatigue,
at follow-up. Helical CT angiography is considered a
potentially revolutionary method for the noninvasive
complete postprocedural assessment of aortic stent-
grafting. Current data justify the use of biphasic CT
angiography as the postprocedural imaging technique
of choice in most patients [118].
Ultrasound offers the advantages of low cost and
lack of radiation exposure. High-quality ultrasound
reliably excludes endoleaks in patients after stent-
grafting of AAAs. There is a substantial variability,
however, in measuring the diameter of aneurysm
sacs; thus, confirmation using an alternative study is
prudent in cases that demonstrate a significant change
in size during follow-up.
MR angiography serves as an attractive alternative
to CT angiography in patients with impaired renal
function or known allergic reaction to iodinated
contrast media. With current techniques, the visu-
alization of aortic stent-grafts (with the exception of
stainless-steel – based devices) is sufficient with MR
angiography. There is evidence that MR imaging is
superior to CT angiography in detecting small type
2 endoleaks or for excluding retrograde perfusion in
patients with suspected endotension.
The role of diagnostic catheter angiography is
limited to assessment of vascular pathways in equi-
vocal cases or for suspected endotension.
Currently, a consensus view about postprocedural
management after aortic stent-graft implantation is
lacking. The authors propose performing a baseline
CT angiography at discharge and a biphasic CT
angiography and Duplex ultrasound scan at theee
months. In patients with no evidence of an endo-
leak, CT angiography, plain film and Duplex sonog-
 S. Thurnher, M. Cejna / Radiol Clin N Am 40 (2002) 799–833
raphy (abdomen) should be repeated every year after
endovascular repair. If an endoleak is present at
follow-up, immediate appropriate treatment should
be initiated.
Acknowledgments
The authors wish to thank Mary A. McAllister for
editorial assistance.
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 Radiol Clin N Am 40 (2002) 835 – 846
MR angiography for assessment of peripheral
vascular disease
Mathias Goyen, MD*, Stefan G. Ruehm, MD, Jörg F. Debatin, MD, MBA
Department of Diagnostic and Interventional Radiology, University Hospital Essen, Hufelandstrasse 55, 45122 Essen, Germany
As the western population continues to age, ather-
osclerotic disease is increasingly prevalent. Although
atherosclerotic disease can manifest itself in all vas-
cular territories, the lower extremities are most fre-
quently affected, with 90% of cases identified below
the aortic bifurcation [1]. Currently, peripheral vas-
cular disease (PVD) accounts for 50,000 to 60,000
percutaneous transluminal angioplasties, implantation
of 110,000 vascular prostheses and 100,000 amputa-
tions annually in the United States alone [1]. The
disease frequently interferes with activities of daily
living, resulting in loss of independence and eco-
nomic productivity. PVD is one manifestation of the
systemic process of atherosclerosis and is frequently
associated with coronary, renal, and carotid arterial
disease. Like atherosclerotic lesions elsewhere, PVD
is characterized by diffuse arterial stenoses and
occlusions. Patients with PVD may present with an
acute limb-threatening event, a chronically threatened
limb, or claudication. With the availability of
improved transluminal and surgical revascularization
techniques, as well as refined pharmacological inter-
ventions for the treatment of PVD, early and accurate
diagnosis, which provides information about the
location, extent, and severity of the arterial involve-
ment, is crucial. Thus, early and precise mapping of
atherosclerotic disease manifestations plays a vital
role in the management of patients with PVD.
Diagnosing PVD usually is a two-step procedure.
First, patients undergo noninvasive testing, which
includes segmental blood pressure and Doppler or
* Corresponding author.
E-mail address: mathias.goyen@uni-essen.de
(M. Goyen).
0033-8389/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 2 1 - 0
plethysmographic blood flow measurements. These
studies assess the presence and severity of PVD and
help localize the disease process to the inflow, out-
flow, or runoff vessels. If these tests, in conjunction
with the clinical examination, identify PVD and are
thought to be amenable to percutaneous or surgical
therapy, the patient is subjected to the next level of
work-up, which consists of some form of morphologic
vascular imaging. Current options include catheter-
based x-ray angiography, computed tomography (CT)
angiography, duplex scanning,and magnetic res-
onance (MR) angiography.
Conventional catheter-based x-ray angiography
has long served as the imaging modality of choice
in this respect and is still considered the gold standard.
High cost, invasiveness, and associated risks [2,3]
have motivated the development and evaluation of
noninvasive peripheral vascular imaging techniques.
MR angiography (MRA) has advantages over CT
angiography, including the availability of a large field
of view, use of non-nephrotoxic contrast material, and
lack of ionizing radiation. Compared to ultrasound,
MR is less operator-dependent and overcomes dif-
ficulties related to acoustic window limitations.
As diagnostic and treatment options for patients
with PVD evolve, a more liberal use of MR angio-
graphic evaluations is emerging. Radiologists in-
volved with these techniques must have a detailed
understanding of what information is needed for
treatment planning if peripheral MRA is to fulfill its
potential as a primary noninvasive imaging modality
for PVD [4].
The aim of this review is to describe existing state-
of-the-art MRA techniques for the assessment of the
lower extremity arterial system. Technique-related as-
pects are highlighted, and the existing clinical experi-
836 M. Goyen et al / Radiol Clin N Am 40 (2002) 835–846
ence is summarized. Finally, some work-in-progress
techniques that are likely to have an impact on MRA of
the lower extremity vessels in the future are discussed.
Noncontrast peripheral MRA
The exquisite sensitivity of the MR experiment
with regard to motion enabled the selective display of
the vascular system without the use of contrast mater-
ial. Unlike other vascular imaging techniques, non-
contrast MRA displays blood flow and not the blood
vessel itself. The two-dimensional time-of-flight (2D
TOF) technique has been the most commonly used
method for acquiring MR angiograms of the peri-
pheral arterial tree. Based on the acquisition of con-
tiguous axial images, the technique is based on the
inflow of fresh unsaturated blood in a saturated slice.
The background tissue is saturated by using radio-
frequency (RF) pulses with a repetition time much
shorter than the T1 values of the surrounding tissues
thereby decreasing its longitudinal magnetization vec-
tor. As inflowing, ie, unsaturated, blood maintains a
large longitudinal magnetization vector, it is delin-
eated as an area of high signal intensity. The 2D TOF
methods have been shown to be accurate for the as-
sessment of infrainguinal arterial disease [5]. Reported
sensitivity and specificity values for detection of
hemodynamically significant stenoses range between
63% and 100% based on the use of invasive catheter
angiography as the standard of reference [6 – 10].
Several practical problems, however, exist when using
the 2D TOF methods to investigate the peripheral vas-
culature. First and foremost, 2D TOF data acquisition
times are prohibitively long, with scan times exceed-
ing 30 minutes per extremity. Second, flow in the
peripheral vasculature can be highly pulsatile, espe-
cially in patients with PVD. Typical velocities in the
popliteal artery are 50 cm/second in systole, but
average only 5 cm/second throughout the cardiac
cycle. Thus, during diastole, there may be reversal
of flow, which can cause artifacts and reduce the net
forward flow. In addition, in the presence of occlu-
sions, arteries may fill in a retrograde fashion, com-
plicating the use of spatial presaturation techniques for
eliminating venous signal [11].
Contrast-enhanced peripheral 3D MRA
Contrast-enhanced (CE) 3D MRA does not suffer
from many of the previously discussed shortcomings,
which is the reason for its rapid integration into the
routine diagnostic armamentarium for the evaluation
of patients with PVD in centers throughout the world
[12,13].
General technical considerations
As with other vascular territories, the contrast-
enhanced approach offers several advantages over
conventional MRA techniques, including short acqui-
sition times, high spatial resolution, and high signal-
to-noise ratios. In many centers, the development of
contrast-enhanced 3D MRA already has had a pro-
found impact on PVD evaluation strategies. Requiring
only a venous puncture and employing contrast agents
characterized by a total lack of nephrotoxicity and an
excellent safety profile [14], 3D MRA techniques
have already lowered the threshold for assessing the
arterial morphology of the lower extremities.
Paramagnetic contrast agents are pivotal for dis-
playing the vascular system with fast three-dimen-
sional gradient-echo sequences [12]. Without the
presence of paramagnetic contrast, these sequences,
characterized by very short repetition times, render
nondiagnostic images void of any intravascular signal.
The presence of paramagnetic contrast in the vascular
system under investigation over the length of the
data acquisition period is essential for successful CE
3D MRA.
Paramagnetic contrast agents shorten the T1-
relaxation time of blood. Gadolinium, which is the
most commonly used paramagnetic substance, has a
high relaxivity and a favorable safety profile when
bound to a chelate. During the short intravascular
phase the intravenously injected T1-shortening con-
trast agent provides signal in the arterial and venous
systems, thereby elevating the vessel to background
contrast-to-noise ratio and eliminating flow artefacts.
Hence, signal of flowing blood is no longer flow-
dependent. Flow-induced artefacts seen with noncon-
trast time-of-flight or phase-contrast MRA techniques
are therefore largely eliminated, and images can be
collected in the plane of the vessels of interest. This
allows coronal coverage of large vascular territories in
short imaging times and generates images that are
similar in appearance to conventional catheter-based
x-ray angiography.
Though similar in principle to spiral CT angiog-
raphy, contrast-enhanced MRA holds considerable
advantages. Beyond the absence of ionizing radiation
and the ability to depict large vascular territories in 3D
imaging volumes, harmful side effects of the para-
magnetic contrast agents used for the MRA examina-
tion are considerably less frequent and less severe than
those associated with iodinated contrast. Paramag-
netic contrast agents are non-nephrotoxic and have a
 M. Goyen et al / Radiol Clin N Am 40 (2002) 835–846
low incidence of anaphylactoid reactions [14]. Thus,
they are safe for use in patients with renal insuf-
ficiency as well as in patients with a history of allergic
reactions to iodinated contrast media. Finally, on CE
3D MRA images, merely the contrast-filled vessels
are displayed. In contrast to CT, bones and calcium are
dark, thereby greatly facilitating the interpretation of
the underlying 3D data sets.
Contrast-enhanced 3D MRA has been shown to be
useful for depiction of the supra-aortic arteries, the
thoracic and abdominal aorta as well as its major
branch vessels. In its initial implementation, lengthy
imaging times ranging between three and five minutes
precluded data acquisition during a breath hold [13].
Ensuing respiratory motion artefacts considerably
degraded image quality. Breath-held data acquisition
did become possible with the use of improved gra-
dient systems permitting considerable reductions in
the minimum repetition (TR) and echo times (TE).
The implementation of fast 3D gradient-echo sequen-
ces on high-performance systems permits the acquisi-
tion of complex 3D data sets within the confines of a
breath hold, in as little as five to ten seconds [15]. This
dramatic reduction of scan time has even allowed the
collection of temporally resolved 3D data sets. This
allows the obtaining of information regarding the tran-
sit of the paramagnetic contrast agent through the
vascular system. Ultrafast 3D data acquisitions in con-
junction with fast table-feeds also permit ‘‘chasing’’
the contrast bolus through several vascular territories
[16,17].
To achieve maximal T1-weighting, spoiled se-
quences should be employed. Spoiling is useful be-
cause it destroys the residual magnetization after each
echo and thus magnifies the effect of T1 relaxation
agents. Repetition and echo times that are as short as
possible should be chosen; a flip angle ranging be-
tween 10
and 30
provides adequate suppression of
the surrounding tissues and has been shown to render
excellent image quality. Section thickness should be
adjusted to between 1.5 and 2.5 mm in order to assure
full coverage of the vascular system under considera-
tion and still permit multiplanar reformations.
The paramagnetic agent is generally administered
via an intravenous catheter that is placed into an
antecubital vein. The flow rate should be adjusted to
ensure injection of the entire contrast volume in a
period about 25% shorter than the acquisition time.
To achieve maximal image quality, the presence of
the intravenously administered contrast bolus in the
vascular territory under consideration must coincide
with the data acquisition period. Several manual and
automated techniques are available to ensure proper
timing of the scan delay. Maximal contrast concen-
837
tration in the vessel of interest should be achieved
during the acquisition of the central, contrast-deter-
mining portion of k-space [15]. Regardless of the
timing regimen or imaging technique employed, use
of an automated injector facilitates contrast timing
and delivery as it allows precise infusion of paramag-
netic contrast using predefined weight-adjusted rates
and volumes.
The high contrast between contrast-containing
luminal (bright) and extraluminal (dark) spins and
the true 3D nature of the acquired data sets provide
the basis for the generation of angiograms employing
a variety of postprocessing algorithms [18]. Analysis,
therefore, should not be limited to maximum intensity
projections or surface shaded display. The three-
dimensionality inherent to the technique can only
be fully exploited if the data are viewed interactively
on a workstation using surface-rendering algorithms.
Endoluminal, virtual angioscopic images can also be
obtained, but their clinical relevance remains to be
determined [18].
Contrast-enhanced methods for peripheral MRA
Assessment of the peripheral arterial system man-
dates coverage from the iliac bifurcation to the pedal
arteries; hence, several 3D data sets need to be
collected for a complete display. Rapid parenchymal
enhancement and contrast-dose limitations had ini-
tially restricted the CE 3D MRA technique to the
display of a single vascular territory contained within
a 40 – 50-cm field-of-view. Following the imple-
mentation of bolus-chase techniques with integrated
table motion algorithms, imaging of up to three
contiguous vascular territories has become possible.
Thus, the pelvic and run-off arteries can be assessed
in a single examination [16,17].
Several approaches have been advocated, includ-
ing a timed single-phase examination with subtraction
to eliminate the effects of preceding contrast injections
[19 – 21] (multi-injection – multistation technique), a
time-resolved method collecting data at several sepa-
rate stations (TRICKS) [22,23], and a slow infusion
technique with incremental table motion [16,17]. The
latter has emerged as the clinical technique of choice
and is known as ‘‘floating-table‘‘ or ‘‘bolus-chase’’
contrast-enhanced 3D MRA.
For the ‘‘bolus-chase’’ technique, the patient is
placed supine in the MR scanner, with arms posi-
tioned either above the head or crossed over the chest.
In order to limit the anterior-to-posterior extent of the
required 3D-imaging volume, the patient’s legs should
be positioned horizontally. Most of the proposed
methods use image subtraction in order to reduce
838 M. Goyen et al / Radiol Clin N Am 40 (2002) 835–846

background signal and improve vessel-to-background
contrast [24,25]. Image subtraction improves vessel
contrast, especially for small arteries. Likewise, dur-
ing multistation examinations, image subtraction may
be used to reduce signal from surrounding stationary
tissues. Thus, following the nonenhanced scout
image, precontrast coronal 3D mask images required
for image subtraction can be prescribed. Subse-
quently, 3D data sets are collected during the infusion
of paramagnetic contrast, extending from the pelvis to
the calves. Three 3D-data sets are collected in imme-
diate succession. The selection of the specific acquisi-
tion technique depends on the available MR scanner
as well as the clinical goals of the examination.
Regarding the infusion of the gadolinium-based
contrast agent, two different infusion protocols have
been proposed: Ho et al and Meaney et al advocate a
relatively slow administration of a fixed volume of 40
ml of gadolinium-based contrast agent at a rate of 0.3
to 0.5 ml/second [16,17]. On one hand, the slow
injection results in lower intra-arterial contrast con-
centration inducing less T1 reduction within the
blood; on the other hand, it provides longer bolus
duration with equal doses of contrast material com-
pared with a fast injection technique. Furthermore, the
contrast agent is extracted by the soft tissues during
the first pass, thereby reducing venous enhancement.
As a result of the lower arterial signal, however, larger
voxel sizes are used, which impair visualization of
small vessels, especially below the knee. Never-
theless, promising results have been reported for the
evaluation of distal vessels using a slow infusion tech-
nique [16,17] (Figs. 1, 2).
The second approach uses faster injection rates
(1 – 2 ml/second), which lead to relatively short
passage times of contrast-enhanced blood. The com-
pact contrast bolus is followed through the peripheral
vascular system. The risk of venous opacification is
higher as the bolus cannot be fully extracted by the
surrounding tissues during first-pass passage. There-
fore, acquisition times have to be kept as short as
possible, which requires very short repetition times
(TR < 5 milliseconds) and hence mandates the use of
high-performance gradient systems. The downside of
short acquisition times relates to limited spatial res-
olution. Nevertheless, excellent results have been
reported using this technique [25,26].
Single-phase 3D acquisitions during the infusion
of gadolinium have also been proposed for evaluating
patients with PVD. These exams are timed using a

Fig. 1. MR angiographic maximum intensity projection dis-

play of a 70-year-old female patient. A dedicated phased array
peripheral vascular coil extending from the aortic bifurcation
to the ankle was used for data collection. In a total acquisition
time of 70 seconds, the pelvic and thigh arteries were imaged
over the first 30 seconds, followed by a 10-second imaging
break, during which the MR table was manually repositioned
to the center of the lower imaging volume. The second data set
containing the lower thigh and and lower limb arteries was
again collected over 30 seconds. Imaging parameters: TR/TE/
Flip = 5.2/1.5/30
, TI 28 ms, 2.4-mm slice thickness,
48 sections, 480  360-mm field-of-view, combined with a
256  192 matrix, spatial resolution 1.8  2.5  1.2 mm. For
determination of the scan delay following contrast bolus
injection, axial multiphase gradient-echo images were
collected at the level of the lower thigh following injection
of a 2 ml Gd-test bolus. A dose of 0.2 mmol/kg body-weight
Magnevist1 (Schering, Berlin, Germany) was injected intra-
venously using an automated injector over 70 seconds. Find-
ings: multiple stenoses in the superficial arteries bilaterally,
occlusion of the peroneal and posterior tibial artery on the
right side, and anterior and posterior tibial artery on the left
side. Note the presence of a small collateral vessel originating
from the right popliteal artery reconstituting the distal
posterior tibial artery.
 M. Goyen et al / Radiol Clin N Am 40 (2002) 835–846 839

dose-timing scan or a triggered mode [19,27 – 29]. ficient spatial resolution have limited the assessment
Best results with high spatial resolution and excellent of the smaller trifurcation vessels. While overall
image quality are achieved in the proximal peripheral sensitivity and specificity values for the femoral and
arteries (Fig. 3). Single -phase 3D acquisitions are popliteal arteries ranged between 81% and 95%,
somewhat limited with regard to the peripheral arter- assessment of the trifurcation and pedal vessels
ies because the determination of contrast arrival times resulted in poorer performance [16,17]. Particularly
in small arteries is difficult, and in patients where the challenging is the delineation of small arteries as
arrival time of contrast material varies between legs potential targets for distal bypass grafting [37,38].
as a result of different disease patterns. These tech-
niques, however, are the best-validated MRA meth-
ods in patients with PVD [30 – 33].
Time-resolved MRA techniques have also been
proposed for the evaluation of the peripheral vascu-
lature [22,34]. Using the 3D time-resolved imaging of
contrast kinetics (TRICKS) acquisition technique, 2D
[34] or 3D [23,35] volumes are collected consecutive-
ly with ultrahigh temporal resolution ( 2 – 6 seconds
per station), thereby isolating the arterial phase of the
contrast passage. Three separate injections are ad-
ministered in escalating doses (0.075, 0.1, and
0.125 mmol/kg body weight). One potential dis-
advantage of this technique relates to the huge amount
of data generated, which must be reconstructed and
evaluated in order to identify the optimal image set
containing the desired arterial information. With the
advent of faster reconstruction times and techniques
for automatically identifying the optimal arterial phase
[36], these limitations are likely to be overcome in the
foreseeable future.
Initially, most investigators used the body coil for
signal transmission and reception [16,17]. Inherently
poor signal-to-noise ratios (SNR) resulting in insuf-

Fig. 2. Coronal maximum intensity projection images of a

3D contrast-enhanced MRA dataset in a 63-year-old male
patient with peripheral vascular disease and claudication at a
distance of <200 m. The images were acquired with flexible
parameters for each of the four fields-of-view (FLEXI-
TRAK) and with a combination of the quadrature body coil
(upper station) and a total runoff peripheral vascular coil
(lower three stations). The abdominal acquisition lasted 20
seconds, the iliac acquisition 15 seconds, the femoral
acquisition 10 seconds, and the tibial acquisition 55 seconds.
Acquisition voxel sizes for the respective stations were 10.0,
5.0, 6.0, and 1.7 mm3 and were all interpolated to half their
size by zero filling. Note that despite the long acquisition
duration depiction of arteries in the lower legs is without any
disturbing venous enhancement. Findings: occlusion of the
infrarenal abdominal aorta down to the common femoral
arteries (Leriche syndrome), excellent depiction of collateral
vessels, no vascular abnormalities of the lower extremities,
except for a medium grade stenosis in the right anterior tibial
artery. Because of the high resolution, even small digital
arteries can be seen. (Courtesy of Tim Leiner, MD, PhD,
Maastricht, The Netherlands.)
840 M. Goyen et al / Radiol Clin N Am 40 (2002) 835–846
Fig. 3. Single-station contrast-enhanced (0.15 mmol/kg body
weight [Gadovist1, Schering, Berlin, Germany]) (1.0 M Gd)
aortoiliac MR-angiogram of a 31-year-old male healthy
volunteer showing excellent delineation of the iliac and
proximal femoral arteries (TR: 2.5 milliseconds, TE: 0.88
milliseconds, flip: 25
, slab thickness: 130 mm, effective
section thickness: 1.35 mm, 96 partitions, field-of-view: 370
 370 mm, matrix: 230  512, acquisition time: 25 seconds).
(Give injection rate in ml)
Recognizing the limitations inherent to a strategy
based on the use of the body coil for signal reception
and transmission, Ruehm et al employ a surface coil
for signal reception, which provides better signal-to-
noise and thus permitts the acquisition of smaller
voxel volumes [38]. Recently, several dedicated
peripheral vascular coils have become available for
signal reception [39,40]. Preliminary results using
these coils are quite promising, as the available data
reveal an SNR increase of up to 400% compared to
images collected with the body coil [40]. Similar
improvements in performance are also reported for
the contrast-to-noise ratio (CNR) values. These dra-
matic improvements in the SNR and CNR directly
translate into improved delineation of arterial mor-
phology (Fig. 4). Thus, more vascular segments are
displayed with better diagnostic image quality. Dif-
ferences are particularly apparent at the level of the
trifurcation vessels.
Generally, all three stations are collected using the
same protocol. Leiner et al show that flexible param-
eters for each station (FLEXI-TRAK) yield higher
SNR/CNR ratios, less venous enhancement, and
better subjective interpretability compared with
imaging with fixed parameters [25].
Future directions
Significant technical advances related to contrast-
enhanced 3D MRA acquisition and reconstruction
strategies continue to occur at a rapid pace. Recently,
the ‘‘shoot and scoot’’ technique has been introduced
for performing multistation bolus-chase 3D MRA
[41]. Spatial resolution is improved by capturing the
center portions of k-space during the initial arterial
phase ‘‘pass’’ and later filling in the remainder of k-
space during the delayed phase. Thus, improved in-
plane spatial resolution of 1 to 2 mm can be achieved
(Fig. 5).
Another promising development regarding in-
creased spatial resolution for stepping-table bolus-
chase 3D MRA is the implementation of sensitivity
encoding (SENSE) data-collection strategies [42,43].
Without an increase in scan time, spatial resolution
can be doubled or even quadrupled. Spatial resolu-
tions as high as 0.9  0.9  1.0 mm (0.81 mm3) have
been achieved in the calves, thereby providing excep-
tional detail of the infrapopliteal vessels, including
small perforating branches [42] (Fig. 6). Spatial res-
olution can also be improved using the PR-hyper-
Fig. 4. Four-station entire run-off MR-angiogram with
flexible parameters (FLEXI-TRAK) of a 58-year-old male
patient with peripheral vascular disease shows the anterior-
posterior 3D MRA obtained with dedicated vascular coils
(phased-array torso-surface coil and peripheral angio-array
coil). The dedicated vascular coils lead to an excellent
delineation of the arterial morphology, especially in the
infrapopliteal vessel segments. The pelvic acquisition lasted
22 seconds, the femoral acquisition 14 seconds, the
popliteal/tibial acquisition 17 seconds, and the tibial/pedal
acquisition 25 seconds. Acquisition voxel sizes for the
respective stations were 1.75, 1.5, 1.3, and 1.0 mm3
(interpolated). A biphasic injection scheme was employed:
20 ml Magnevist1 with a flow rate of 1 ml/second, followed
by 15 ml Magnevist1 with a flow rate of 0.4 ml/second.
History of embolic occlusion of the left common iliac artery.
Findings: high-grade stenosis of the left common iliac artery
with peripheral emboli occlusion of the proximal posterior
tibial artery, stenosis of the proximal part of the fibular
artery. (Courtesy of Jörg Barkhausen, MD, University
Hospital Essen, Germany.)
 M. Goyen et al / Radiol Clin N Am 40 (2002) 835–846 841

TRICKS algorithm [44] (Fig. 7). This technique uses

a two-stage acquisition in which low spatial frequen-
cies are acquired in the first phase using TRICKS
encoding. In the second stage, high spatial frequencies
are collected after venous opacification. The time-
resolved PR-TRICKS data acquired in the first stage
can be used for temporal correlation analysis.
Unaltered high spatial frequencies from the second
stage are added to increase slice resolution.

Whole-body MRA—Angio SURF

In addition to improved spatial or temporal resolu-

tion, the latest high-performance gradients also offer

Fig. 5. Three-station 3D MRA with elliptical centric view

ordering and automated table motion (shoot-and-scoot) in a
healthy volunteer. Three 40-cm field-of-view stations (abdo-
men-pelvis, thigh, calf) with 5-cm overlap were prescribed
(TR 4.2/TE 1.5; matrix 256  256; slices 44; thick 2.8 mm;
acquisition time: 27 seconds/station, 88 seconds total).
Contrast administration: 0.2 mmol/kg Gd-based contrast
agent (diluted to 40 ml) @ 1ml/second with 20 ml saline @
1 ml/second. Segmented volume acquisitions can yield satis-
factory arterial illustration if the arterial phase central k-space
fraction is sufficient (at least 34%). (Courtesy of Vincent B.
Ho, MD, Uniformed Services University and National
Institutes of Health, Bethesda, MD, USA.)

extended anatomical coverage with the stepping-table

bolus-chase technique. This results in the concept of
‘‘whole-body MRA’’ [45], which in its current imple-
mentation allows assessment of the entire human
vascular system in one examination (with the excep-
tion of the intracerebral and coronary vessels). Be-
cause atherosclerosis is a systemic disease possibly
affecting any portion of the arterial system, an imag-
ing approach allowing assessment of the entire vas-
842 M. Goyen et al / Radiol Clin N Am 40 (2002) 835–846
culature may prove to be beneficial. Correlation with a
limited number of regional digital subtraction angio-
grams (DSA) exams reveals the diagnostic perform-
ance of whole-body MRA to be sufficient to warrant
use as a noninvasive alternative to DSA. In contrast
with the imaging strategies focused on the peripheral
vasculature alone, the whole-body MRA approach
documents additional clinically relevant disease in
unsuspected arterial territories [46].
The performance of whole-body MRA can be
further improved by using the Angio SURF-system
(MR-Innovation, Essen, Germany), which integrates a
torso-surface coil for signal reception [46]. Extended
coverage, high diagnostic accuracy, noninvasiveness,
lack of side-effects, and very short examination times
combine to open interesting perspectives regarding
the use of this technique for vascular disease screening
(Fig. 8).
New MRA contrast agents
Currently, only extracellular nonbinding gadolin-
ium (Gd) chelates with a concentration of 0.5 M have
regulatory approval for use in humans. In the United
States, no agent is currently approved for MRA by
the FDA, and any such use constitutes off-label use of
an approved drug. Several paramagnetic intravascular
Gd-based agents as well as superparamagnetic com-
pounds are currently undergoing clinical and preclin-
ical testing [47].
As mentioned previously, for peripheral MRA
these 0.5 M extracellular contrast agents are adminis-
tered at a low infusion rate, resulting in a relatively
late venous enhancement. The disadvantage of a low
infusion rate, on the other hand, is the prolongation
and dilution of the contrast bolus within the blood-
stream resulting in a relatively moderate degree of
contrast enhancement. With higher infusion rates the
local concentration of the contrast in the vessel of
interest is higher, but because of a faster venous return
there is a shorter arterial/venous time window for
imaging. Contrast compounds with higher concentra-
tion formulations such as Gadovist1 1.0 M (Schering,
Berlin, Germany) may be advantageous when slow
Fig. 6. Three-station 3D MRA using SENSE and elliptical
centric phase encoding (WAKI-TRAK). Three-station
protocol using a four-channel phased-array body coil in
the upper station (Synergy Body Coil), the built-in body
coil in the middle station, and the five-channel phased-array
spine coil (Synergy Spine Coil—three middle elements
used) in the lower station. Field-of-view of 440 mm with an
upper station resolution of 384  208 with 2.8 mm true slice
thickness (TR = 4.3, scan duration 11 seconds, voxel size
1.1  2.1  2.8 mm, SENSE factor 2.0 in phase, 1.0 in
slice), middle station 256  230 with 2.8 mm true slice
thickness (TR = 4.3, scan duration 12 seconds, voxel size
1.7  1.9  2.8 mm), and lower station 448  448 with 1.0-
mm true slice thickness (TR = 4.8, scan duration 77 seconds,
voxel size 1.0  1.0  1.0 mm). Contrast administration: 40
cc of Gadoteridol (ProHance, Bracco Diagnostics, Princeton,
NJ), biphasic injection: 20 ml at 1.5 to 2 ml/second, followed
by 20 ml at 1.0 to 1.5 ml/second; 25-ml saline flush followed
at the same final rate. (Courtesy of Jeffrey H. Maki, MD,
PhD, Seattle VAHCS/University of Washington, USA.)
 M. Goyen et al / Radiol Clin N Am 40 (2002) 835–846 843

Schering, Berlin, Germany) and Gadovist1 1.0 M in

pelvic MRA are promising with regard to arterial
enhancement [48].
Some newer agents, such as Multihance1 (Brac-
co, Milan, Italy), have higher relaxivity and different
routes of excretion but still distribute into the extra-
cellular space. Blood pool or intravascular contrast
agents are sufficiently large or bind to large mole-
cules when injected. This prevents them from leak-
ing out of the capillaries and confines them to the
intravascular compartment for extended periods of

Fig. 7. Infrapopliteal contrast-enhanced 3D MRA examina-

tion using the PR-hyper-TRICKS algorithm. This technique
uses a two-stage acquisition in which low spatial frequencies
are acquired in the first phase using TRICKS encoding. In
the second stage, high spatial frequencies are collected after
venous opacification. Unaltered high spatial frequencies
from the second stage are added to increase slice resolution.
Compared to the PR-TRICKS examination, the voxel size
can be decreased from 0.94  0.94  2.5 mm3 to 0.94 
0.94  1.25 mm3 = > PR-hyper-TRICKS increases through-
plane resolution while maintaining high in-plane resolution.
(Courtesy of Timothy J. Carroll, PhD, University of
Wisconsin – Madison, Madison, WI, USA.)

infusion protocols are used, and preliminary results

comparing a 0.5-M contrast agent (Magnevist1,

Fig. 8. Three-dimensional whole-body MR-angiogram using

Angio SURF consisting of five 3D data sets collected over
72 seconds. The acquisition time for each 3D data set
amounts to 12 seconds. During a 3-second acquisition break,
the table was manually repositioned to the center of the
subsequent image volume. With five successive acquis-
itions, craniocaudal coverage thus extended over 180 cm,
while the total data acquisition time amounted to 72
seconds. Multihance1 (Bracco, Milan, Italy) was adminis-
tered at a dose of 0.2 mmol/kg BW at a rate of 1.3 ml/second
for the first half and 0.7 ml/second for the second half of the
contrast volume, followed by a 30 ml saline flush using an
automated injector (MR Spectris1, Medrad, PA). The scan
delay was determined with a 2-ml test bolus at the level of
the descending aorta. The quality of the whole body MR
angiogram is sufficient to assess the arterial system from the
supraaortic arteries to the runoff vessels.
844 M. Goyen et al / Radiol Clin N Am 40 (2002) 835–846
time [47]. The major disadvantage of intravascular
contrast agents is the early venous enhancement leav-
ing only a very short window for arterial imaging.
This represents a particular problem in the lower
legs, where venous overlap can seriously impair the
ability to assess the arteries. In view of the rapid
progress of MRA techniques using extracellular
agents, the future of intravascular contrast agents
for morphological imaging of the arterial vascular
tree (with the possible exception of the coronary
arteries) remains uncertain.
Summary
Contrast-enhanced 3D MRA is emerging as a
powerful noninvasive imaging modality for the
assessment of patients with PVD. Its clinical utility
using current technology has already been well estab-
lished, and the continuous development of hard- and
software will likely result in significantly improved
performance. Thus, Gd-enhanced MRA is likely to
emerge as the dominant noninvasive imaging mo-
dality for PVD worldwide.
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 Radiol Clin N Am 40 (2002) 847 – 865

MR angiography of the renal arteries

Daniel A. Leung, MD*, Klaus D. Hagspiel, MD, J. Fritz Angle, MD,
David J. Spinosa, MD, Alan H. Matsumoto, MD, Sabah Butty, MD
Division of Angiography/Interventional Radiology and Special Procedures, Department of Radiology,
University of Virginia Health System, Charlottesville, VA 22908, USA

Renovascular disease has long been recognized as
a common treatable form of nonessential hyperten-
sion and is implicated as the underlying cause in 1%
to 5% of patients with elevated blood pressure [1].
The most common etiologies are fibromuscular dys-
plasia (FMD) and atherosclerosis. FMD usually
occurs in younger female patients with characteristic
angiographic findings involving the stenotic distal
renal arteries, which rarely progress to occlusion.
Atherosclerosis, on the other hand, is perceived
widely to be a progressive disease with many lesions
advancing to complete occlusion [2,3]. Patients with
chronically diminished renal perfusion can suffer
from a permanent reduction in renal function, known
as ischemic nephropathy. Ischemic nephropathy,
which is almost always the result of atherosclerosis,
is increasingly common in the aging population [4].
Indeed, some studies suggest that 10% to 40% of
elderly hypertensive patients with newly documented
end-stage renal disease and no identifiable primary
renal disease have significant renal artery stenosis [5].
The devastating consequences of renal failure, for
the individual and as a public health concern, and the
widespread prevalence of hypertension have driven
the need for a reliable, safe, and noninvasive method
for diagnosing renal artery stenosis [6]. The large
number of available noninvasive diagnostic modali-
ties is a reflection of the lack of a single adequate
test. Diagnostic tests for the detection of renal artery
stenosis are of two types: those that demonstrate ana-
tomic abnormalities and those that detect physiologic
* Corresponding author.
E-mail address: dal3b@virginia.edu (D.A. Leung).
abnormalities. Methods belonging to the latter group
include captopril renal scintigraphy and renal vein
renin measurements. Unfortunately, these tests do not
provide reliable predictive information on the poten-
tial value of renal revascularization. Also, their accu-
racy is limited in patients with bilateral disease and in
patients with renal parenchymal disease. The most ac-
curate anatomic tests include duplex ultrasonography
(DUS), computed tomographic angiography (CTA),
and magnetic resonance angiography (MRA). DUS
is hampered by a high technical failure rate, operator-
dependence, and lack of angiographic images, whereas
CTA uses ionizing radiation and requires administra-
tion of nephrotoxic iodinated contrast agents. Three-
dimensional (3D) contrast-enhanced MRA [7 – 10] is
the technique that forms the backbone of vascular
magnetic resonance (MR) studies and is conceptually
similar to CTA. No ionizing radiation is required,
however, and gadolinium contrast agents are found
to be safe, even at higher doses, in patients with renal
insufficiency [11]. In addition, the 3D volumetric
nature of contrast-enhanced MRA allows easier 3D
postprocessing than CTA and offers some advantages
over conventional angiography, such as profiling the
renal artery ostium or identifying eccentric lesions and
intraluminal filling defects. Hence, 3D contrast-
enhanced MRA effectively overcomes the limitations
of other noninvasive diagnostic tests and expands the
indications for renal artery screening to a wider spec-
trum of patients.
At most institutions that have MRA, conventional
angiography is performed only as part of an interven-
tional procedure and in young hypertensive patients
suspected of having FMD in whom results of MRA
are equivocal. Apart from suspected renal artery
stenosis, indications for MRA include mapping arter-

0033-8389/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 2 6 - X
848 D.A. Leung et al / Radiol Clin N Am 40 (2002) 847–865
ial anatomy prior to renal revascularization and
abdominal aortic aneurysm repair, evaluating renal
bypass grafts and renal transplant anastomoses, and
assessing vascular involvement by renal tumors.
Many studies demonstrate the accuracy of con-
trast-enhanced MRA for the detection of significant
renal artery stenosis compared with conventional
angiography [9,12 – 27]. Because arterial signal in
3D contrast-enhanced MRA is not dependent on
flowing blood, it is less susceptible to spin-dephasing
and in-plane flow artifacts, which plague traditional
noncontrast MRA techniques [28 – 30], such as time-
of-flight (TOF) and phase-contrast (PC). Nonetheless,
the spatial resolution of contrast-enhanced MRA
remains well below that of conventional angiography,
which makes MRA prone to overestimation of sten-
oses. For this reason, many investigators advocate
acquisition of complementary MR sequences to as-
sess the hemodynamic or functional significance of
stenoses, in addition to the morphologic evaluation
afforded by contrast-enhanced MRA [31 – 33]. This is
useful particularly in cases where stenoses are of
borderline significance (50 – 60%) based on morpho-
logic or angiographic criteria.
This article presents techniques for a comprehen-
sive approach to renal MRA (including an evaluation
of both anatomy and function); discusses normal
findings, variation, and pitfalls; and reviews its
applications and findings in patients with renal vas-
cular disease.
Technique
A comprehensive renal artery imaging study must
strive to answer all the imaging questions pertinent to
the patient. These questions include identifying the
number and origin of the renal arteries; detecting,
localizing, and characterizing renal artery stenoses;
and defining the anatomy or pathologic involvement
of adjacent vascular structures, such as the aorta and
the renal veins. In addition, the imaging study should
demonstrate renal parenchymal anatomy cortical
thickness and kidney size and identify incidental
neoplastic lesions of the kidney.
3D contrast-enhanced MRA
Contrast-enhanced MRA forms the backbone of
MR examinations of the renal arteries. A high-res-
olution 3D T1-weighted gradient-echo (GRE) pulse
sequence is used in conjunction with intravenous
injection of high-dose gadolinium contrast material.
With this technique, images of the renal, aortoiliac,
and mesenteric arteries are acquired during a 20- to
30-second breath hold. The sequence is repeated
during the venous phase to evaluate the renal veins
and inferior vena cava (IVC).
Hardware considerations
3D contrast-enhanced MRA can be performed on
any MR system. The gradient strength of a given
system determines the time required for data acquisi-
tion. In its initial implementation for aortic imaging
using conventional gradients, imaging times range
from 3 to 5 minutes, depending on the number of
sections acquired [8]. Data acquisition is performed
during shallow respiration. Although image quality is
sufficient for visualization of large vessels, smaller
vessels are not adequately resolved for diagnostic
purposes, particularly those subject to respiratory
motion, such as the distal renal arteries.
‘‘High-performance’’ gradient systems allow a
reduction in imaging times such that an entire 3D
data set can be sampled within a comfortable breath-
hold interval [7,9,10]. Gradient switching capabilities
with an achievable slew rate in the region of 120 mT/
m/millisecond should be considered a prerequisite for
breath-hold gadolinium-enhanced MRA. Such gra-
dient systems are standard on modern high-field MR
scanners. Images obtained during breath holding are
shown to improve image quality significantly [9].
As with conventional MR imaging, better image
quality is produced with the use of a phased-array coil
for signal transmission and reception. This is crucial
for adequate depiction of small or distal branches in
gadolinium-enhanced MRA of the renal arteries.
Pulse sequence
The pulse sequence generally used for gadolin-
ium-enhanced MRA is a 3D Fourier transform GRE
sequence. T1 weighting and background suppression
is achieved by spoiling, which is accomplished by
radiofrequency or gradient techniques. In order to
optimize image quality in 3D gadolinium-enhanced
MRA, several factors bear consideration when select-
ing parameters for the 3D T1-weighted GRE pulse
sequence. The trade-off between acquisition time and
spatial resolution is adjusted relative to the breath-
holding capability of a patient. This should be ascer-
tained and coached prior to imaging so that a repro-
ducible level and length of apnea is maintained
during data acquisition. Some patients benefit from
oxygen administration and hyperventilation. The slab
thickness of the 3D imaging volume, as defined by
the product of section thickness and number of
sections, is then tailored to adjust the acquisition time
to the breath-hold interval. Typically, 36 to 64 sec-
 D.A. Leung et al / Radiol Clin N Am 40 (2002) 847–865
tions of 2- to 3-mm thickness constitute the 3D slab
with at least 160 phase-encoding steps. A field-of-
view (FOV) of 30 to 36 cm usually suffices to cover
the vascular anatomy from the celiac artery to the
iliac arteries. The patient’s arms should be raised
above the head or elevated on cushions beside the
body to avoid aliasing.
Correct positioning of the imaging volume
ensures adequate coverage of the area of interest,
which includes the full extent of the renal arteries and
the aortoiliac arteries where accessory renal arteries
may arise. Imaging in the coronal plane allows most
efficient coverage of the relevant anatomy while
minimizing slice thickness. The 3D slab is best
prescribed on axial or sagittal localizer images.
Because image resolution is inversely proportional
to slab thickness for a given acquisition time, the
anteroposterior dimensions of the imaging volume
require precise placement in order to maximize image
quality without sacrificing image information. The
anterior border of the volume should be positioned
immediately anterior to the most ventral portion of
the infrarenal aorta. If a large aneurysm is present, its
anterior-most aspect is excluded from the imaging
volume in the interest of maintaining a section
thickness of approximately 2 to 3 mm. The same
applies to the posterior most portions of the kidneys.
These structures are readily demonstrated on axial
and sagittal images from additional sequences.
In general, it is desirable to image as quickly as
possible with 3D gadolinium MRA, because this
allows a higher injection rate, which translates into
a tighter bolus and enhanced arterial signal. Also,
faster acquisitions cause less motion-related artifact
and enable a shorter breath-hold interval. The repe-
tition time (TR) and echo time (TE) for the 3D GRE
sequence should be kept to a minimum. Modern MR
scanners with ‘‘high-performance’’ gradients allow a
TR of approximately 3 to 5 milliseconds, which
translates into an acquisition time ranging from 20
to 30 seconds. The TE should be kept below 3
milliseconds to counter the effects of spin dephasing
that can cause signal loss in areas of turbulence,
resulting in overestimation of stenoses. If the TE is
kept between 2 and 2.5 milliseconds, fat and water
will be out of phase, thereby resulting in maximal
suppression of fat signal and optimized vessel-to-
background contrast. Adjusting the flip angle has a
minimal effect on image contrast and is best kept at
approximately 30
to 60
.
Contrast administration and bolus timing
Arterial signal in 3D contrast-enhanced MRA is
based solely on the T1 shortening effect of the
849
gadolinium bolus during its first pass through the
vascular territory of interest; therefore, correct timing,
administration, and dosing of the gadolinium bolus
are critical to arterial contrast and image quality. Use
of an automated infusion pump facilitates the contrast
administration process and results in highly repro-
ducible injections. Hand injection from inside the
scanner room is also feasible, although slightly less
reliable. An extracellular paramagnetic MR contrast
agent, such as a gadolinium chelate, is infused via a
peripheral venous access, usually an antecubital vein.
In general, 0.2 to 0.3 mmol/Kg gadolinium contrast
material is administered, which corresponds to
approximately 40 mL in an individual of average
size. With advances in MR technology resulting in
shorter data acquisition times, the dose of gadolinium
required to achieve arterial contrast may be reduced.
In addition, the use of intravascular contrast agents,
which are currently undergoing clinical testing, prom-
ises to reduce further the dose requirements. Regard-
less of the gadolinium dose, accurate bolus timing is
critical to the image quality of gadolinium-enhanced
MRA. The short parenchymal phase of contrast
passage through the kidneys makes accurate bolus
timing particularly important in gadolinium MRA of
the renal arteries, because delayed data acquisition
causes venous enhancement and obscuration of arte-
rial anatomy. Alternatively, premature data acquisi-
tion results in diminished arterial signal.
Ideally, peak arterial artery enhancement in the
area of interest is timed to coincide with acquisition
of the center of k-space, which is primarily respon-
sible for image contrast. Because k-space mapping
occurs in sequential fashion as a default setting on
most MR scanners, this corresponds to the middle of
the data acquisition. The peripheral k-space lines
determine image detail, so it is not necessary to
maximize arterial contrast during this phase of data
acquisition. For this reason, the effect of the gadolin-
ium bolus need only last for part of the scan duration,
which allows for a reduced contrast dose and a higher
injection rate. The injection rate should be adjusted to
produce a contrast bolus lasting approximately one
half to two thirds of the scan duration. Typically, an
injection rate ranging from 2 to 4 mL/second is used
for gadolinium MRA. Whereas a tight bolus
improves contrast-to-noise ratio and image quality,
it requires precise timing of the gadolinium bolus.
There are several strategies for achieving accurate
bolus timing: the test bolus technique, the automatic
triggering technique, MR fluoroscopy, and MR
digital subtraction angiography (DSA).
The test bolus technique is the most universally
applicable because it does not require additional
850 D.A. Leung et al / Radiol Clin N Am 40 (2002) 847–865
software. With this technique, the time taken for a
small amount of gadolinium (1 – 2 ml) to travel from
the injection site, usually an antecubital vein, to the
renal arteries is timed by acquiring sequential images
through the abdominal aorta at the level of the renal
arteries at fixed time intervals. It is important to flush
the test bolus with a sufficient amount of saline to
advance the gadolinium at least into the superior vena
cava. A single-slice multiphase GRE acquisition is
prescribed traversing the abdominal aorta in the
sagittal or axial plane with a new image being
updated every second for approximately 40 seconds.
The contrast travel time is determined either by visual
inspection or by mapping signal intensity within a
region-of-interest placed over the abdominal aorta at
the level of the renal arteries.
As the name implies, the automatic triggering
technique for bolus timing employs a pulse sequence
that automatically detects contrast arrival at the ves-
sels of interest and then triggers the 3D gadolinium
MRA sequence [34,35]. Such sequences are commer-
cially available as software on modern MR systems.
With this technique, the operator selects a region of
the aorta at the level of the renal arteries to be
sampled continuously with a single voxel sequence.
The signal within the sampling area increases as the
leading edge of the contrast bolus arrives in the
abdominal aorta. Typically, a threshold of 20% signal
increase is chosen as a trigger for initiation of the 3D
gadolinium MRA sequence. By employing centric
encoding, where the central k-space data is sampled
at the start of scan, there is synchronization of the
arterial phase of the contrast bolus and the acquisition
of the contrast-determining portion of k-space.
MR fluoroscopy is a variation on the automatic
triggering technique in which two-dimensional (2D)
GRE images of the abdominal aorta are updated rap-
idly in real-time during gadolinium injection [36].
When contrast arrival is identified, the 3D MRA
sequence is initiated by the operator or automatically
by the computer. This technique is highly reliable for
triggering 3D gadolinium MRA [36].
With continuous advances in gradient hardware
and development of sophisticated pulse sequences,
acquisition times are reduced to the point where
vascular MRA is performed independent of contrast
travel time. These techniques, also known as MR
DSA, allow acquisition of several 3D data sets during
the first pass of the gadolinium bolus [37 – 39]. As
such, they provide hemodynamic flow information,
similar to conventional DSA. For example, a dimin-
ished rate of contrast material transit through the
kidney related to renal artery stenosis is appreciated
with this technique.
Image analysis
3D gadolinium-enhanced MRA is evaluated best
on an independent workstation with 3D reconstruction
capabilities. It is important to review the 3D data set
using 3D postprocessing techniques in order to exploit
the advantages and maximize the diagnostic yield of
the technique. Tortuous renal artery anatomy is un-
folded by scrolling through the 3D volume in coronal
and axial planes using multiplanar reformations. With
this technique, renal artery ostia is thoroughly eval-
uated and eccentric plaques easily identified. This
capability represents a major advantage of 3D gado-
linium MRA over projection angiographic techniques
such as conventional angiography.
Projection type images are generated with 3D
gadolinium MRA using the maximum intensity
projection (MIP) algorithm. The best way to produce
useful images using this technique is to target each
renal artery individually and reconstruct coronal and
axial oblique subvolume MIP images. When per-
forming MIP reconstructions, it is important to be
aware of potential artifacts. For example, if the MIP
is too thick, this may artifactually create the appear-
ance of a stenosis. Alternatively, if a subvolume MIP
is too narrow, a tortuous vessel may course out of
the evaluated volume, resulting in the appearance of
an obstruction.
Assessment of hemodynamic significance
The limited spatial resolution of 3D gadolimium
MRA makes evaluation of the functional significance
of a stenotic renal artery lesion challenging, espe-
cially if it is of borderline import based on angio-
graphic criteria (ie, 50 – 60%). Generally, gadolinium
MRA is prone to overestimation of stenoses (Fig. 1).
The assessment of hemodynamic significance can be
problematic with conventional angiography, if anal-
ysis is derived solely from morphologic criteria.
Whereas a translesional pressure gradient is measured
during conventional angiography, MR must rely on
special pulse sequences that provide functional
information. These include 3D PC angiography
[24,31,40], cardiac-gated cine PC flow measurements
[32,41], and extra-slice spin-tagging perfusion imag-
ing [42,43].
3D PC MRA
3D PC MRA is a noncontrast flow-dependent
MRA technique that employs the signal void pro-
duced by turbulent flow distal to a stenosis to
demonstrate hemodynamic significance (Fig. 2).
The rationale behind this method is that only a
significant stenosis causes disruption of poststenotic
 D.A. Leung et al / Radiol Clin N Am 40 (2002) 847–865 851

Fig. 1. A 63-year-old patient with atherosclerosis and progressive renal failure. (A) The 3D gadolinium-enhanced MRA shows
high-grade ostial right renal artery stenosis and subtotal stenosis of left renal artery at an early bifurcation. (B) Conventional
angiogram confirms MRA findings. Note mild overestimation of the left renal artery stenosis on MRA.

laminar flow, resulting in intravoxel phase dispersion
and a drop in signal. In order to optimize sensitivity
to turbulent flow, a velocity-encoding value ranging
from 20 to 60 cm/second should be chosen, whereby
the exact value is tailored to the patient’s age and
cardiac status. A lower value should be chosen in
older patients and patients with congestive heart
failure. Wasser et al found that 3D PC MRA and
conventional DSA are not statistically different
regarding the estimation of hemodynamic signifi-
cance of renal artery stenoses when compared with
translesion pressure measurements [40], albeit in a
small sample.
Flow measurements
Several studies investigate the ability to dem-
onstrate the hemodynamic alterations of stenotic renal
artery lesions using cardiac-gated PC flow measure-
ments [32,41,44].
With these techniques, quantitative flow volume
measurements and blood flow profiles across a car-
diac cycle are obtained. Using a technique analogous
852 D.A. Leung et al / Radiol Clin N Am 40 (2002) 847–865

Fig. 2. (A) A 3D gadolinium-enhanced MRA in a patient with refractory hypertension shows high-grade right renal artery
stenosis and mild left renal artery stenosis. (B) Findings are confirmed at 3D phase-contrast MRA, which demonstrates
turbulence-induced signal loss within the right renal artery (arrowheads) but normal signal in the left renal artery.

to Doppler evaluation of flow waveforms, Schoen-
berg et al evaluate the hemodynamic effects of
significant renal artery stenosis [32]. The investiga-
tors use a qualitative assessment of flow waveforms
and a quantitative analysis of time to maximum flow
to demonstrate a sensitivity of 100% and a specificity
of 93% in the identification of significant ( > 50%)
renal artery stenosis when compared with conven-
tional angiography.
Another study uses quantitative flow measure-
ments to establish a renal flow index, relating flow
volume to renal mass. The investigators find a renal
flow index of less than 1 ml/min that correlates with
renal ischemia [44]. Such studies of function ulti-
mately may help identify patients who are good
candidates for renal artery revascularization proce-
dures by predicting the likelihood of a therapeutic
response to revascularization [45].
Extra-slice spin-tagging perfusion-weighted imaging
Several methods for the noninvasive assessment of
renal perfusion are reported [42,46,47]. The authors
have experience with a technique known as extra-slice
spin-tagging perfusion-weighted imaging [42,43].
This technique uses a double-inversion tagging pre-
paration followed by a rapid acquisition to generate
perfusion maps of the kidneys in the axial plane. A
parenchymal perfusion defect is an indication of
arterial inflow obstruction from renal artery stenosis
(Fig. 3). The technique is useful particularly for
 D.A. Leung et al / Radiol Clin N Am 40 (2002) 847–865
demonstrating asymmetric perfusion to the kidneys in
the case of unilateral renal artery stenosis [43].
Assessment of renal anatomy
Apart from localizer images, several other pulse
sequences should be employed for the assessment
of renal size and parenchymal disease. A sagittal
T1-weighted sequence is useful for the evaluation of
kidney size and corticomedullary differentiation and
is used also to prescribe the 3D gadolinium MRA
sequence. For this purpose, either a T1-weighted spin-
echo (SE) sequence or a T1-weighted GRE sequence
is used. In addition to T1-weighted sagittal imaging,
T2-weighted axial images are obtained to rule out a
renal mass, which may supersede evaluation of the
renal arteries (Fig. 4). T2-weighted turbo SE images
with fat suppression are the most appropriate for this
purpose, because a renal malignancy is readily iden-
tified and differentiated from a renal cyst.
Applications of renal MRA
Normal findings and anatomic variants
Review of a renal MRA study begins with evalu-
ation of the kidneys. The normal length of the
kidneys ranges from 11 to 13 cm, and there is
typically mild size asymmetry of approximately
1 cm in favor of the left kidney. Normal variants
involving the kidneys are recognized easily on renal
MRA studies. These include renal agenesis, pelvic
kidney, crossed fused ectopia, and horseshoe kidney.
The latter is often associated with supernumerary
renal arteries. Corticomedullary differentiation of
the kidney usually is visualized with 3D gadolinium
MRA and 3D PC MRA. Perirenal structures, includ-
ing the adrenal glands, also are evaluated readily on
sagittal T1 and axial T2-weighted images.
3D gadolinium-enhanced MRA with adequate
arterial contrast allows evaluation of the renal arteries
to the level of the bifurcation into segmental branches.
Though segmental and smaller renal artery branches
usually are visualized on these studies, their eval-
uation for the presence of pathology is less reliable
because of their small size and the limited spatial
resolution. Not infrequently, gadolinium MRA studies
produce poor quality images. Most of the time, this is
related to inaccurate bolus timing or motion-related
artifact from patients who are not able to suspend
respiration adequately [48,49]. In these cases, the
complementary sequences, such as 3D PC MRA,
must be used to evaluate the renal arteries.
853
Approximately 30% of kidneys are supplied by
more than one renal artery. The identification of
accessory renal arteries is an important part of a
renal MRA study, particularly in patients evaluated
as potential kidney donors and in patients undergoing
preoperative evaluation for aortic surgery or ne-
phrectomy. In addition, renovascular hypertension
can be related to an obstructive lesion involving an
accessory renal artery. Accessory renal arteries usu-
ally arise from the abdominal aorta. In rare instances,
however, they originate from the common iliac
arteries; thus, it is important to include these in the
3D volume for gadolinium MRA. Several studies
demonstrate the ability of 3D gadolinium MRA to
detect accessory renal arteries with sensitivity and
specificity greater than 90% when compared with
conventional angiography.
Other vascular variants that should be recognized
in presurgical patients undergoing renal MRA include
duplicated renal veins and retroaortic and circum-
aortic renal veins.
Renal artery stenosis
The most common indication for renal MRA is the
evaluation for renal artery stenosis in patients sus-
pected of having renovascular hypertension or ische-
mic nephropathy. Clinical manifestations vary from an
incidental finding of renal artery stenosis to refractory
hypertension and progressive renal failure. Advances
in pharmacologic therapy allow correction of hyper-
tension in most patients. Blood pressure control is not
always optimal, however, and medication is expensive
and associated with side effects and compliance
problems. In addition, the progressive nature of renal
artery occlusive disease may lead to loss of renal
function despite blood pressure control [6,50]. It is,
therefore, important to identify patients with renovas-
cular hypertension or ischemic nephropathy who may
benefit from renal artery revascularization [50]. The
majority of obstructive renal artery lesions, particu-
larly in patients with ischemic nephropathy, are
related to atherosclerosis [51]. The second most com-
mon etiology of renal artery stenosis is FMD [52],
which typically affects younger female patients. Other
causes of renal artery stenosis are rare and include
congenital stenosis or coarctation, Takayasu’s arte-
ritis, neurofibromatosis, radiation injury, dissection,
iatrogenic stenosis, and external compression.
Atherosclerosis
Atherosclerotic renal artery disease accounts for
60% to 70% of renal artery lesions [51]. Men in their
fifth, sixth, or seventh decade of life predominantly
854 D.A. Leung et al / Radiol Clin N Am 40 (2002) 847–865

are affected, but renal artery stenosis is not uncom-
mon in women of similar ages or in younger adults.
Usually, atherosclerotic renovascular disease is a
manifestation of generalized atherosclerosis, as dem-
onstrated by the high rate of concomitant coronary
and peripheral vascular disease [53,54]. Atheroscler-
otic renovascular disease generally is viewed as
progressive in nature, with approximately 5% to16%
of untreated lesions progressing to complete occlu-
sion [50]. High-grade stenoses supplying a solitary
kidney and high-grade bilateral renal artery stenoses
are at the highest risk for progression to occlusion.

Fig. 3. (A,B) Subvolume coronal maximum intensity projections (MIPs) of 3D gadolinium-enhanced MRA in a hypertensive
patient shows high-grade ostial left renal artery stenosis and mild-to-moderate right renal artery stenosis of unclear significance.
(C) Coronal MIP of 3D phase-contrast MRA demonstrates turbulence-related signal loss in the area of the proximal left renal
artery (arrowheads) but normal signal in the right renal artery. (D) Findings at extra-slice spin-tagging perfusion imaging also
suggest significant left renal artery stenosis with diminished perfusion of the left kidney and normal perfusion of the right
kidney. (E) Conventional angiography confirms MR findings of high-grade left renal stenosis and mild (nonsignificant) right
renal artery stenosis.
 D.A. Leung et al / Radiol Clin N Am 40 (2002) 847–865 855

Fig. 3 (continued ).

Bilateral disease is reported to occur in 32% to 78% lesions involving the ostial and proximal portions
of cases [55,56]. of the renal arteries (Fig. 5). Distal renal artery
Typical angiographic features of atherosclerotic lesions are less common and usually occur at branch
renovascular disease include eccentric plaque-like points. Because renal artery stenosis often is asso-
856 D.A. Leung et al / Radiol Clin N Am 40 (2002) 847–865

Fig. 4. (A,B) Coronal maximum intensity projections (MIPs) of a screening 3D gadolinium-enhanced MRA in a hypertensive
patient demonstrates two right renal arteries and possibly two left renal arteries or an early bifurcation of a single left renal artery.
(C) Subvolume axial MIP clearly shows two separate left renal arteries originating from the same level of the aorta. (D) Axial
T2-weighted spin-echo image identifies left renal mass consistent with renal-cell carcinoma.
 D.A. Leung et al / Radiol Clin N Am 40 (2002) 847–865 857

Fig. 5. (A) A 3D gadolinium-enhanced MRA in a patient with hypertension and progressive renal insufficiency shows bilateral
renal artery stenoses, right greater than left. (B) Conventional carbon dioxide angiogram confirms MRA findings.

ciated with generalized atherosclerosis, concomitant
aortoiliac disease with plaque formation is a com-
mon finding. Significant stenoses are often associ-
ated with poststenotic dilation of the renal artery,
bridging collateral vessels, and a reduced size of the
affected kidney, which are readily identified at 3D
gadolinium-enhanced MRA.
Several investigators report a high diagnostic
accuracy of 3D gadolinium-enhanced MRA for the
detection of renal artery stenosis, using conventional
angiography as the standard of reference, with sensi-
tivities and specificities ranging from 88% to 100%
and 71% to 100%, respectively (Table 1). Other
studies demonstrate functional changes indicative of
the severity of stenosis [31 – 33,42,44]. Apart from
poststenotic dilation of the renal artery and renal
parenchymal changes, these include delayed enhance-
ment and asymmetric concentration of gadolinium,
poststenotic signal loss on 3D PC MRA images, loss
of the early systolic peak on cardiac-gated cine PC
waveforms, and asymmetric renal perfusion on extra-
slice spin-tagging images (see Fig. 3).
Fibromuscular dysplasia
FMD accounts for an estimated 30% to 40% of
renal artery stenoses and typically affects a younger

Table 1.
Sensitivity and specificity of 3D contrast-enhanced MR angiography in the evaluation of renal artery stenosis using conventional
angiography as the standard of reference
Authors Year n Sensitivity (%) Specificity (%) Degree of stenosis (%)
Prince et al [9] 1995 19 100 93 >75
Holland et al [20] 1996 63 100 100 >50
Snidow et al [25] 1996 47 100 89 NA
Postma et al [66] 1997 38 100 96 >50
Steffens et al [26] 1997 50 96 95 NA
Hany et al [18] 1997 39 93 98 >50
De Cobelli et al [14] 1997 55 100 97 >50
Rieumont et al [23] 1997 30 100 71 >50
Hany et al [18] 1998 103 93 90 NA
Bakker et al [12] 1998 50 97 92 >50
Schoenberg et al [24] 1999 26 100 95 >50
Leung et al [21] 1999 60 90 86 >60
Thornton et al [27] 1999 62 88 98 >50
De Cobelli et al [15] 2000 45 100 93 >50
Shetty et al [67] 2000 51 96 92 NA
Bongers et al [13] 2000 43 100 94 >50
Mittal et al [22] 2001 26 95 93 >50
Fain et al [16] 2001 25 97 92 >50
858 D.A. Leung et al / Radiol Clin N Am 40 (2002) 847–865
patient population than atherosclerotic renovascular
disease [52]. There are four types of FMD: medial
fibroplasia, perimedial fibroplasia, medial hyperpla-
sia, and intimal fibroplasia. Medial fibroplasia is the
most common of the four lesions, accounting for 60%
to 70% of cases. Women are affected more often than
men, and the diagnosis usually is made between the
ages of 30 and 50 years. It usually affects the distal
portion of the main renal artery with the characteristic
angiographic ‘‘string-of-beads’’ appearance and fre-
quently extends into the main segmental branches.
Medial fibroplasia is bilateral in the majority of cases,
but rarely progresses to occlusion. Perimedial fibro-
plasia, on the other hand, is considered a more
progressive lesion that also affects the distal main
renal arteries and may advance to occlusion. This
lesion accounts for 15% to 25% of FMDs and almost
exclusively affects women between the ages of 15
and 30 years. Angiographically, perimedial fibropla-
sia also appears as a ‘‘string of beads.’’ Unlike with
medial fibroplasia, however, the beads do not appear
aneurysmal. Medial hyperplasia and intimal fibropla-
sia are uncommon lesions, accounting for approxi-
mately 5% of fibrous renal artery disease. Both
lesions affect children and teenagers and appear
angiographically as smooth linear stenoses in the
proximal or distal main renal arteries. As with peri-
medial fibroplasia, these lesions can progress to renal
artery occlusion with subsequent atrophy of the
affected kidney.
FMD affects the distal renal arteries, and its
angiographic findings can be subtle. Therefore, the
diagnosis of FMD with MRA is more challenging
than that of atherosclerotic renovascular disease. The
distal renal arteries tend to be smaller than the
proximal renal arteries with less arterial contrast and
lower contrast-to-noise ratio. Also, the distal renal
arteries are more prone to motion artifact and venous
overlay [49]. In addition, the angiographic diagnosis
of FMD relies often on the identification of subtle
vessel wall irregularities. The spatial resolution of 3D
gadolinium-enhanced MRA is limited and, at best, on
the order of 1 mm3. These factors make consistent
diagnosis of FMD with MRA difficult, unless find-
ings are classic and marked (Fig. 6). To date, there is
not been a systematic evaluation of the diagnostic
accuracy of 3D gadolinium-enhanced MRA for the
detection of FMD.
Renal artery aneurysm
Renal artery aneurysms usually occur as a mani-
festation of atherosclerosis or FMD. Less common
etiologies include neurofibromatosis, polyarteritis
nodosa, tuberous sclerosis, iatrogenic injury, and
traumatic injury. Typically, large aneurysms and
those affecting the main renal arteries or large
segmental branches are well documented on 3D
gadolinium MRA images. Because of its limited
spatial resolution, however, the depiction of small
intrarenal aneurysm of polyarteritis nodosa may be
less reliable.
The decision to treat a renal artery aneurysm
usually is based on its size and risk of rupture. 3D
gadolinium-enhanced MRA can provide the neces-
sary morphologic information to help guide that
decision. Furthermore, the post-processing capabil-
ities afforded by the volumetric 3D data sets in
gadolinium MRA offer some distinct advantages over
other imaging modalities, including conventional
angiography, in the preoperative evaluation of renal
artery aneurysms. Multiplanar reformations and sub-
volume MIPs allow unproblematic profiling and
measurement of the aneurysm neck and differenti-
ation between saccular and fusiform aneurysms.
These factors are crucial when choosing between a
percutaneous endovascular and open surgical
approach for treatment.
Renal artery dissection
The most common cause of renal artery dissection
is iatrogenic injury by catheter manipulation or bal-
loon dilation (Fig. 7). Isolated noniatrogenic dissec-
tion is rare, with most spontaneous renal artery
dissections being an extension of aortic dissection.
Aortic dissection extending into a renal artery can
compromise flow to the kidney resulting in the same
clinical manifestations as other causes of renal artery
stenosis. Alternatively, a renal artery arising from a
collapsed true lumen or false lumen may compromise
renal perfusion [57].
3D gadolinium-enhanced MRA is a useful tech-
nique for evaluating aortic dissection in stable
patients and for follow-up studies. With the help of
multiplanar reformations and subvolume MIPs, it is
possible to diagnose the type of aortic dissection,
differentiate slow flow from thrombus, recognize
entry and re-entry tears, and identify visceral and
renal artery involvement [8]. The adjunctive use of
functional sequences, such as PC flow measurements
or extra-slice spin tagging, may help identify asym-
metric perfusion to the kidneys.
Renal transplant donors
3D gadolinium-enhanced MRA offers a non-
invasive alternative to catheter angiography for the
 D.A. Leung et al / Radiol Clin N Am 40 (2002) 847–865 859

Fig. 6. A 42-year-old female patient with difficult-to-control hypertension. (A) Maximum intensity projection (MIP) and (B)
subvolume MIP of 3D gadolinium-enhanced MRA shows fibromuscular dysplasia involving the distal right renal artery (arrow).
(C) Extra-slice spin-tagging perfusion image demonstrates mildly diminished perfusion of the right kidney compared with
the left.

evaluation of renal vascular anatomy in potential
renal transplant donors [58 – 60]. It is important to
identify accessory renal arteries and venous variants,
such as duplicated, retroaortic, or circumaortic renal
vein, prior to transplantation. Failure to do so may
complicate surgery and jeopardize the outcome of
the transplant.
Again, 3D gadolinium-enhanced MRA, including
venous-phase imaging, usually defines the vascular
anatomy sufficiently for preoperative planning purpo-
ses. Scrolling through the 3D data set using axial and
coronal multiplanar reformations is the best way to
identify accessory renal arteries and define venous
anatomy. The combination of MRI and MRA with re-
cently developed MR urography techniques [61 – 63]
offers the potential of a comprehensive MR-based pre-
transplant imaging evaluation.
Transplant renal artery stenosis
A rising serum creatinine level or new onset
hypertension in a renal transplant recipient may be
860 D.A. Leung et al / Radiol Clin N Am 40 (2002) 847–865

caused by a transplant renal artery stenosis. If
untreated, arterial inflow obstruction may result in
renal allograft failure. Typically, transplant renal
artery stenosis occurs at the anastomosis to the iliac
artery. Alternatively, aortoiliac inflow disease prox-
imal to the anastomosis may also obstruct arterial
perfusion of the transplant. Evaluation for transplant
renal artery stenosis with MRA is analogous to the
technique described for detection of native renovas-
cular disease [64,65]. Care must be taken to include
the entire transplant and iliac arteries in the 3D
imaging volume. Delayed, venous-phase imaging

Fig. 7. (A) A 60-year-old patient with refractory hypertension undergoes percutaneous transluminal angioplasty of left renal
artery stenosis (arrow) as shown on conventional angiogram. (B) Completion digital subtraction angiography following
percutaneous transliminal angioplasty shows dissection at the angioplasty site (arrowhead). The lesion is not stented in order to
preserve flow into a segmental branch originating from the proximal renal artery. (C) Maximum intensity projection (MIP) and
(D) multiplanar reformation of follow-up 3D gadolinium-enhanced MRA shows persistent dissection flap in the inferior aspect of
the left renal artery (arrow).
 D.A. Leung et al / Radiol Clin N Am 40 (2002) 847–865 861

Fig. 7 (continued ).

allows evaluation of transplant vein patency (Fig. 8). Summary

Diminished renal parenchymal enhancement or
absence of gadolinium excretion may be a sign of
renal transplant rejection. The presence of metallic
clips represents a potential pitfall in renal transplant
MRA, because susceptibility artifacts from clips
adjacent to the anastomosis can mimic a stenosis.
During, the past decade, MRA has evolved from an
experimental technique into the modality of choice for
the noninvasive evaluation of renovascular disease.
The recent widespread application of MRA for these
indications has been driven primarily by the advent of
862 D.A. Leung et al / Radiol Clin N Am 40 (2002) 847–865

Fig. 8. (A) A 3D gadolinium-enhanced MRA of a right kidney transplant shows a widely patent transplant renal artery
anastomosed to the iliac artery. Delayed phase imaging (B) shows a patent transplant renal vein.

3D contrast-enhanced MRA, which provides a fast,
reliable technique for imaging large vascular territories
and generates images, after postprocessing, similar in
appearance to digital subtraction angiography. The
cross-sectional volumetric nature of contrast-enhanced
MRA affords some advantages over conventional
catheter angiography. Although 3D contrast-enhanced
MRA forms the backbone of vascular MR studies,
several adjunctive sequences are employed to max-
imize the diagnostic yield of the examination. For
example, flow-dependant imaging is used to com-
plement the morphologic images of contrast-enhanced
MRA by providing hemodynamic information. As
such, MRA is unique among noninvasive imaging
modalities in that it offers a comprehensive evaluation
of anatomy and function. The availability and reliabil-
ity of MRA extend renal artery screening to a wider
spectrum of patients. Current applications of renal
MRA range from detection of renal artery stenosis to
evaluation for renal transplant donors.
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 Radiol Clin N Am 40 (2002) 867 – 886

MR angiography of the mesenteric vasculature

Klaus D. Hagspiel, MDa,*, Daniel A. Leung, MDa, J. Fritz Angle, MDa,
David J. Spinosa, MDa, Duke G. Pao, MDb, Eduard E. de Lange, MDc,
Sabah Butty, MDa, Alan H. Matsumoto, MDa
a
Department of Radiology, Division of Angiography and Interventional Radiology,
University of Virginia Health System, Charlottesville, VA 22908, USA
b
Interventional Radiology, Mori, Bean and Brooks, Jacksonville, FL 32256, USA
c
Department of Radiology, Division of Thoracoabdominal Radiology,
University of Virginia Health System, Charlottesville, VA 22908, USA

Until recently, the evaluation of the mesenteric
circulation has been completely within the realm of
catheter angiography [1 – 4]. Doppler sonography
gives anatomic and functional information, but is
hampered by its high operator dependency and the
fact that the mesenteric vasculature frequently is not
accessible because of overlying bowel gas. Computed
tomographic angiography (CTA) experienced a
quantum leap with the introduction of multidetector-
row spiral CT scanners. CTA, however, involves
ionizing radiation and the use of potentially nephro-
toxic contrast agents. Magnetic resonance imaging
(MRI) has been used for the assessment of the
mesenteric vasculature since the early 1990s; how-
ever, not until the advent of gadolinium enhanced
three-dimensional (3D) magnetic resonance angiog-
raphy (MRA) has the technique found widespread
use. This article reviews the magnetic resonance (MR)
techniques used for the evaluation of the mesenteric
vasculature and their application for the assessment of
its normal anatomy and pathological conditions.
Anatomy of the mesenteric vasculature
Mesenteric arterial system
The blood supply to the intestinal tract is derived
from the three major anterior branches of the ab-
* Corresponding author.
E-mail address: kdh2n@virginia.edu (K.D. Hagspiel).
dominal aorta: the celiac artery (CA), the superior
mesenteric artery (SMA), and the inferior mesenteric
artery (IMA) [2] (Fig. 1). A multitude of variants
exists. MRA in its most recent implementation allows
the detailed assessment of the normal and abnormal
vascular anatomy in the majority of cases [5].
Celiac artery
The CA arises from the ventral surface of the aorta
at the T12-L1 interspace. It supplies the upper abdom-
inal viscera. In 65% of patients, the CA has a classic
branching pattern into three major vessels: the splenic
artery, common hepatic artery, and left gastric artery.
In 35% of patients, the branching pattern of the CA
is variable. The splenic, common hepatic, or left
gastric artery may arise directly from the aorta or from
the SMA. The proper hepatic artery typically divides
into the left and right hepatic artery. This branching
pattern is present in 50% of all individuals. The
remaining 50% have replaced or accessory hepatic
arterial branches (Figs. 1, 3). The gastroduodenal
artery arises from the common hepatic artery in
approximately 75% of patients and usually has two
main branches: the superior pancreaticoduodenal
artery and the right gastroepiploic artery. The superior
pancreaticoduodenal artery forms an anastomotic
arcade with the inferior pancreaticoduodenal artery
[1,4] (Fig. 3).
Superior mesenteric artery
The SMA typically arises from the ventral aspect
of the aorta approximately 1 cm below the origin of

0033-8389/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 2 7 - 1
868 K.D. Hagspiel et al / Radiol Clin N Am 40 (2002) 867–886

Fig. 1. Mesenteric MRA showing aberrant right hepatic artery off the superior mesenteric artery (SMA). (A) Anterior-posterior
view of the abdominal aorta. The lateral view (B) shows patent celiac artery (CA), SMA, and inferior mesenteric artery. (C)
Subvolume maximum intensity projection shows the CA with splenic artery, left gastric, common hepatic, gastroduodenal, and
left hepatic and replaced right hepatic arteries (arrowhead) of the SMA. Note level of detail of the jejunal and the ileal branches.
The arcades are not visualized.

the CA [1,2,4] (see Fig. 1). Rarely, a single celiomes- first branch of the SMA. The jejunal and ileal artery
enteric trunk arises directly from the aorta. The branches usually originate from the left side of the
inferior pancreaticoduodenal artery typically is the SMA. A distinguishing feature of the jejunal and ileal
 K.D. Hagspiel et al / Radiol Clin N Am 40 (2002) 867–886 869

branches is the presence of arcades, which anasto-

mose with adjacent branches. The most distal arcades
run along the mesenteric border of the bowel and give
off the straight vasa rectae, which reach the antime-
senteric border [1 – 4]. The arcades are not visualized
routinely with MRA [5]. The SMA gives off three
right-sided branches. These are the middle colic
artery, the right colic artery, and the ileocolic artery.

Inferior mesenteric artery

Fig. 2. Normal venous anatomy shows patent splenic vein,
superior mesenteric vein, main portal vein, and left and right
portal veins. Note coronary vein (arrowhead).
The IMA arises from the ventral aspect of the
aorta approximately at the level of the L3 vertebral
body and measures between 1.2 and 5.5 mm in
diameter at its origin, which makes it difficult to
consistently image with MRA [2,4] (Figs. 1, 9). The
first branch of the IMA is an ascending branch, which
can consist of either the left colic artery alone or a
common trunk of the left colic and sigmoid arteries.
The IMA then gives off the sigmoid branches
(not originating from the left colic artery) [3,4]. More
distally, the IMA becomes the superior hemor-
rhoidal artery.

Fig. 3. Patient with median arcuate ligament compression syndrome. (A) Anterior-posterior view of the contrast-enhanced 3D
MRA shows enlarged pancreaticoduodenal arcades connecting the superior mesenteric artery with the gastroduodenal artery
(arrowheads). (B) Selective superior mesenteric arteriogram also shows the enlarged pancreaticoduodenal arcades with complete
filling of the distribution of celiac artery. Note supply of the left lobe of the liver via a hepatic branch of the left gastric artery as a
normal variant (arrows).
870 K.D. Hagspiel et al / Radiol Clin N Am 40 (2002) 867–886
Fig. 4. (A) Coronal subvolume maximum intensity
projection of the celiac artery (CA) and superior mesenteric
artery origins shows a stenosis caused by superior
indentation of the proximal CA (arrowheads) the result
of median arcuate ligament compression. (B) The axial
multiplanar reformatted image shows the indentation the
result of the transversely crossing ligament (arrow).
Collateral arteries between the vascular territories
Knowledge of collateral pathways between the
mesenteric arteries is of utmost importance, espe-
cially in the evaluation of mesenteric ischemia. More
than 50 collateral pathways in the large and small
bowels are described [1,4,6]. The marginal artery of
Drummond is situated along the mesenteric border of
the colon and formed by the anastomotic continuation
between the right, middle, and left colic arteries.
Riolan’s arc is situated more centrally within the
mesentery and is an inconstant anastomosis between
the middle and left colic arteries. The meandering
artery is also situated within the mesentery and is a
very large, tortuous vessel communicating between
the SMA and IMA. It potentially represents an
enlarged Riolan’s arc [6] (Fig. 9).
The dominant collateral pathway between the CA
and the SMA is via the gastroduodenal artery and the
pancreaticoduodenal arcades (see Fig. 3). As a result
of anatomical variants, however, those pathways may
be altered significantly [4].
Mesenteric venous anatomy
The mesenteric venous anatomy parallels the
arterial distribution [4,5,7,8]. The portal vein (PV)
is formed by the splenic and superior mesenteric
veins (SMVs) [9] (Fig. 2). The pancreatic, left gastro-
epiploic, short gastric, and inferior mesenteric veins
and splenic vein branches drain into the main splenic
vein. The inferior mesenteric vein (IMV) receives its
supply from the left colic, sigmoid and superior
hemorrhoidal veins. It usually joins the splenic vein
prior to the junction of the splenic vein with the SMV.
The SMV receives its contribution from jejunal, ileal,
right colic, and middle colic veins. Additional con-
tributions to the SMV include the duodenal, pancre-
atic, and right gastroepiploic veins. The coronary
veins (right and left gastric veins) usually drain
directly into the PV. The PV then divides into the
right and left portal branches at the porta hepatis.
Approximately one half of patients have the PV
bifurcation outside the liver capsule. A common
normal variant of the portal venous system is trifur-
cation of the main PV, which is present in about 8%
of patients [10]. In these patients, the main PV
divides into the right posterior segmental branch,
the right anterior segmental branch, and the left PV.
MR techniques used for the evaluation of the
mesenteric vasculature
Time-of-flight MRA
Although it is one of the earliest MRA techniques,
time-of-flight (TOF) MRA is used only rarely for the
 K.D. Hagspiel et al / Radiol Clin N Am 40 (2002) 867–886 871

evaluation of the mesenteric and portal vasculature.
This is mostly because of the long scan times for
three-dimensional (3D) TOF, which preclude breath-
hold imaging and misregistration artifacts in breath
hold two-dimensional (2D) TOF [11 – 13]. Also, this
technique is more sensitive to through-plane flow than
it is to in-plane flow. This makes it difficult to image
accurately the mesenteric vasculature with its tortuous
course and frequently changing directions. Another
complicating factor is the triphasic nature of splanch-
nic arterial blood flow, because the naturally occurring
retrograde diastolic flow diminishes the signal on
TOF and phase-contrast (PC) MRA. Systolic gating
improves image quality but further increases scan
duration [5,11,14,15]. Also, TOF techniques tend to
overestimate the degree of stenosis. Nevertheless,
TOF MRA has been used successfully, especially
for evaluation of the portal venous system [12].

Fig. 5. (A) Patient with abdominal aortic aneurysm, stenosis of the proximal celiac artery as a result of median arcuate ligament
compression (arrow), and (B) high-grade stenosis of the inferior mesenteric artery, the result of a large ostial plaque (arrow). No
symptoms of mesenteric ischemia are present.
872 K.D. Hagspiel et al / Radiol Clin N Am 40 (2002) 867–886
PC MRA
PC MRA allows the direct quantitative evaluation
of flow direction and velocity. The proton spin phase is
modulated by altering the first moment of the magnetic
field in all three directions. This modulation causes
spins moving in the encoded direction to aquire a
phase shift, which is then measured. Some of the
disadvantages of the TOF techniques, such as lack of
sensitivity in certain flow directions, do not apply to
PC MRA. In order to create an MR angiogram from the
phase shift within a voxel, however, the flow velocities
must be estimated and an appropriate velocity-encod-
ing gradient must be chosen prior to scanning. If this
has not been set correctly, severe aliasing artifacts can
occur. For these reasons, PC imaging has not found
widespread acceptance in the MR community. Several
groups, however, report the use of two-dimensional
(2D) PC MRA with and without breath holding and the
use of a 2D electrocardiographic (ECG)-gated cine PC
technique for the functional evaluation of the mes-
enteric vasculature [16 – 18]. These techniques allow
quantitative flow measurements (flow velocities and
flow volume). To date, PC MRA is used to measure
flow in the SMA and SMV, PV, azygos vein, renal
arteries, and so forth [19 – 25]. Systolically-gated 3D
PC MRA techniques also have been used successfully
for the detection of stenoses within the proximal
portions of the CA and the SMA [15].
Contrast-enhanced 3-D MRA
The technique of contrast-enhanced (CE) 3D MRA
is identical to that described by Leung et al in their
article on renal MRA in this issue. In order to max-
imize efficiency, however, the authors prescribe the
imaging plane differently. Whereas the renal arteries
are evaluated using a coronal slab, a sagittal slab is
chosen for the mesenteric vasculature, if the origins of
the arteries are under investigation. Examinations
geared towards assessment of the portomesenteric
venous system typically are performed in the coronal
orientation. Other groups use the coronal approach
routinely for all cases. Modern high-performance
gradient systems allow the acquisition of high resolu-
tion scans within a short breath hold [26 – 28]. These
fast scan times also reduce artifacts resulting from
peristalsis. Because gadolinium-enhanced MR tech-
niques rely on the shortening of T1 and not on flow,
they are not, or are only minimally, susceptible to in-
plane flow and other artifacts [29]. The authors use 30
to 40 cc of contrast injected at a rate of 2.0 cc/second
using a power injector for all patients [30]. Only in
patients with low body weights are weight-adjusted
volumes used, never exceeding 0.3 mmol/kg body
weight. In order to optimize bolus timing, the authors
use a test bolus technique. Other contrast timing
methods are the use of empiric scan delays, MR
fluoroscopic triggering, and automated bolus detec-
tion. The authors always perform dual-phase CE MRA
with the first phase timed for maximum arterial
enhancement and a second phase timed at mesenteric
venous enhancement after a time delay of 10 to
15 seconds between the two acquisitions [8]. The
use of fat saturation appears to improve image quality,
as does the use of digital subtraction techniques where
a data set acquired before the contrast injection is
subtracted from the contrast enhanced set [31].
Several groups have investigated the influence of
caloric stimulation on image quality. Two groups
report significantly improved image quality and con-
trast-to-noise ratios for the mesenteric arterial and
venous systems [31,32], whereas another group look-
ing at the CA, SMA, and IMA find no visually
detectable differences in the number or conspicuity
of the vessels [33]. The use of anticholinergic agents
proves not to have positive impact on image quality
[31]. Compared with catheter angiography, state-of-
the art CE 3D MRA performs favorably (as assessed
by k values) in the common and proper hepatic
arteries, the splenic artery, the SMA, and the portal,
superior mesenteric, and splenic veins [34]. Agree-
ment is poor, however, for the evaluation of the intra-
hepatic arteries, the SMA branches, and frequently the
IMA, and catheter angiography remains necessary for
the detailed evaluation of these vessels [35,36]. Other
studies confirm that CE 3D MRA is comparable to
DSA in the evaluation of the arterial system and
superior in the evaluation of the PV [37].
Bolus tracking
Bolus tracking is a technique that allows assess-
ment of the presence and direction of flow in the PV
(Fig. 6). Briefly, a 2D gradient-echo sequence is used
with three or four readouts at 20, 40, 60, and
80 milliseconds after application of a presaturation
pulse orthogonal to the PV [38]. In one study
involving 60 patients prior to liver transplantation,
bolus tracking MRA and duplex Doppler sonography
concur in the assessment of flow direction in 54
(90%) patients, and both procedures enable detection
of occlusive PV thrombus in one patient [12].
Measurement of blood oxygen saturation in the SMV
Flow-independent measurement of blood T2
allows the calculation of the blood oxygen saturation
 K.D. Hagspiel et al / Radiol Clin N Am 40 (2002) 867–886 873

Indications for mesenteric MRA/MRV

Mesenteric ischemia

Acute mesenteric ischemia

Acute interruption of the blood supply to the small
bowel or colon is a catastrophic event, which carries a
high morbidity and mortality rate. Recent mortality
rates for acute mesenteric ischemia (AMI) exceed
60% [1]. The four major causes of acute mesenteric

Fig. 6. Two images from a bolus tracking MRA showing

presence of flow and hepatopetal direction as bright signal
moving through the dark saturation band (arrowheads).

(%HbO2). Because deoxyhemoglobin is paramag-

netic and oxyhemoglobin is not, an increase of
deoxyhemoglobin reduces the T2 of blood. This
effect has been exploited to demonstrate a pathologic
decrease in the percentage of oxygenated blood in the
SMV, in an animal model, and in patients with
chronic mesenteric ischemia (CMI) [39].

Imaging post-processing

The authors interpret all scans on a dedicated

workstation that allows rapid review of the source
images, which are the primary diagnostic tool. The
primary reconstruction algorithms for CE 3D MRA
are the multiplanar reformatting and maximum
intensity projection algorithms (Fig. 7). Subvolume Fig. 7. Patient with dissection of descending thoracic and
or targeted MIPs often display relevant anatomy abdominal aorta involving the mesenteric vessels (A).
to a better extent. Occasionally, the authors use Multiplanar reformatted axial images show the celiac artery
volume-rendering techniques, but not routinely sub- (left) and superior mesenteric artery (right) to originate from
traction techniques. the anterior (true) lumen (B).
874 K.D. Hagspiel et al / Radiol Clin N Am 40 (2002) 867–886
ischemia are SMA embolus, SMA thrombosis, mesen-
teric venous thrombosis, and nonocclusive mesenteric
vasoconstriction. Aortic dissections also cause AMI
on rare occasions. Because of the serious clinical
status and urgent need for a diagnosis, MRA is
performed only rarely in this setting.
Acute superior mesenteric artery embolism. Acute
emboli to the SMA account for approximately 40% to
50% of all episodes of AMI [1]. These patients
typically have a clinical history of cardiovascular
disease. The majority of emboli in the SMA lodge
just beyond the origin of the middle colic artery. The
angiographic hallmark of an embolic occlusion is the
abrupt termination of the vessel (cut-off sign). Non-
occlusive emboli usually are visualized as filling
defects within the vessel lumen. Angiography is the
diagnostic modality of choice and is accurate, but
MRA also is capable of demonstrating these acute
occlusions. In one study, CE MRA is compared with
DSA in a porcine acute embolic segmental mes-
enteric ischemia model. Sensitivity and specificity
for the two modalities are 91%/100% and 80%/90%,
respectively [40]. In patients with prior embolic
events, recanalized vessels may be seen. The MRA
appearance of a septic embolus and mycotic pseudo-
aneurysm of the SMA in a patient with enterococcal
endocarditis also is published [41].
Acute mesenteric artery thrombosis. Acute mes-
enteric arterial thrombosis typically is associated with
a pre-existing atherosclerotic lesion. In up to 50% of
cases, a history of intestinal angina is obtained [1]. In
contrast to the abrupt catastrophic onset of symptoms
associated with an embolus to the SMA, the abdom-
inal pain and symptoms associated with acute mes-
enteric arterial thrombosis may be more insidious
because of the development of collateral circulation.
Occlusion of the SMA is typically within the first
2 cm of its origin (in contrast to acute embolic
occlusions), and there is typically no defined me-
niscus or intraluminal filling defect. MRA can show
these findings in addition to the visualization of
collateral vessels [1] (Fig. 10).
Mesenteric venous thrombosis. Recent reports from
the United States and Scandinavia suggest that mes-
enteric venous thrombosis (MVT) accounts for
approximately 5% to 15% of all cases of AMI [1].
The most common associated risk factors are portal
hypertension, hypercoagulable state, trauma, intra-
abdominal inflammatory diseases, the use of oral
contraceptives, and recent surgery affecting the por-
tomesenteric venous system, especially splenectomy
[1,42 – 44]. Acute mesenteric ischemia develops
when MVT is associated with a lack of adequate
venous collaterals resulting in the development of
intestinal mucosal edema and subsequent arterial
hypoperfusion. The clinical presentation of patients
with acute MVT is characterized by pain out of
proportion to the physical findings.
Dual-phase CE 3D MRA is highly accurate for the
evaluation of SMV and PV thrombosis [8,31] (Fig. 8).
Nonocclusive mesenteric ischemia. Nonocclusive
mesenteric ischemia (NOMI) is thought to be respon-
sible for approximately 25% of cases of AMI and its
mortality rate is as high as 70% [45]. NOMI usually
develops during an episode of cardiogenic shock or a
state of hypoperfusion, in which excessive sympa-
thetic activity results in secondary vasoconstriction of
the mesenteric arteries. This entity is not described in
humans, but Li and coworkers successfully use SMV
HbO2 and volume flow-rate measurements in vivo to
diagnose and monitor mesenteric ischemia as a result
of hemorrhagic shock in a canine model [46].
Aortic dissection. Approximately 5% of patients
with aortic dissection develop mesenteric ischemia
as a complication of the dissection process [1,47 – 49].
MRA is an excellent modality to assess these patients
and 2D TOF and gadolinium-enhanced techniques are
used successfully in this setting [11]. MRA classifies
the dissection, defines entry and reentry points, differ-
entiates thrombus from slow flow, and evaluates
branch vessel involvement [11,37] (see Fig. 7). Iso-
lated dissections of the SMA either in association with
cystic degeneration or as a complication of catheter
angiography are rare [50]. The CE 3D MRA appear-
ance is described in one case [51].
Chronic mesenteric ischemia
Atherosclerotic chronic mesenteric ischemia
CMI usually is caused by severe atherosclerotic
disease and is characterized by a classical clinical
triad of postprandial abdominal pain, weight loss, and
the patient’s avoidance of food [1]. With advanced
age, the abdominal aorta and mesenteric arteries
frequently are involved with atherosclerosis. A recent
autopsy study shows significant stenoses of the
mesenteric and celiac arteries in 67% of subjects
80 years of age or older [52]. Whereas atherosclerosis
of the mesenteric branches is frequent, CMI is rel-
atively uncommon (Fig. 5). This is primarily related
to the rich mesenteric, collateral circulation. This
collateral network in the mesenteric system makes it
difficult to estimate the degree of mesenteric vascular
 K.D. Hagspiel et al / Radiol Clin N Am 40 (2002) 867–886
Fig. 8. Portal and mesenteric vein thrombosis. Massive
distention of the portal vein (PV) and the superior
mesenteric vein (not shown) as a result of acute thrombosis.
(A) A subvolume maximum intensity projection of a
contrast-enhanced 3D MRA, which shows the enlarged
hypointense thrombosed (arrow) PV caudal to the common
hepatic artery. (B) A magnetization prepared 2D time-of-
flight image in coronal orientation also showing the large
hypointense thrombus (arrow).
stenosis necessary to cause intestinal angina [1,53]. It
is believed that at least two of the three main vessels
875
must be affected either by occlusive or stenotic
disease in order to produce clinical symptoms,
although exceptions to this rule exist (Figs. 9, 10).
CMI in the setting of proximal or segmental mes-
enteric artery stenosis or occlusion in only one
affected vessel is rare, but can occur (Fig. 11).
Several groups have investigated the flow dynamics
in patients with CMI. Cine cardiac-gated PC MRA is
used to show that flow rates in the SMA and SMV
correlate well [19] and that patients with CMI show a
significantly reduced rate of post-prandial flow aug-
mentation in the SMV compared with control patients
[21]. Furthermore, measurements of the percent flow
change in the SMA 30 minutes after a meal provide
the best discriminator between patients with and
without CMI [16,17]. These investigators found that
whereas SMA and SMV flow increases in healthy
and diseased subjects, the ratio between SMV and
SMA flow decreases with increasing disease severity.
This is contributed to the fact that in less severe forms
of CMI collaterals maintain adequate SMV perfusion;
however, in severe cases, the collaterals are no long-
er sufficient. As mentioned previously, the evaluation
of blood oxygenation in the SMV shows a decrease
in postprandial oxygenation to be a sensitive indicator
of CMI and (in animals) of AMI [39,40]. In addi-
tional work, Li et al [54] show that measurements of
SMV blood T2 after at least 6 hours of fasting and 15
and 35 minutes after ingestion of a meal allow
differentiation of patients with CMI from normals;
therefore, conversion of T2 measurements to estimate
oxygen saturation may not be necessary [54].
Despite the impressive results with functional
studies, morphological imaging of patients suspected
of having CMI using MRA remains the diagnostic
mainstay in almost all MR centers worldwide. The
evaluation of patients with suspected CMI is the most
frequent indication for mesenteric MRA at the
authors’ institution. Published results for the evalu-
ation of patients with CMI exist for 3D PC MRA [15]
and CE 3D MRA [33,36,55]. These studies report on
the morphological evaluation of the proximal mes-
enteric vessels. Results for systolically-gated 3D PC
MRA are disappointing, because only 66% of all
stenoses are detected using catheter angiography as
the gold standard [15]. These investigators also report
false positive results. MRI CE 3D MRA performs
consistently better with sensitivities and specificities
of 100% and 95% in one small series of 14 patients
with angiographic or surgical correlation [36]. CE 3D
MRA is also well suited for the evaluation of patients
with aortic occlusion (Leriche syndrome) and mes-
enteric involvement [56] (Fig. 12). Whereas the tech-
nique appears fairly accurate in the evaluation of
876 K.D. Hagspiel et al / Radiol Clin N Am 40 (2002) 867–886

stenoses of the CA and SMA, the IMA poses a
challenge to MRA because of its small size and
because stenoses of the IMA tend to be overestimated.
Also, interobserver variability is good to excellent for
the celiac and SMAs, but poor for the IMA (k 0.90,
0.92, and 0.48, respectively) [34]. These results refer
to stenoses or occlusions for the very proximal seg-
ments of these vessels. The periphery of the splanch-
nic vessels currently cannot reliably be assessed with
MRA, although on high-quality studies, this is occa-
sionally possible (see Figs. 1, 11).
Nonatherosclerotic causes of CMI
Fibromuscular dysplasia (FMD) is a rare but well
recognized cause of CMI. No descriptions of its MR
appearance in the mesenteric circulation appear in the
literature to date.
Median arcuate ligament syndrome is caused by
extrinsic compression of the CA or the celiac neural
plexus by the central tendon of the crura of the
diaphragm [57,58]. The angiographic findings are
seen best on a lateral aortogram and consist of a
smooth indentation of the superior aspect of the
proximal CA. This indentation is more marked clas-
sically on expiration than on inspiration [58]. This
entity is demonstrated with contrast and noncontrast
MRA techniques [59] (see Figs. 3, 4).
MRA is an excellent means of following patients
with aortic dissection without the risk of radiation or
contrast nephrotoxicity (Fig. 7).

Fig. 9. Patient with severe chronic mesenteric ischemia. The anterior-posterior aortogram angiogram (A) shows an enlarged
meandering artery coming off the inferior mesenteric artery (IMA) (arrow). The celiac trunk and the superior mesenteric artery
(SMA) are not visualized. The lateral aortogram (B) shows a proximal occluded celiac artery (arrow) and SMA (arrowhead).
The oblique distal abdominal aortogram (C) shows a high-grade stenosis of the proximal IMA as a result of an eccentric plaque
(circle). The corresponding 3-D contrast-enhanced MRA (D) shows occlusion of the celiac (arrow) and SMAs (arrowhead) and
a high-grade stenosis of the proximal IMA (E). Enlarged meandering artery (arrowhead).
 K.D. Hagspiel et al / Radiol Clin N Am 40 (2002) 867–886 877

Fig. 9 (continued ).

CMI is described as one of the protean manifes- ability to assess luminal and vascular wall changes.
tations of vasculitides, especially Takayasu’s arteritis. The technique is valuable for the assessment of the
MRA bears promise in this application because of its aorta and its side branches [60]. Stenoses, occlusions,
878 K.D. Hagspiel et al / Radiol Clin N Am 40 (2002) 867–886

Fig. 10. Patient with chronic mesenteric ischemia. (A) Short occlusion of the superior mesenteric artery, (B) a high-grade osteal
inferior mesenteric artery stenosis.

vascular wall thickening, wall enhancement, and
increased signal on T2 and STIR images are reported
in vasculitides [61,84].
CMI summary
3D gadolinium-enhanced MRA is a major non-
invasive screening technique for patients suspected of
having CMI. It is well suited for the detection of
atherosclerotic occlusive disease in the proximal CA
and SMA and the assessment of patients with aortic
dissection. It has limitations, however, and physicians
using this modality should be aware of the inability
of this technique to assess reliably the peripheral
SMA branches and the IMA. Abnormal morpholog-
ical findings can be corroborated with functional
flow measurements.
MR portography
MRA allows the evaluation of the portomesen-
teric venous system with great accuracy. A mul-
 K.D. Hagspiel et al / Radiol Clin N Am 40 (2002) 867–886 879

Etiologies of PV thrombosis (PVT) include sepsis,

neoplasm, inflammation, coagulopathy, and idio-
pathic PVT [44]. Cirrhosis with decreased portal
venous flow can also cause PV thrombosis. In some
cases of chronic PV occlusion, cavernous transforma-
tion results [65] (Fig. 17). In this condition, collateral
vessels in the porta hepatis and gallbladder fossa
bypass the occlusion and reconstitute the intrahepatic
PVs. Splenic vein thrombosis can be caused by
pancreatitis, neoplasms, splenectomy, hypercoagu-
able states, or various other etiologies (Fig. 13). In
these cases, the splenic vein then drains through
portoportal collaterals, such as the short gastric veins,
to the coronary vein, the gastroepiploic veins, and the
arc of Barkow. Acute PV thrombosis has been
initially described on spin-echo sequences, but is
better diagnosed with MRA [42,43]. No study is

Fig. 11. Subvolume maximum intensity projection of a 3D

gadolinium-enhanced MRA in a patient with isolated stenosis
of the superior mesenteric artery just beyond the origin of a
jejunal branch (arrow) following radiation therapy.

titude of approaches are used, but recently sequen-

tial 2D TOF techniques and PC MRA techniques
have been completely replaced by CE 3D MRA
techniques. Indications for MR portography are
portal hypertension, PV thrombosis, and prior to
surgery of tumors of the liver, the pancreas and
the bile ducts and before liver transplantation
[7,62 – 64].
The evaluation of patients with portal hy-
pertension is one of the most frequent indica-
tions for portal MRV. The finding of thrombosis,
and particularly occlusion of the portal venous
system, potentially changes the management of
these patients.
Assessment of the patency of the portomesen-
teric veins and potential collateral pathways is
achieved best with gadolinium-enhanced 3D MRA
(Fig. 8). Collaterals frequently seen are the coronary
(left gastric) veins (see Fig. 2), short gastric veins
(Fig. 13), esophageal and paraesophageal veins Fig. 12. An 84-year-old male patient with Leriche’s
(Fig. 14), recanalized umbilical veins (Fig. 15) syndrome and symptoms of chronic mesenteric ischemia.
Note moderate stenosis at celiac artery origin (arrow) and
and the azygos/hemiazygos system [9]. There also
significant stenosis at superior mesenteric artery origin
are left- (Fig. 16) and right-sided splenorenal shunts
(arrowhead). There is reconstitution of the isolated inferior
and gastrorenal shunts, which can always be seen mesenteric artery (IMA) (curved open arrow) via non-
on MRA if they are of sufficient size. The superi- visualized collaterals. The IMA is one of the collateral
ority of MRA for the evaluation of the portal pathways for reconstitution of the perfusion at the lower
system is proved over Doppler sonography, but extremity via superior hemorrhoidal to internal iliac
not CTA [12]. branches (not shown).
880 K.D. Hagspiel et al / Radiol Clin N Am 40 (2002) 867–886
Fig. 13. Splenic vein occlusion with portoportal collaterals.
Maximum intensity projection image of patient with short
occlusion of the splenic vein (arrow) demonstrating flow
through the short gastric veins to the coronary vein and then
portal vein (arrowhead).
published addressing the question: Which MRA
technique is superior for the evaluation of PVT?
But the authors use a combination of sequential 2D
Fig. 14. Esophageal and paraesophageal varices in a patient
with portal hypertension as shown on a subvolume
maximum intensity projection (between arrows).
Fig. 15. Patient with portal hypertension and splenomegaly
has massively enlarged recanalized umbilical vein originat-
ing off the left portal vein (arrowheads).
TOF using magnetization preparation and CE 3D
MRA (see Fig. 8).
Resectability of pancreatic cancer and
other malignancies
In the absence of metastases, arterial or portome-
senteric vein invasion predicts a patient’s resectability
Fig. 16. Left splenorenal shunt (arrow) and short gastric
varices (arrowheads).
 K.D. Hagspiel et al / Radiol Clin N Am 40 (2002) 867–886 881

and only hope for cure. MRA, in conjunction with

MRI and MR cholangiopancreatography, reliably di-
agnoses and assesses the resectability of pancreatic
adenocarcinoma [66 – 68]. 3D MRA achieves a sensi-
tivity of 96% and specificity of 89.5% (positive
predictive value [PPV], 92.3%; negative predictive
value [NPV], 94.4%) in a series of 143 patients with
benign and malignant diseases of the pancreas with
surgical correlation [67]. Results using this technique
are better than in previous studies using 2D inflow
and 3D PC MRA [69,70]. Findings consistent with
unresectability are encasement and vascular occlusion
(Figs. 18, 19)

Assessment of living related liver

transplant donors

As a result of the shortage of cadaveric liver

Fig. 17. Patient with status post-thrombosis of the portal
vein (PV) and superior mesenteric artery (SMA) with cav-
ernous transformation of the PV (arrowheads) and multiple
collaterals in the distribution of the superior mesenteric
vein (arrows).
transplants, living related liver transplant (LRLT)
has been developed [71]. Prior to this operation,
preoperative definition of the donor vascular struc-
tures (hepatic veins, hepatic artery, and portal vein)
and the biliary system in the donors was of utmost

Fig. 18. Occlusion of the superior mesenteric vein (SMV) in a patient with a large pancreatic adenocarcinoma. (A) Subvolume
maximum intensity projection (MIP) image demonstrating abrupt occlusion of the SMV (arrows). (B) MIP image slightly more
anterior shows collateral flow from SMV to splenic vein via gastroepiploic vein (arrow).
882 K.D. Hagspiel et al / Radiol Clin N Am 40 (2002) 867–886

Fig. 19. (A) Encasement of the splenic artery (arrow) in a patient with a pancreatic adenocarcinoma shown on celiac arteriogram.
3D contrast-enhanced (CE) MRA shows the same finding (B). There also is encasement of the portal venous confluence (arrow)
as demonstrated on indirect splenoportography (C) and 3D CE MRA (D).

importance. It is the role of imaging in this clinical
setting to define conditions in which transplantation
is contraindicated and to identify anatomic variations
that may alter the surgical approach [72]. Catheter
angiography, CT, sonography, and endoscopic ret-
rograde cholangiography all are performed in poten-
tial donors. The combination of MR volumetry,
venography, angiography, and cholangiography, how-
ever, may be sufficient for donor work-up in the
majority of cases [73 – 75]. These investigators rec-
ommend catheter angiography only in cases where
MRA is suboptimal and intraoperative cholangio-
 K.D. Hagspiel et al / Radiol Clin N Am 40 (2002) 867–886
Fig. 20. Portal vein (PV) stenosis in a patient with a liver
transplant. Stenosis of the PV (arrow) at the anastomotic
site. This was later proved hemodynamically not significant
by percutaneous portography and pressure measurements.
graphy in cases with unclear biliary anatomy or
duct variants.
Assessment of liver transplant patients
The evaluation of vascular complications of liver
transplantation is a well established indication for
mesenteric MRA in many institutions including the
authors’ [76 – 79] (Fig. 20). In a study of 13 liver
transplant recipients suspected of having vascular
complications, conventional angiography or surgery
identified 10 vascular complications. These include
transplant hepatic artery thrombosis (n = 3) or stenosis
(n = 3), PV stenosis (n = 1) or occlusion (n = 2), and
suprahepatic inferior vena cava (IVC) stenosis (n = 1).
All 10 complications are diagnosed correctly with
gadolinium-enhanced 3D MRA. There was agreement
between results of MR angiography and conventional
angiography or surgery in 58 of 62 vessels evaluated
(94%). There was minor disagreement in four vessels
(6%) [80]. MRI/MRA holds promise of allowing a
comprehensive evaluation of patients after liver trans-
plantation. Some investigators believe that it even-
tually may emerge as the sole diagnostic imaging
modality for this patient population [72,81].
Gastrointestinal hemorrhage
The detection of a bleeding source in patients with
recurrent episodes of gastrointestinal hemorrhage can
883
be a significant challenge. Usually nuclear medicine
and catheter angiographic techniques are applied for
this purpose. Hilfiker et al, however, demonstrate the
possibility of detecting the source of hemorrhage in
animal models with MRI using macromolecular
(intravascular) contrast media (MMCM) [82]. Be-
cause the contrast agent stays within the vascular
system for extended periods of time, extravasation of
contrast into the intestinal lumen allows identification
of the source of bleeding. In addition, these inves-
tigators demonstrate in an animal model that the
sensitivity of 3D MRI after administration of an
intravascular contrast agent is superior compared with
scintigraphy with 99mTc-labeled red blood cells. MRI
correctly characterizes all 18 gastrointestinal hemor-
rhages created in six pigs, resulting in 100% sen-
sitivity and specificity. The corresponding values for
scintigraphy are 78% and 72%, respectively. Also,
interobserver variability is significantly better with
MRI [83]. Studies of this method in humans do not
exist because of the unavailability of MMCM for
human use.
Summary
MRA has evolved from a research tool to a robust
clinical diagnostic modality. In many centers world-
wide, it is the technique of choice for evaluating pa-
tients with suspected CMI, assessing operability of
patients with pancreatic cancer, and investigating the
portal system. Evolving indications include the as-
sessment of liver transplant patients before and after
transplant and of living related liver transplant
donors. The search for the bleeding source in patients
with gastrointestinal hemorrhage may be an indica-
tion in the future, once intravascular contrast agents
become available.
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 Radiol Clin N Am 40 (2002) 887 – 898

MR imaging of atherosclerotic plaque

C. Joon Choi, MD, PhD a, Christopher M. Kramer, MD a,b,*
a
Cardiovascular Division, Department of Internal Medicine, University of Virginia Health System,
Charlottesville, VA 22908, USA
b
Department of Radiology, University of Virginia Health System, Charlottesville, VA 22908, USA

Magnetic resonance imaging (MRI) is a promising monocyte-derived macrophages, T lymphocytes,

method for imaging of atherosclerotic plaque. Recent
advances have validated MR measures of plaque
location and volume in the vessel wall in the aorta,
carotid arteries, and even coronary arteries and the
ability to follow plaque volume serially. As spatial and
temporal resolution has advanced, MRI is able to
measure not only the thickness of the vessel wall
and plaque but also to characterize directly compo-
nents of atherosclerotic plaque such as the lipid core,
the fibrous cap, calcium, and thrombus. Newer ap-
proaches include intravascular and transesophageal
MRI techniques for improving plaque imaging. Stand-
ard contrast agents and novel contrast agents in
development are used to identify various components
of plaque. The state-of-the-art of MR imaging of
atherosclerotic plaque is reviewed in this article.
The vulnerable atherosclerotic plaque
Atherosclerosis is a systemic disease of the vessel
wall in elastic arteries including the aorta, carotid, and
coronary arteries [1]. Components of atherosclerosis
include (1) connective tissue extracellular matrix
including collagen, proteoglycans, and fibronectin
elastic fibers; (2) crystalline cholesterol, cholesterol
esters, and phospholipids; and (3) cells such as
This work was supported by a grant from the
Commonwealth of Virginia Health Research Board.
* Corresponding author. Department of Radiology,
University of Virginia Health System, Box 800170,
Charlottesville, VA 22908, USA.
E-mail address: ckramer@virginia.edu (C.M. Kramer).
and smooth muscle cells [2]. A novel concept of
the ‘‘vulnerable plaque’’ recently has been proposed
[3]. The vulnerable atherosclerotic plaque is rupture-
prone, whereas the stable plaque is less likely to
rupture. Atherosclerotic plaque stability is depends
on three factors: (1) lipid core, (2) fibrous cap and its
thickness, and (3) inflammation within the cap. The
vulnerable plaque is thought to have a thin fibrous
cap, large lipid core, and significant inflammatory
cell infiltration. An imaging technique that can
identify these different components of the plaque
ultimately may have an impact on therapy. Given
that the thickness of the thin fibrous cap may be as
little as 65 to 150 mm [4], high signal-to-noise ratio
with high spatial and temporal resolution is mandated
for any imaging technique used.
The concept of plaque vulnerability can be exem-
plified by the coronary arteries. The activity of
coronary plaque is disproportional to the coronary
stenosis by coronary angiography. When coronary
angiography is performed after myocardial infarction
to define the culprit lesion in patients who had coro-
nary angiography months before an index myocardial
infarction, the severity of two thirds of the culprit
lesions is less than 50% stenosis at the time of the
first angiogram, and only 15% demonstrated greater
than 70% stenosis [5,6]. These studies document that
most acute coronary syndromes occur when the
underlying coronary artery is not flow-limiting. The
fibrocalcified coronary plaque is more stable plaque
that generates clinically stable angina pectoris. The
vulnerable plaque is prone to rupture and produce
acute coronary syndromes including unstable angina,
myocardial infarction, and sudden cardiac death.
Therefore, tissue characterization of the coronary

0033-8389/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 1 9 - 2
888 C.J. Choi, C.M. Kramer / Radiol Clin N Am 40 (2002) 887–898
plaque using any invasive or noninvasive imaging
technique is a clinically important goal.
Advantages of MRI
MRI has advantages over other imaging modalit-
ies in the evaluation of atherosclerotic plaque [4].
Standard invasive techniques including x-ray angiog-
raphy, intravascular ultrasound, angioscopy, and
optical coherence tomography suffer the disadvantage
of the risk of arterial invasion. Noninvasive tech-
niques also exist, such as surface B-mode ultrasound
and ultrafast CT. All these techniques can identify
luminal stenosis, wall thickness, and plaque volume,
but none offer the ability to characterize the chemical
composition of plaque components. MRI is nonin-
vasive and safe, does not require ionized intravascu-
lar contrast agents, can image in any plane, and can
provide information on tissue composition. Limita-
tions do exist, however. Patients with claustrophobia
and metallic devices such as pacemakers, defibrilla-
tors, and cerebral aneurysm clips are unable to enter
the MR environment. Cardiac arrhythmias may limit
the image quality of cardiac imaging, although they
may not handicap the imaging of plaque in the aorta
or carotid arteries.
MRI plaque characterization ex vivo and in
animal models
Radiofrequency (RF) stimulation during MRI
excites 1H atoms. The return of the hydrogen nucleus
to the basal state following the cessation of the RF
pulse is called relaxation. The time required for the
longitudinal vector to return to its value prior to the
RF pulse is called longitudinal relaxation time (T1).
T1 depends on the physical and chemical magnetic
environment and is different for different tissues: 850
milliseconds for myocardium, 1000 milliseconds for
blood, and 260 milliseconds for fat at 1.5T. Images
can be T1-weighted (T1W), in which tissues with a
short T1 appear bright, whereas those with a long T1
appear dark. The loss of energy as a result of phase
coherence is known as transverse relaxation, and the
time that elapses until a position of equilibrium is
called transverse relaxation time (T2), which depends
on the local static magnetic environment. Images can
be T2-weighted (T2W), in which tissues with a long
T2 appear bright and those with a short T2 appear
dark. T2 of myocardium is 60 milliseconds, blood
1200 milliseconds, and fat is 84 milliseconds. The
principle that different tissue types have different T1
and T2 has been applied to characterize tissue com-
ponents of atherosclerotic plaque.
Early studies demonstrated that the atheromatous
core within plaque, mostly composed of cholesterol
and cholesterol esters in solid crystal or liquid-crys-
talline state, was associated with shortened water T2
when compared to collagenous cap and normal
media. Consequently, bright areas on T2W images
from arterial walls do not correspond to lipid rich
regions, but to regions predominantly composed of
fibers such as collagen, elastin, and proteoglycan
either in media or in collagenous caps, and dark areas
on T2W correspond to lipid-rich regions [7 – 9]. More
studies have addressed this issue by selectively view-
ing the short-T2 lipids in atherosclerotic plaques
[10,11]. These lipids do not demonstrate signal loss
when a fat suppression pulse is used, such as that
used for coronary lumen imaging [12,13].
Two main components of the mature atheroscle-
rotic plaque are atheromatous gruel in the core and
sclerotic fibrosis around that core. Using 1H-NMR
spectroscopy at 9.4T, 4.7T, and 1.5T in human aorta,
Toussaint et al demonstrated that water T2 is shorter
in the lipid-rich core of atherosclerotic plaques than
in the collagenous cap or normal media [13]. At 9.4 T,
T2 is 20.2 milliseconds for the atheromatous core,
30.1 milliseconds for the collagenous cap, and 29.5
milliseconds for normal media; at 4.7 T, T2 is 54.7
milliseconds, 79.3 milliseconds, and 80.7 milli-
seconds, respectively. In Fig. 1 the T2W image
demonstrates high intensity in the collagenous cap,
Fig. 1. Fibrofatty plaque in aorta. T2W MRI image identifies
a collagenous cap on plaque, which completely covers the
atheromatous core. T2W contrast also reveals a circum-
ferential black ‘‘line’’ on the luminal side of the vessel
corresponding to lipid infiltration. (Adapted from Toussaint
JF, Southern JF, Fuster V, et al. T2-weighted contrast for
NMR characterization of human atherosclerosis. Arterio-
scler ThrombVasc Biol 1995;15:1533 – 42; with permission.)
 C.J. Choi, C.M. Kramer / Radiol Clin N Am 40 (2002) 887–898 889

Table 1
MRI signal intensity
Imaging sequence Fibrocellular Lipid rich Hematoma Calcification
PDW High Intermediate Variable Nil
T1W High Intermediate Variable Nil
T2W High Low Variable Nil
Reprinted from Worthley SG, Helft G, Fuster V, et al. High resolution ex vivo magnetic resonance imaging of in situ coronary
and aortic atherosclerotic plaque in a porcine model. Atherosclerosis 2000;150:321 – 9; with permission.

which has a longer T2, and dark density in the lipid As atherosclerosis progresses, the complex plaque
core, which has a shorter T2. These findings corre- may also contain thrombus. Recent evidence from a
spond well to histopathology. This difference enables rabbit model of thrombosis demonstrates that T2W
generation of high contrast in T2W images and imaging 48 hours after thrombus formation allows
provides a unique method for discriminating collage- accurate measurement of thrombus size, length, and
nous from lipid-rich plaque regions. Calcifications do anatomic location [15]. The signal intensity, however,
not generate appreciable signal because of their low on T2W imaging may depend upon age of the
water content and are detected on T1W images as thrombus [16]. The more acute the thrombus, the
areas of low signal. These authors conclude that the higher the signal on T2W imaging, as shown in a
combination of T1W and T2W sequences permits in swine model [16].
vitro identification of the atheromatous lipid-rich Using T1W, T2W, and PDW MRI sequences
core, fibrous cap, calcifications, media, and perivas- (termed a multispectral imaging approach [17]),
cular fat. different tissue components of complex atheroscle-
From a swine model of coronary and aortic rotic plaque have been characterized. Among multi-
atherosclerosis induced by a combination of athero- spectral imaging types, T2W imaging has been the
genic diet and balloon injury, Worthley et al [14] most effective. The contribution of PDW imaging is
demonstrate that the MR images correlate with
matched histopathologic sections for both the coro-
nary arteries and the aorta. MRI accurately charac-
terizes complex atherosclerotic lesions, including
calcified, lipid rich, fibrocellular, and hemorrhagic
lesions. The authors propose a schema for plaque
characterization according to the signal intensity
patterns seen using different MR sequences in the
same tissue (Table 1). Calcium is dark on T1W, T2W,
and proton density-weighted (PDW, a combination of
T1- and T2-weighting) images. Fibrocellular compo-
nents appear light on T1W, T2W, and PDW images.
The lipid rich core appears light on T1W and PDW,
but dark on T2W image. Thrombus signal is variable.
As seen in Fig. 2, with T1W imaging, calcifications
are well defined by signal loss, but there is less contrast
between the other regions. The calcifications are also
well visualized with T2W and PDW imaging. The
dense fibrocellular cap is easily distinguished from the
less dense body of the plaque containing regions of Fig. 2. Series of three MR imaging sequences of the same
abdominal aortic section and the corresponding histopathol-
extracellular lipid deposition on T2W imaging and on
ogy section, highlighting the various signal intensities for
PDW imaging. Plaque hematoma is also well visual-
each atherosclerotic plaque component with the different
ized with both T2W and PDW imaging. There is less MRI sequences (see text for more detailed explanation).
tissue contrast, however, between the lipid-rich areas (Reprinted from Worthley SG, Helft G, Fuster V, et al. High
and the hematoma with the PDW and T2W images, resolution ex vivo magnetic resonance imaging of in situ
than for either of these two plaque components and the coronary and aortic atherosclerotic plaque in a porcine
dense fibrocellular regions. model. Atherosclerosis 2000;150:321 – 90; with permission.)
890 C.J. Choi, C.M. Kramer / Radiol Clin N Am 40 (2002) 887–898

more limited. For practical purposes, T1W and T2W
images may be enough to define lipid-rich plaque.
Ongoing improvements in MR image resolution and
decreases in acquisition time, together with new
MRI techniques including navigator echo, contrast
enhancing agents, and diffusion weighting, should
lead to further improvements in atherosclerotic
plaque characterization.
Human aortic plaque imaging
Atherosclerosis is a systemic disease and ather-
oma in the aortic arch is a marker of generalized
atherosclerosis. Because of its location, proximal
plaque in the aorta distal to the aortic valve and
proximal to the left subclavian artery correlates with
cerebral infarction especially in plaque with thickness
of 4 mm or greater in a prospective case-control study
[18]. This study uses transesophageal echocardiogra-
phy (TEE) to identify the culprit aortic plaque.
MRI using T2W and PDW techniques to assess
atherosclerotic plaque thickness, extent, and com-
position in the descending aorta has recently been
compared with TEE [19] (Fig. 3). An electrocardio-
graphic (ECG)-gated double-inversion-recovery –
fast-spin-echo (FSE) sequence is employed and a
four-element (two anterior and two posterior)
phased-array coil used for signal reception to obtain
an improved signal-to-noise ratio [20]. A double-
inversion-recovery magnetization preparation pulse
is selected to suppress signal from flowing blood

Fig. 3. In vivo MR images from patient with 4.5-mm – thick plaque in descending thoracic aorta. (A) T1W; (B) proton density
weighted (PDW); (C) T2W; (D) corresponding transesophageal echocardiography image. MR images show an example of
American Heart Association type IV/Va plaque with dark area in center (arrow) identified on T2W image as a lipid-rich core (C).
Lipid-rich core is separated from lumen by fibrous cap. Because of the improved flow suppression of the double-inversion-
recovery FSE sequence of T2W and PDW imaging compared with the conventional SE with radiofrequency presaturation pulses
of T1W imaging, the differentiation between slow flow and plaque is determined only from the T2W and PDW images. (From
Fayad ZA, Nahar T, Fallon JT, et al. In vivo magnetic resonance evaluation of atherosclerotic plaques in the human thoracic
aorta: a comparison with transesophageal echocardiography. Circulation 2000;101:2503 – 9; with permission.)
 C.J. Choi, C.M. Kramer / Radiol Clin N Am 40 (2002) 887–898
[21]. The inversion time (TI) for the double-inversion-
recovery preparation pulses is determined close to the
null point of the blood signal. The improved flow
suppression of the double-inversion-recovery FSE se-
quence, compared with conventional spin-echo T1W
imaging with radiofrequency presaturation pulses,
allows differentiation between slow flow and plaque
using the former sequence.
From 25 matched cross-sectional aortic plaque im-
ages in 10 patients, there is good agreement between
MR and TEE assessment of aortic plaque type, plaque
extent, and maximum plaque thickness. TEE, how-
ever, is invasive, requires premedication, and artifacts
from calcifications and difficulties with the near field
signal-to-noise ratio may prevent plaque visualization.
In addition, ultrasound imaging including TEE and
intravascular ultrasound (IVUS) is not able to dis-
criminate chemical composition of plaque [22].
Kramer et al demonstrates the ability of MRI to
differentiate fibrous cap, lipid core, and thrombus
components of atherosclerotic plaque within abdom-
inal aortic aneurysms in patients prior to surgery [23].
The resected plaque is examined histopathologically
and compared to the MRI performed two days prior
to surgery. The thin fibrous cap is seen as bright on
T2W imaging. In addition, signal intensity of throm-
bus is brighter than that of the lipid core, which
demonstrates low signal on T2W imaging.
Human carotid plaque imaging
Because of its superficial location in the neck,
minimal motion, and available tissue pathology from
carotid endarterectomy (CEA), carotid artery plaque
has been considered an excellent target for MRI of
atherosclerosis. In a study by Toussaint et al [24],
seven lesions from six patients are imaged in vivo
prior to CEA, and T2 in various plaque regions are
quantified. Measurements in vitro on the resected
fragment are repeated and compared with histology.
T2 values calculated in vivo correlate closely with in
vitro measurements for each plaque component. The
authors conclude that T2W imaging by MRI allow
discrimination of lipid core, fibrous caps, calcifica-
tions, normal media, and adventitia in human athe-
romatous plaques in vivo.
Subsequent work has been aimed at the ability to
quantify plaque. As opposed to other imaging mo-
dalities, such as contrast angiography, which provides
information on lumen size but not plaque size, MRI
can noninvasively determine the arterial wall area.
Yuan et al [25] conduct a study to determine the
accuracy of in vivo MRI for measuring the cross-
891
sectional maximum wall area of atherosclerotic
carotid arteries in a group of patients undergoing
CEA. Maximum wall-area measurements from the
ex vivo MRI using a custom-made phased-array coil
are used as the reference standard and compared with
maximum wall area measurements from the corre-
sponding in vivo MR study. Close agreement be-
tween the in vivo and ex vivo measurement confirm
the accuracy of MRI for quantification of plaque in
atherosclerotic carotid lesions (Fig. 4). This study
provides the basis for MRI monitoring of lesion size
in future studies examining plaque progression and/
or regression.
Recently expanding the horizons beyond imaging
plaque volume, the same group of investigators aims
to characterize plaque vulnerability including meas-
ures of thickness of the fibrous cap. This measure is
limited, using conventional imaging modalities such
as intravascular ultrasound. Hatsukami et al [26] apply
a MRI sequence, termed ‘‘bright-blood three-dimen-
sional multiple overlapping thin-slab angiography
(3D-MOTSA),’’ to develop a semiquantitative evalu-
ation of fibrous cap thickness in carotid atheroscler-
otic plaque. When a thickness of 0.25 mm is chosen as
the level for distinguishing between thick and thin
fibrous caps, this 3D-MOTSA technique demonstrates
its ability to differentiate between thick and thin caps
and recent cap rupture. In 22 subjects scheduled for
carotid endarterectomy, thick fibrous caps are demon-
strated by a unique dark band between the white
lumen and gray wall. Thin fibrous caps show no band
between white lumen and gray wall and recent cap
rupture shows no band between the white lumen and
gray wall with a bright gray region near lumen with or
without an irregular lumen surface, depending on the
extent of cap rupture. When 36 sites are available for
Fig. 4. Cross-sectional image of common carotid artery on in
vivo (A) and ex vivo (B) T1-weighted MRI with outline of
lumen and the carotid artery outer wall boundary (OWB).
The area of signal void (arrow) adjacent to the lumen (L)
represents a region of dense calcification, confirmed by
histologic examination. (Adapted from Yuan C, Beach KW,
Smith LH Jr, et al. Measurement of atherosclerotic carotid
plaque size in vivo using high resolution magnetic resonance
imaging. Circulation 1998 98:2666 – 71; with permission.)
892 C.J. Choi, C.M. Kramer / Radiol Clin N Am 40 (2002) 887–898

comparison between MRI and histology, there is a
high level of agreement between MRI and histological
findings. These findings indicate that high-resolution
MRI with a 3D-MOTSA protocol is capable of dis-
tinguishing intact, thick fibrous caps from intact thin
and disrupted caps in atherosclerotic human carotid
arteries in vivo.
In vivo MRI and characterization of the carotid
plaque have been performed using a multicontrast/
multispectral approach (ie, T1W, T2W, and PDW
images) with high-resolution black-blood spin and
FSE-based MRI sequences. Yuan et al [17] add a 3D
time-of-flight (TOF) technique to T1W, T2W, and
PDW techniques to evaluate differential contrast-
weighted images to improve the accuracy of iden-
tifying the lipid-rich necrotic core and acute intra-
plaque hemorrhage in vivo in 18 patients scheduled
for CEA undergoing preoperative carotid MRI. TOF
is a bright-blood technique originally developed for
angiography. As demonstrated in Fig. 5, the TOF
image reveals distinct lumen boundary that some-
times is not well defined by other sequences. Pre-
vious studies demonstrate good sensitivity and
specificity for identifying plaque constituents by use
of spin-echo based sequences primarily T2W and
PDW imaging on ex vivo MRI [12,13].
There is good agreement between MRI and his-
tological findings; overall accuracy (95% CI) of
multispectral MRI is 87% (80% to 94%), sensitivity
is 85% (78% to 92%), and specificity is 92% (86% to
98%). Yuen et al [17] show that TOF and T1W
images are also valuable for identifying lipid-rich
necrotic core and intraplaque hemorrhage in vivo.
Specifically, the authors find that both acute intra-
plaque hemorrhage and lipid-rich necrotic core
regions can appear hyperintense on T1W imaging
compared with the adjacent muscle. Furthermore,
acute intraplaque hemorrhage can be distinguished
from the lipid-rich necrotic core by the presence of
high signal intensity in the TOF images.
Human coronary and coronary wall imaging
Initial efforts to image the human coronary arte-
ries were targeted at imaging of the lumen for
detection of stenosis severity. The difficulties of
coronary imaging include cardiac and respiratory
motion, small vessel size of only several millimeters
in diameter, and nonlinear tortuous coronary arterial
course [14]. The initial approach used by most
centers is a two-dimensional T1W breath-hold gra-

Fig. 5. MR images with four contrast weightings demonstrating typical appearance of lipid-rich necrotic-core (LR-NC) along with
matched histology sections with Mallory’s trichrome staining and antimacrophage antibody CD-68 staining. Major plaque tissue
types at this image location include large LR-NC, foam cells, and loose matrix. Core (purple double arrowhead) is identified by
hyperintense signals on T1W image and isointense signals on time-of-flight image versus adjacent muscle. Large accumulations
of lipid-rich foam cells (green arrow) have signal intensity similar to LR-NC on T1W images but appear hyperintense on both
proton density weighted and T2W images. Loose matrix (red double arrowheads) appears hyperintense on PDW and T2W
images. L indicates lumen; ICA, internal carotid artery; and ECA, external carotid artery. Bar = 1 mm. (Adapted from Yuan C,
Mitsumori LM, Ferguson MS, et al. In vivo accuracy of multispectral magnetic resonance imaging for identifying lipid-rich
necrotic cores and intraplaque hemorrhage in advanced human carotid plaques. Circulation 2001;104:2051 – 6; with permission.)
 C.J. Choi, C.M. Kramer / Radiol Clin N Am 40 (2002) 887–898 893

dient-echo technique with fat suppression [27] that
requires multiple sequential breath holds and is
limited by the variability of the breath holds and
the tortuosity of coronary vessels. Despite these
limitations, these initial reports are promising. Data
from a wide variety of centers, however, has been
more variable [28]. Three-dimensional techniques are
in development, including the use of real-time navi-
gator echos that follow a structure such as the dome
of the diaphragm, but are limited by long acquisition
times [29]. Recently developed techniques involving
T2 weighting and free-breathing show promise [30].
When studied in a prospective, multicenter fashion,
these techniques show good sensitivity for left main
and multivessel disease, but somewhat limited spe-
cificity for stenosis detection [31].
Most recently, investigators have endeavored to
image not the coronary lumen, but the coronary wall
itself. Black-blood MR methods [32,33] that null the
signal from the blood are essential to visualize the
coronary wall, as white-blood MR coronary angiog-
raphy using several sequences, such as gradient echo,
echo planar, and spiral, does not provide signal from
the coronary wall. Fayad et al [34] use a black-blood
high-resolution MRI method without motion or
blood-flow artifacts and with 0.46-mm in-plane reso-
lution to visualize the wall of major epicardial cor-
onary arteries in eight normal subjects and five
patients with coronary disease as shown in Fig. 6.
Smaller side branches are not visualized. The average
coronary wall thickness for each cross-sectional
image in normal subjects is 0.75 mm with a range

Fig. 6. Coronary angiogram from 76-year-old male patient shows high-grade stenosis in proximal left anterior descending (LAD)
(arrows, A). In vivo, cross-sectional, black-blood MR images of LAD lumen in normal subject (B) show normal lumen (elliptical
lumen shape) in same patient; wall image (C) shows large eccentric plaque with heterogeneous signal intensity (maximum
thickness, 5.73 mm). Blood flow in coronary artery lumen is suppressed with velocity-selective inversion preparatory pulses. LV
indicates left ventricle; RV, right ventricle; and RVOT, right ventricular outflow tract. (Adapted from Fayad ZA, Fuster V, Fallon JT,
et al. Noninvasive in vivo human coronary artery lumen and wall imaging using black-blood magnetic resonance imaging.
Circulation 2000;102:506 – 10; with permission.)
894 C.J. Choi, C.M. Kramer / Radiol Clin N Am 40 (2002) 887–898
from 0.55 to 1.0 mm. The patients with coronary
disease with < 40% stenosis assessed by coronary
angiography show localized wall thickness of 4.38
mm with a range from 3.30 to 5.73 mm. Botnar et al
[35] use a real-time navigator for respiratory gating
and real-time slice-position correction with a black-
blood FSE sequence with similar results to the study
of Fayad et al [34], demonstrating feasibility of imag-
ing and quantification of human coronary atheroscle-
rotic plaque by MRI.
Plaque characterization has been performed in the
coronary artery of a pig [14]. Limitations of spatial
resolution and motion artifact still hamper the
application of MRI to plaque characterization in
human coronary arteries. As these technical limita-
tions are gradually overcome, investigators will begin
to aim at the identification of the vulnerable plaque in
the human coronary artery.
Interventional MR plaque imaging
Because of the hurdles of spatial resolution and
cardiac and respiratory motion, ‘‘external’’ MR
imaging using a body array coil currently is not able
to accomplish plaque characterization in human cor-
onary arteries. Recent advancements in the field of
‘‘internal’’ MR imaging with intravascular MRI
(IVMR) and transesophageal MRI may have important
roles as a bridge between invasive and noninvasive
imaging and allow coronary plaque catheterization.
IVMR technology employs intravascular receiver
coils. Because of the close proximity between the
imaging coil and the vessel with IVMR imaging,
signal-to-noise ratio is sufficient to achieve high-
resolution arterial images. In in vivo and ex vivo
animal models, plaque imaging with IVMR has been
achieved with excellent spatial resolution in a variety
of arterial systems including the coronary arteries [36 –
40]. Potential limitations for human application
include heat generation along the catheters and pos-
sible thrombus formation. Despite these limitations,
the ability to detect and define complex plaque has
been validated against histopathology [41].
Two classes of IVMR devices are currently avail-
able; one is an IVMR coil, which behaves like an
interventional guide wire, and the other is an IVMR
catheter, which behaves like an intravascular ultra-
sound catheter. The coil system has 100-cm total
length, 6-cm imaging length, 4- to 24-cm field of view,
and outer diameter of 0.030 in, which is a thicker wire
than currently used interventional coronary guide
wires with outer diameter of 0.014 in [36,41]. There
are some advantages of the catheter system. A variety
of clinically available 0.014-in coronary guide wires
could be used to locate this IVMR catheter to the
region of interest and it is an ‘‘inside-out’’ design that
permits imaging of walls with catheter positioned
within the lumen [42]. In-plane resolution using these
IVMR devices is approximately 80 – 150 mm.
Correia et al image 11 thoracic human aortas
obtained at autopsy using an IVMR receiver coil
and validate its ability to accurately assess plaque
size and composition. As in Fig. 7, the fibrous cap is
recognized as a dark structure and necrotic lipid-rich
core appears as a bright area beneath the fibrous cap.
T2 value for the fibrous cap is 49.2 milliseconds and
necrotic core, 76.9 milliseconds.
Rogers et al use an opposed solenoid IVMR coil
integrated into a 5F double-lumen catheter and inter-
faced to a clinical 0.5T interventional MR scanner to
evaluate plaque components in human carotid endar-
terectomy specimens from 17 patients [42]. Seven
plaque components are evaluated: fibrous cap,
smooth muscle cells, organizing thrombus, fresh
thrombus, lipid, edema, and calcium. In addition to
T1W, T2W, and PDW multispectral sequences, the
authors find that magnetization transfer contrast,
inversion recovery, and gradient-echo imaging
approaches are time efficient and able to distinguish
the major atherosclerotic plaque components.
Transesophageal MRI is another approach to
plaque imaging of the descending aorta. Shunk et al
[43] use a flexible 1.2-mm loopless RF receiver [40]
inside a nasogastric tube that is interfaced with a
clinical 1.5T scanner to image the aortic wall of
8 patients without, and 14 patients with, aortic
atherosclerosis. Plaque thickness is measured with
high accuracy compared with TEE and offers a more
accurate assessment of the circumferential extent of
disease than TEE as a result of improvements in
signal-to-noise ratio in the near field. Limitations
include the semi-invasive nature of the procedure
and some nonuniformity of signal-to-noise ratio.
MR contrast agents in plaque imaging
To date, gadolinium-based (Gd) derivatives are
the only MR contrast agent approved for clinical
application. Kramer et al image aortic plaque in
patients before abdominal aortic aneurysmal surgery
using T1W imaging before and several minutes after
infusion of Gd-DTPA. The fibrous cap demonstrates
a significant increase in signal intensity on the post –
Gd-DTPA images. Fibrous caps with an inflamma-
tory cellular component demonstrate higher signal
than those without, suggesting that hyperenhance-
 C.J. Choi, C.M. Kramer / Radiol Clin N Am 40 (2002) 887–898 895

Fig. 7. Axial T2-weighted intravenous MR (IVMR) image of aortic cross section with atherosclerotic plaque (A, arrow). The
IVMR image shows a dark region on top of the plaque, which corresponds to the fibrous cap shown by histopathology (B,
Masson stain). The region inside the plaque, the necrotic core, is bright by IVMR. (Adapted from Correia LC, Atalar E, Kelemen
MD, et al. Intravascular magnetic resonance imaging of aortic atherosclerotic plaque composition. Arterioscler Thromb Vasc
Biol 1997;17:3626 – 32; with permission.)

ment after Gd-DTPA may be a marker of inflam-
mation within the fibrous cap [23].
Several emerging MR contrast agents tested in
animal models hold promise for targeted imaging of
plaque. One novel MR contrast agent detects fibrin in
vitro on human thrombus. Fibrin-targeted paramag-
netic lipid-encapsulated perfluorocarbon nanopar-
ticles, formulated with Gd-DTPA, bind densely to
fibrin clots as visualized by scanning electron micro-
scopy [44,45]. This suggests the potential for sensitive
and specific detection of microthrombi that form on
the intimal surfaces of unstable atherosclerotic plaque.
Superparamagnetic iron oxides are poised to
become an important MRI contrast agent. Once these
896 C.J. Choi, C.M. Kramer / Radiol Clin N Am 40 (2002) 887–898
agents are in magnetic field, the magnetic moments of
individual iron atoms in these particles become
aligned to produce a net magnetic moment that is
several times larger than those of typical paramag-
netic molecules. This net magnetic moment in turn
causes susceptibility effect that leads to low signal
intensity on T2- and gradient-echo T2*-weighted
images. By this mechanism, Ruehm et al [46] report
that ultrasmall superparamagnetic particles of iron
oxides are phagocytosed by macrophage in athero-
sclerotic plaques of the aortic wall of hyperlipidemic
rabbits in a quantity sufficient to cause susceptibility
effects detectable by MRI as low signal in the wall.
Thus, targeted MR contrast agents are promising
tools in the efforts to image the vulnerable athero-
sclerotic plaque.
MRI to monitor therapy
Several therapeutic agents have been used in
attempts to achieve atherosclerotic plaque regres-
sion. Although it is well known that statin therapy
dramatically reduces major cardiac adverse effects in
patients with established cardiovascular disease,
including reduction in mortality by 25% to 30%
[47], plaque regression is harder to demonstrate
using angiographic techniques [48]. Angiographic
improvement in coronary stenosis is usually modest
in coronary regression studies [48], suggesting that
plaque stabilization because of a reduction in lipid
content may be the principle benefit of aggressive
cholesterol lowering. MRI can provide detailed
measurements of atherosclerotic plaque size. Studies
in animal models demonstrate beneficial effects of
low-cholesterol diet on the regression of atheroscle-
rotic plaque [49].
MRI studies of plaque regression and progression
have recently begun in patients. Among 60 patients in
the Familial Atherosclerosis Treatment Study (FATS),
eight patients who treated with intensive lipid-low-
ering regimen using niacin 2.5 gm/day, lovastatin
40 mg/day, and colestipol 20 gm/day for 10 years
are compared with eight untreated control patients
matched with age, baseline low density lipoprotein,
and triglyceride [50]. In this study, prolonged inten-
sive lipid-lowering treatment is associated with a
markedly decreased lipid content within the plaque
by MRI measurement of lipid core area, a character-
istic of clinically stable plaques. Significant reduction
in carotid vessel luminal area or plaque area, how-
ever, is not detected by MRI.
For the first time, recent evidence validates MRI
as an effective tool to detect plaque regression with
lipid-lowering therapy [51]. Eighteen asymptomatic
hypercholesterolemic patients with documented
aortic and carotid atherosclerotic plaques are fol-
lowed up to 12 months using black-blood MRI
technique after lipid-lowering therapy with simvas-
tatin [50]. Although no changes in lumen area, vessel
wall thickness, and vessel wall area are observed at
6 months, at 12 months significant reductions in
vessel wall thickness and vessel wall area, without
changes in lumen area, are observed in both the aorta
and carotid artery. This study opens the door for
future MRI studies of the effect of interventions on
atherosclerosis in humans.
Summary
MRI is a powerful noninvasive imaging tool with
high spatial resolution that continues to prove its
value in determining atherosclerotic plaque size,
volume, and tissue components. Multispectral MRI
sequences have been validated to characterize athero-
sclerotic plaque components in animals; they have
recently been applied to human aorta and carotid
artery and are being used to identify the vulnerable
plaque. The ability to measure wall thickness in hu-
man coronary artery wall has been realized. Future
developments may allow plaque characterization in
the coronary arteries with surface coil imaging, but
intravascular MRI may play an important role in this
regard. Novel contrast agents for identifying inflam-
mation and thrombus within atherosclerotic plaque
will aid in the identification of higher-risk athero-
sclerotic disease. Lastly, MRI has progressed to the
point where it can be used in serial studies of
atherosclerotic plaque progression and regression in
the face of therapeutic intervention. MRI will con-
tinue to evolve an important role in imaging of
atherosclerotic plaque.
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 Radiol Clin N Am 40 (2002) 899 – 919

Body MR venography
Sabah Butty, MD, Klaus D. Hagspiel, MD*, Daniel A. Leung, MD,
J. Fritz Angle, MD, David J. Spinosa, MD, Alan H. Matsumoto, MD
Department of Radiology, Division of Angiography and Interventional Radiology, University of Virginia Health System,
Charlottesville, VA 22908, USA

Venous pathology presents in various ways Time-of-flight MRV

throughout the body. In the past, several diagnostic
modalities, each with its own limitations, have been
used to evaluate the venous system. Sonography,
although inexpensive and readily available, is limited
by operator dependence, poor acoustic window, inac-
cessible anatomy, and body habitus. Contrast venog-
raphy may be undesirable because its invasiveness,
radiation exposure, incomplete filling of veins, and
nephrotoxic and allergic reactions to iodinated con-
trast. Some of the downfalls of iodinated contrast
administration are also encountered with computed
tomography. Impedance plethysmography is limited
in that distal thrombi are not detected and sensitivity
may be less than previously reported. Direct throm-
bus imaging using radiolabelled fibrinogen is not
widely available [1]. Magnetic resonance venography
(MRV) has overcome many of the obstacles of
traditional modalities with an exquisite ability to
depict vascular anatomy in multiple projections for
various pathologies. Its evolution will depend on its
integration with other diagnostic modalities [2].
Techniques for MRV
MRV is an entity separate from magnetic res-
onance arteriography (MRA) because of differences
in flow and disease patterns. MRV techniques can be
divided into noncontrast MR venography, such as
time-of-flight (TOF) and phase-contrast (PC) tech-
niques, and contrast-enhanced (CE) MR venography.
* Corresponding author.
E-mail address: kdh2n@virginia.edu (K.D. Hagspiel).
TOF MRV relies on flow-related enhancement
using a short repetition time (TR) gradient-echo pulse
sequence. Signal results from manipulation of the
longitudinal magnetization of stationary spins. If the
TR is well below the T1 relaxation time of stationary
tissues, T1 recovery is avoided, which results in very
little signal intensity or spin saturation of stationary
tissues. Consequently, blood outside the imaging
slice will not receive radiofrequency (RF) energy,
and thus retain full longitudinal relaxation. Upon
entering the slice, the longitudinal magnetization is
tipped into the transverse plane by an excitation
pulse, producing high-signal intensity. This is re-
ferred to as ‘‘entry-slice phenomenon,’’ ‘‘inflow
enhancement,’’ or ‘‘flow-related enhancement.’’ In-
flow signal depends on echo time (TE), TR, slice
thickness, slice orientation, blood flow velocity, and
flip angle. Differentiation of venous from arterial
signal is accomplished by placing a presaturation
band in the upstream direction of arterial flow, which
nulls inflowing arterial spins [3 – 5].
Intraluminal signal is maximized when blood
receives only one RF pulse before flowing out of
the imaging plane. Signal loss from spin saturation
occurs when blood flows parallel to the region of RF
excitation long enough to receive multiple excita-
tions. This phenomenon occurs when the vessels of
interest are oriented parallel to the imaging plane.
Flip-angle selection is important and dependent on
slice orientation to the axis of the vessel. Decreasing
the flip angle minimizes in-plane flow saturation
because it takes more RF pulses to drive the longi-
tudinal magnetization to equilibrium (minimum sig-
nal). Too small a flip angle may produce noisy

0033-8389/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 2 8 - 3
900 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919

images, whereas too large a flip angle may saturate
venous signal. A flip angle of 20° to 25° is optimal
for in-plane flow. For through-plane flow, a flip angle
of 45° is optimal [3 – 5]. For TOF imaging, venous
signal is maximized when slices are acquired perpen-
dicular to the direction of blood flow. This orientation
often displays a vessel in cross-section allowing for
evaluation of the vessel wall, vessel diameter, and
intraluminal filling defects (Figs. 1, 2).
As with most magnetic resonance (MR) sequences,
TOF can be performed using a two-dimensional (2D)
or three-dimensional (3D) acquisition. Unlike 2D
TOF imaging, where multiple thin sections of a vessel
are sequentially excited, the 3D technique involves
excitation of a volume of tissue that is divided simul-
taneously into thin sections. Advantages of 2D TOF
are large coverage area, detection of slow flow, and
sensitivity to T1 effects. For these reasons, 2D TOF is
ideal for venous imaging. The disadvantages of 2D
TOF are decreased resolution, saturation of in-plane
flow, and ‘‘venetian-blind’’/respiratory artifact. More-
over, breath-hold 2D TOF may suffer from slice
misregistration if the breath holds are not consistent
[5]. Because of the lengthy scan times precluding
breath-hold imaging, 3D TOF is used rarely for
body MRV.
Phase-contrast MRV
PC MRV uses velocity differences and phase shifts
of moving spins to provide signal in flowing vessels
[3 – 5]. With PC, imaging sensitivity to flow depends
on the strength of the flow-encoding gradients. The
gradient amplitude determines the velocity-encoding
value or Venc. The ideal Venc is slightly greater than
the fastest velocity in the vessel of interest. A sug-
gested Venc for body MRV is 20 cm/second [6].
Smaller Vencs produce images that can detect slower
flow. Flow that is faster than the specified Venc
may produce a phase shift greater than 180°, which
looks identical to flow in the opposite direction. This
artifact, known as aliasing, is used to determine
increased flow at the site of a stenosis.
Like TOF, 2D and 3D acquisitions may be applied
to PC imaging. Advantages of PC MRV, compared to
TOF MRV, are sensitivity to a variety of vascular
velocities, reduced intravoxel dephasing, increased
background suppression, and simultaneous acquisi-
tion of magnitude and phase images. Because phase
shift is proportional to flow velocity, PC imaging
allows quantification of both flow velocity and vol-
ume. Disadvantages of PC imaging are long scan
duration, sensitivity to turbulence and pulsatility, and
image degradation from extravascular motion [5]. PC
techniques are used rarely for body MRV.
Contrast-enhanced MRV
CE MRV exploits the gadolinium-induced venous
signal using a 3D gradient-echo sequence. Because
CE MRV depends on recirculation of contrast mate-
rial, it can be used on patients with limited intra-
venous access. CE MRV may be performed using
a direct or indirect approach. With the indirect ap-
proach, nondiluted contrast is injected in a nontar-
geted vein/extremity and imaged during its first pass.
Because considerable dilution of contrast occurs by
the time it arrives to the area of interest, images are
acquired in the early equilibrium phase to avoid
redistribution. Alternatively, the direct approach uses
significantly less contrast because of targeted admin-
istration proximal to the area of interest. The direct
technique involves injection of dilute contrast in a
peripheral vein and imaging of the draining venous
system. Thus, it is analogous to conventional venog-
raphy. The contrast material typically is administered
in a 1:20 dilution with saline [7]. Although this
method provides superior contrast-to-noise ratio,
evaluation is limited only to those veins that drain
from the site of injection (Fig. 3).

Fig. 1. Appearance of acute and chronic deep-vein thrombosis (DVT) on 2D time-of-flight (TOF) MRV. (A) 2D TOF MRV
demonstrates an acute DVT (arrow) with absent signal in the left common femoral vein. Normal-signal intensity is present in the
right common femoral vein. (B) 2D TOF MRV demonstrates an acute DVT of the right popliteal vein (large arrow) with
collateral veins (arrowheads) via the right greater saphenous vein. Normal-signal is demonstrated in the left popliteal vein (small
arrow). (C) 2D TOF MRV demonstrates an acute DVT of paired peroneal veins. (D) maximum intensity projection (MIP) of an
axial 2D TOF MRV demonstrates chronic DVT with extensive recanalization changes of the left common femoral vein and
left external iliac vein (arrowheads), evidenced by synechia and wall irregularities. Numerous collateral thigh veins are
present. (E) 2D TOF MRV axial image of the pelvis demonstrates a linear area of absent flow signal in the left common
femoral vein. This represents a synechia, which is consistent with chronic DVT. (F) MIP of an axial 2D TOF MRV of the
lower extremities demonstrates the decreased flow signal in the proximal and mid-right superficial femoral vein consistent
with partial recanalization.
S. Butty et al / Radiol Clin N Am 40 (2002) 899–919 901
902 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919

Fig. 1 (continued ).
 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919 903

moglobin in fresh thrombus, whereas other tissues

contribute little or no signal [8].

Fig. 1 (continued ).

Thrombus imaging

Various MR techniques exist for the identification

and evaluation of thrombus in veins. Noncontrast and
contrast techniques can be used to image thrombus
material. The noncontrast techniques rely on changes
in T1 of thrombus itself. Contrast techniques exploit
enhancement patterns in the thrombus and the vessel
wall. These enhancement patterns help age a throm-
bus and may ultimately help direct therapy.

Direct thrombus imaging

After thrombus formation, a predictable reduction
in the T1 of the clot occurs, providing high-signal
intensity on T1-weighted images. This T1 reduction
depends on the formation of methemoglobin. De-
pending on the stage of organization, thrombi may
then show high-signal intensity on T1-weighted
sequences if methemoglobin is present. Macro-
Fig. 2. A 44-year-old female patient with history of
phages, which contain hemoglobin degradation prod-
myasthenia gravis and recently placed central venous
ucts, invade the margin of thrombi in large numbers
catheter in the right common femoral vein. The work-up
during thrombus organization, thereby explaining the for persistent lower extremity edema includes an unremark-
signal intensity loss observed in the periphery of able venous duplex examination. (A) A small focal thrombus
thrombi on T2-weighted images in the late stages of in the right external iliac vein is demonstrated and likely the
thrombus organization [8]. Special sequences have result of the recently placed central venous catheter. (B) A
been developed that are optimized to detect methe- conventional venogram confirms this finding.
904 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919

MR appearance of thrombosed veins after inflammatory changes that occur in the setting of an
administration of gadolinium acute deep-vein thrombosis (DVT) [9]. As a result, a
With CE MRV, gadolinium accumulates in the pattern of peripheral gadolinium enhancement is seen
vein wall and the perivenous tissue because of the around an acutely thrombosed vein. This ‘‘bulls-eye’’
 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919 905

sign, which is the characteristic enhancement pattern

of a thrombosed vein, fades with thrombus organiza-
tion and resolving inflammation. The ratio of signal
intensity at the periphery versus the center of the
thrombosed vein is used to differentiate acute from
chronic venous thrombosis [9].

Thrombus imaging agents

Imaging of thrombus material has been performed
using ultrasmall superparamagnetic iron oxide
(USPIO) particles in a rabbit model. USPIO particles
produce a strong T1 effect and a strong T2 or T2*
effect that can be exploited. In this stagnation throm-
bus model, the investigatoars find that the USPIO
effect is statistically significant for the T1-weighted
sequence, but not for the T2*-weighted sequence.
The USPIO effect on the T1-weighted sequence is
dependent on thrombus age with pronounced sig-
nal increase in 3-, 5-, and 7-day-old thrombi.
Fresh (1-day-old) and largely organized (9-day-old)
thrombi do not show enhancement. The investigators
conclude that USPIO-enhanced MR imaging may be
advantageous in detecting thrombi in special circum-
stances [10]. Thus, direct thrombus imaging may
demonstrate thrombi in occluded vessels that are
not filled during conventional venography or are
not detected by flow-sensitive MR techniques of
TOF and PC [10].
Image reconstruction
Post-processing techniques are useful because
they provide a comprehensive display of complex
vascular anatomy. A 3D acquisition facilitates post-
processing techniques. Frequently used algorithms
are multiplanar reconstruction (MPR), maximum
intensity projection (MIP), and volume rendering.
The algorithm used to reformat data determines
how vascular anatomy is perceived [5].
Multiplanar reconstruction
MPR is a postprocessing method commonly avail-
able on workstations. For MPRs, extraction of a 2D
Fig. 4. A 52-year-old male patient who presents for a
preoperative evaluation for a known right renal neoplasm,
presumably renal cell carcinoma. Large right renal mass
(large arrow) with local hepatic invasion (curved arrow).
This tumor shows significant venous involvement (small
arrow) with extension in the intrahepatic portion of the
inferior vena cava. There is invasion of the left renal vein
(small arrow) by tumor thrombus from the right-sided
neoplasm. Slight enhancement of the thrombus is present,
consistent with tumor thrombus.
projection is made from 3D volume information. The
MPR algorithm permits cross-sectional interrogation
of the 3D volume of data in any desired plane. Hence,
MPR images sometimes can demonstrate complex 3D
anatomy of tortuous vessels better than the source
images (Fig. 12D).
Maximum intensity projection
MIP is a postprocessing technique that produces
3D images (Fig. 1D). With MIP, a projection ray is
passed through the volume of data so that the data is
projected on a 2D plane. Instead of summing the
signal intensity along the rays, a projective image is
calculated by penetrating the data volume with a set
of parallel projection rays and selecting along each of

Fig. 3. Varices in a 54-year-old woman who was obese and referred for assessment of the superficial venous system prior to bypass
surgery. (A) Coronal MR venographic image (gradient echo 2D TOF, 5.2/1.5; flip angle, 30°) illustrates the deep and superficial
venous systems from the level of the ankles to just below the aortic bifurcation. The inferior vena cava (IVC) was inadvertently cut
off because of the misplacement of the coil. Varicosity of the main stem of the great saphenous vein (arrows) is seen affecting the
left great saphenous vein. The superior section of the right great saphenous vein was suitable for bypass surgery. (B) Coronal
conventional venograms obtained in the right extremity also show the right great saphenous vein to be suitable for bypass surgery.
(From Ruehm SG, Wiesner W, Debatin JF. Pelvic and lower extremity veins: contrast-enhanced three-dimensional MR
venography with a dedicated vascular coil-initial experience. Radiology 2000;215:421 – 7; with permission.)
906 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919

these rays only the data point that represents the
intensity maximum. This process is repeated at dif-
ferent angles. Subsequently, the images are combined
to produce a 3D perception of the vascular structures.
This reconstruction technique is referred to as MIP
with a ray-trace algorithm or depth queuing [5]. The
ray-trace algorithm provides the viewer with the
perception of depth. Multiple projections with differ-
ent angles prove useful in delineating spatial informa-
tion. It is possible to reconstruct projection images in
any desired orientation that appear similar to a
conventional angiogram [3,5].
Direct volume rendering
Volume rendering is a technique that provides high-
quality 3D images. Volume rendering is a two-step
process consisting of classification and rendering.
Classification is the process of determining tissue

Fig. 5. (A) Maximum intensity projection (MIP) of a 2D time-of-flight (TOF) MRV demonstrates normal venous anatomy; right
renal vein (closed arrow), right ovarian vein (open arrow), left ovarian vein (arrowheads), and superior mesenteric vein (curved
arrow). (B) 2D TOF MRV demonstrates a right renal vein (long arrow), left ovarian vein (closed arrow), and left renal vein
(open arrow). Noticeably absent is the right ovarian vein. (C) An axial computed tomographic image provided for correlation
demonstrates the thrombosed right ovarian vein (arrow). (D) MIP from gadolinium-enhanced MRV of the abdomen in another
asymptomatic patient shows an enlarged patent left ovarian vein.
 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919 907

Fig. 5 (continued ).

types and assigning brightness levels/colors to each
voxel. During classification, a partial transparency
(0 – 100%) is assigned to the tissue or signal-intensity
classes. Rendering is the second stage of this tech-
nique; it involves image projection to form a simulated
3D image. External and internal structures can be
evaluated with direct volume rendering [5,11,12].
Clinical applications of MRV
MRV has applications in many clinical settings. In
most instances, it complements other venous imaging
modalities. In some cases, it is the primary diagnostic
modality.Following is a discussion of the role of MRV
role in the diagnosis of various venous pathologies.
Deep-vein thrombosis
DVT is the third most common cardiovascular
disease after myocardial infarction and cerebrovascu-
lar disease. Approximately 5,000,000 episodes are
reported annually [13]. Ninety percent occur in the
lower extremities and 10% in the upper extremities.
Upper extremity DVTs have become more common
with the placement of central venous access devices.
908 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919
Most DVTs originate in the soleal veins in the deep-
venous system of the calf, 20% of which extend
proximally. The concern is potential pulmonary
emboli, which account for 10,000 to 30,000 deaths
among the 170,000 to 200,000 cases diagnosed
annually [14]. It is important to verify the diagnosis
of DVT/pulmonary embolus to avoid the unnecessary
exposure or withholding of anticoagulation. Because
the sensitivity and specificity of physical examination
for DVT are less than 50%, identification of risk
factors is paramount [13]. These include age, trauma,
obesity, previous thromboembolic phenomena, var-
icose veins, underlying malignancy, oral contracep-
tives, prolonged immobilization, postoperative/
postpartum states, hypercoaguable states (ie, protein
C deficiency or protein S deficiency), and cardiac
disease [15]. Permanent vein and valve damage
following DVT may result in post-thrombotic syn-
drome, a loosely used term for chronic limb edema,
pain, skin hyperpigmentation, claudication, and
development of venous stasis ulcers in the months
or years after the initial event [15,16].
Sonography and conventional venography are the
primary diagnostic modalities for the evaluation of
DVT. When these methods are not conclusive, many
physicians resort to MRV for a definitive diagnosis.
2D TOF is the MR technique of choice, but 3D
gadolinium-enhanced MRV is used also for the dia-
gnosis of DVTs. Acute and chronic DVT can be
imaged with these techniques (Figs. 1, 2).
Fig. 6. A 42-year-old female patient who is dependent on hemodialysis via a dialysis loop graft in the left forearm. Indirect
gadolinium-enhanced 3D MRV demonstrates occlusion of the left subclavian vein (arrows) with collaterals.
Many studies establish the accuracy of 2D TOF
MRV in identifying lower-extremity DVT [14,17].
Carpenter et al [17] compare MRV to conventional
venography in 85 patients for evaluation of DVT
from the inferior vena cava (IVC) to the popliteal
vein. The sensitivity, specificity, positive predictive
value, and negative predictive value of 2D TOF MRV
are 100%, 96%, 90%, and 100%, respectively [17].
For the infrapopliteal region, Evans et al examine
61 patients for DVT using flow augmentation (com-
pression and decompression) and ultrafast imaging.
Preliminary results demonstrate a sensitivity and spec-
ificity for infrapopliteal DVT of 87% and 97%, respec-
tively. In this same study, complete concordance of
MRV with ascending venography was noted for thigh
DVTs [18].
MRV appears to offer definite advantages over
sonography in pelvic imaging. In a retrospective
analysis of 769 MR examinations for DVT by Sprit-
zer et al, 34 of the 167 examinations positive for DVT
demonstrate isolated pelvic DVTs. In this subset of
patients, the frequency of isolated DVT detected with
MRV is higher than that reported in previous studies
with sonography or ascending venography. More-
over, MRV should be performed for patients sus-
pected of having pelvic DVT or with high clinical
suspicion in the presence of a negative sonographic
examination [14]. Additionally, sonography shows
persistent abnormalities in approximately 40% of
patients with previous deep-vein thrombosis at one-
 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919 909

year follow-up, making it difficult to differentiate neovascularity of tumor thrombus is responsible for a
chronic from acute DVT [1]. higher degree of adherence to the venous wall than
Ruehm et al report their experience using direct bland thrombus. In 431 consecutive patients with
contrast-enhanced 3D MRV. Because of the T1-short- radical nephrectomy for RCC, Kallman et al [25]
ening effect of gadolinium, all vessels containing
contrast are displayed, regardless of the underlying
flow characteristics. Superficial and perforating veins
that contain slow or even retrograde flow are easily
differentiated from occluded or partially thrombosed
vessels. The in-plane saturation effects and spin
dephasing artifacts encountered with 2D TOF are
eliminated. The versatility of the direct contrast-
enhanced 3D MRV (Fig. 3) also is used for the
evaluation of post-thrombotic changes, varicosities,
and assessment of the greater saphenous vein prior to
bypass surgery [19].

Renal-vein thrombosis

Until recently, renal-vein thrombosis (RVT) was

discovered mainly at autopsy [19]. RVT is believed to
affect up to 0.5% of the population, but its exact
incidence is unknown, because patients may be
asymptomatic or recover spontaneously [20]. Diag-
nosis of RVT is difficult because of the highly
variable clinical and radiographic presentations.
The etiology of RVT is variable, but can be
extrinsic or intrinsic. The intrinsic form is triggered
by an intrarenal thrombotic event precipitated by
acidosis, hemoconcentration, or arteriolar constric-
tion. In adults, this process is typically the result of
an underlying renal neoplasm. Additional intrinsic
causes include membranous glomerulonephritis, pye-
lonephritis, amyloidosis, polyarteritis nodosa, sickle
cell anemia, cardiac disease/low-flow states, trauma,
diabetic nephropathy, lupus nephropathy, coagulop-
athy, dehydration, or trauma. Extrinsic processes
include umbilical vein catheterization, extension of
IVC thrombosis, pancreatitis, retroperitoneal fibrosis,
metastasis, and pancreatic tail carcinoma [20].
MRI and MRV are used for the diagnosis of RVT.
By the late 1980s, MRI emerged as the most accurate
and sensitive technique to assess renal cell carcinoma
(RCC) and tumor thrombus, respectively [21 – 23]
(Figs. 4, 5). RVT due to an underlying neoplasm is
most commonly the result of renal cell carcinoma, but
may be seen with lymphoma, transitional cell carcin-
oma, or Wilms’ tumor. RCC tumor thrombus extends
into the renal vein, IVC, and right atrium in 20%,
10%, and 2% of cases, respectively [24]. In these
instances, surgery is the only therapeutic option. The Fig. 7. A 77-year-old male patient with history of metastatic
surgical approach and required intraoperative sup- liposarcoma. Gadolinium-enhanced MRV demonstrates a
portive measures depend on the cephalad extent of focal nonenhancing lesion within the suprahepatic inferior
thrombus and presence of IVC wall invasion. The vena cava consistent with thrombus.
910 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919

correlate imaging procedures (computed tomography,
MR imaging, sonography, and venography) with
pathology and surgical findings. MR imaging, using
spin-echo and gradient-echo techniques, is performed
in 26 of the 29 patients with tumor thrombus beyond
the distal portion of the renal vein that is normally
ligated, demonstrating a sensitivity of 100% [25].
Narumi et al retrospectively examine 81 patients with
85 RCCs to determine the MR imaging protocol for
evaluation of renal masses. Gradient-echo images
demonstrate 100% sensitivity and 98% specificity
for detection and characterization of venous involve-
ment by tumor [26].
MR imaging characterizes renal vein and IVC
involvement by RCC with a higher accuracy for
staging than computed tomography [27]. Standard
sequences supplemented with 3D gadolinium-
enhanced images provide high contrast and spatial
resolution. Contrast enhancement of tumoral throm-
bus is emphasized in some studies, but inconsistently

Fig. 8. A 5-year-old male patient with history of short-gut syndrome. (A) Maximum intensity projection (MIP) of an axial 2D
time-of-flight (TOF) MRV for central venous mapping demonstrates superior vena cava (SVC) occlusion with multiple collateral
vessels about the neck and chest. The very distal portion of the SVC (arrow) reconstitutes via collaterals, prior to emptying into
the right atrium. The MRV was helpful in guiding placement of the right internal jugular central venous catheter (B).
Conventional venography (C) confirms presence of SVC occlusion. (D,E) MIP of an axial 2D TOF MRV in the frontal and
lateral projections demonstrates occlusion of the infrahepatic inferior vena cava (IVC). The intrahepatic IVC (arrow) is patent.
MRV was helpful for locating a central venous access site. A transhepatic central venous catheter was placed (F) in this patient
with known SVC occlusion.
S. Butty et al / Radiol Clin N Am 40 (2002) 899–919 911

Fig. 8 (continued ).
912 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919

observed by others, because tumor thrombi can be
less vascularized than the primary renal tumor.
Laissy et al study the performance of gadolinium-
enhanced TOF MRV in 26 patients with RCC
and tumor thrombus. For detection of venous throm-
bus, the sensitivity and specificity are100% and
96%, respectively [21]. Using gadolinium-based con-
trast for evaluation of bland versus neoplastic
thrombus, a sensitivity and specificity of 89% and
96%, respectively, is achieved [21]. In conclusion,

Fig. 9. A 50-year-old female patient with a duplicated inferior vena cava. (A) T1-weighted axial image demonstrates the presence
of a duplicated inferior vena cava (IVC) (large arrow). Normal right-sided IVC (small arrow). (B) Coronal 2D time-of-flight
demonstrates a duplicated IVC. The right renal vein is normal (small arrow). Blood from the left pelvis empties into the left renal
vein (large arrow). (C) A 55-year-old female with a 10-year history of hypertension. Incidental finding of a retro-aortic left renal
vein is noted on the MRV.
 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919 913

Fig. 10. May-Thurner syndrome. (A) The left image demonstrates conventional venography with simultaneous injection via the
right and left common femoral veins. The linear defect overlying the left common iliac vein (white arrow) is the result of
compression from the overlying right common iliac artery. The right image is a gadolinium-enhanced MRV of the same patient,
which demonstrates compression of the left common iliac vein from the overlying right common iliac artery (black arrow). (B) A
33-year-old male patient with history of pancreatitis. Maximum intensity projection of a 2D time-of-flight MRV demonstrates
narrowing of the infrahepatic IVC (arrows) as a result of a pseudocyst (not shown). Also seen are chronic changes of May-
Thurner syndrome with multiple collaterals via the lumbar veins (arrowheads).
914 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919

Fig. 11. A 29-year-old female patient with history of shortness of breath with a clinical concern for an atrial septal defect.The
gadolinium-enhanced MRV, however, demonstrates partial anomalous pulmonary venous return. (A) The right upper lobe
pulmonary veins empty into the superior vena cava as opposed to the normal drainage pattern of the lower lobe pulmonary veins
(B), which empty into the left atrium.

Fig. 12. A 28-year-old male patient with a known venous malformation of the left calf. The patient has had several percutaneous
sclerotherapy treatments in the past. (A) Axial short tau inversion recovery image demonstrating hypointense signal (arrow)
within the lesion that has undergone sclerotherapy. The peripheral hyperintense areas represent nonsclerosed portions of the
lesion. (B) Direct puncture venogram shows the appearance of the malformation. (C) Subtracted maximum intensity projection
image using indirect gadolinium-enhanced MRV acquired during a late venous enhancement phase shows the lesion in the lateral
aspect of the calf. (D) An axial multiplanar reconstruction image from the same 3D data set as in (C) demonstrates no
enhancement in sclerosed central portion (arrow) of the lesion.
 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919 915

Fig. 12 (continued ).

MRV is an accurate, noninvasive diagnostic modal-
ity for RVT without the nephrotoxic risk encoun-
tered with those modalities dependent on iodinated
contrast agents.
Ovarian-vein thrombosis
Septic puerperal ovarian-vein thrombosis (SPOVT)
presents on the second or third postpartum day in
1:600 to1:2000 deliveries. Puerperal sepsis occurs in
only 2% to 3% of vaginal deliveries [28] but in up to
20% of patients following cesarean section [29].
Frequent nonseptic etiologies are pelvic inflammatory
disease, gynecologic surgery, malignant neoplasms,
and chemotherapy. Involvement of the right, left,
and bilateral ovarian veins occurs in 80%, 6%, and
14% of patients, respectively. The right side is
affected more often as dextrotorsion of an enlarged
uterus may compress the right ureter and right
ovarian vein. SPOVT may extend into the IVC. A
13% and 4% rate of pulmonary embolus and death,
respectively, are reported in postpartum ovarian-vein
thrombosis [30,31].
Although computed tomography and sonography
have served as the traditional modalities for diag-
nosis, in a prospective comparative study by Kubik-
Huch et al of 26 patients, MRV, using the 2D TOF
technique, proves superior to computed tomography
and duplex-Doppler ultrasound. The sensitivity and
specificity of MRV for SPOVT are 100%. Kubik-
916 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919
Fig. 12 (continued ).
Huch et al recommend MRV for patients with incon-
clusive sonographic findings and persistent suspicion
for SPOVT [32] (Fig. 6).
Evaluation of central venous occlusion with
venous mapping
Central venous occlusion often results in conges-
tion, edema, and venous hypertension. The under-
lying cause varies, but previous radiation therapy,
extrinsic mass/compression, or inflammation fre-
quently is present. Common central venous occlusive
conditions include superior vena cava (SVC) and
inferior vena cava (IVC) syndrome.
SVC syndrome may be the result of a complete or
partial occlusion of the SVC or its tributaries. Primary
or spontaneous occlusion is exceedingly rare. Eighty
to ninety percent of secondary obstructions are neo-
plastic in origin. Common offending neoplasms are
bronchogenic carcinoma (greater than 50%), lym-
phoma, and mediastinal tumors. Granulomatous
diseases, aneurysms, constrictive pericarditis, and
substernal goiter are among the non-neoplastic causes
[15]. Catheter-induced occlusion or stenosis has
become a more frequent cause of SVC syndrome.
IVC syndrome can have intrinsic or extrinsic
etiologies. Intrinsic caval occlusion typically has a
neoplastic etiology (leiomyoma, leiomyosarcoma,
and endothelioma), but may be non-neoplastic (con-
genital membrane). Extrinsic obstruction often
occurs at the mid-IVC as a result of enlarged lymph
nodes or an adjacent retroperitoneal, renal, pancre-
atic or hepatic mass. Functional obstruction can
result from a pregnant uterus, valsalva maneuver,
or supine positioning with a large abdominal mass
(Figs. 7, 8, 10B).
Venous mapping is increasingly important as
placement and complications of central venous
access devices are a common occurrence (Fig. 6).
The goal of imaging is to determine the presence of
collaterals, the presence of thrombus, and venous
patency (Fig. 8). These are all are crucial questions
for patients dependent on central venous access for
chemotherapy, hyperalimentation, and hemodialysis.
Sonography is limited in the evaluation of these
patients [19]. For example, sonography fails to detect
occlusion of the medial segment of the subclavian
vein and nonocclusive subclavian vein thrombi in
45% and 43% of cases, respectively, in one study
[33]. Despite being the gold standard, contrast
venography can evaluate only a single draining
system with each venipuncture. MRV is a com-
prehensive examination visualizing all veins that
help guide successful placement of central venous
catheters and may be predictive of unsuccessful
outcomes [34].
Rodenwaldt et al [35] employ several MR tech-
niques to examine the diagnostic value of MRV for
the assessment of the central veins. In 25 patients,
all thromboses and tumor cones in the central veins
are detected with the combined use of electrocar-
diographically-triggered black-blood half-Fourier
acquisition turbo-spin-echo (HASTE) and 2D cine-
fast low-angled shot (FLASH) techniques (a 2D TOF
variant) [35]. Rose et al [33] use 2D TOF MRV to
assess possible central venous access sites in 19
 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919
patients with advanced infra- and supradiaphragmatic
central venoocclusive disease. They demonstrate a
sensitivity of 97%, specificity of 94%, positive pre-
dictive value of 94%, and negative predictive value of
94% in 21 MRV examinations performed in the 19
patients [33].
In a study of 37 patients by Thornton et al, 3D
gadolinium-enhanced MRV is 100% sensitive, spe-
cific, and accurate in the diagnosis of abnormalities
affecting large central veins of the body [36]. In a
prospective study of 16 patients for evaluation of
central venous thromboocclusive disease of the chest
by Kroencke et al [37], gadolinium-enhanced MRV
does not miss any finding obtained by sonography,
conventional venography, or computed tomography.
Moreover, the complete extent of disease, regarding
involvement of SVC, subclavian, brachiocephalic,
internal jugular, or axillary veins, is characterized in
94% of patients [37].
Central venous anomalies
Although congenital central venous anomalies
occur infrequently, they are important developmental
abnormalities. Noncontrast and gadolinium-enhanced
3D MRV can accurately and rapidly diagnose a wide
spectrum of venous anomalies.
The systemic types of central venous anomalies
tend to be asymptomatic. These anomalies involve the
IVC more often than the SVC. IVC anomalies occur
in 1% of the general population. The more common
IVC anomalies include a retroaortic left renal vein
(1.8 – 2.4%), IVC duplication (0.2 – 3.0%) (Fig. 10),
left-sided IVC (0.2 – 0.5%), and circumaortic left renal
vein (8.7%) [15] (Fig. 9). Less frequent IVC anom-
alies, such as interruption and abnormal insertion of
the IVC, tend to be associated with heterotaxy syn-
dromes and cyanosis, respectively.
Iliac vein compression syndrome or May-Thurner
syndrome (Fig. 10) is an example of variant anat-
omy that can lead to venous compression or occlu-
sion. Specifically, the left common iliac vein is
compressed as it passes between the right common
iliac artery and the spine. Consequently, venous
intima injury from long-standing compression results
in the formation of webs or ‘‘spurs’’ in the lumen,
obstructing venous flow.
Unlike most systemic venous anomalies, which
tend to be asymptomatic, pulmonary venous anom-
alies can manifest as cyanosis because of obstruction
or shunts associated with cardiac anomalies. Partial
anomalous pulmonary venous return (PAPVR) is far
more common than total anomalous pulmonary ve-
nous return (TAPVR). TAPVR, associated with 2% of
917
congenital heart disease, typically presents in infants.
In TAPVR, pulmonary venous return is through a
systemic vein(s) rather than the left atrium [38].
Unlike TAPVR, PAPVR (Fig. 11) manifests later
in life, and may be isolated or associated with cardiac
defects (0.5 – 0.7%). A right upper pulmonary lobe
vein emptying into the SVC or right atrium is most
common and is associated with atrial septal defects
(in particular the sinus venosus type). In a less
frequent form, right pulmonary veins emptying into
the IVC present as a ‘‘scimitar’’ in a hypogenetic
right lung on conventional chest radiography. Anom-
alous left pulmonary veins are less common than
anomalous right pulmonary veins. PAPVR can be
confused with a persistent left SVC. In PAPVR of the
left upper pulmonary lobe, the vertical vein courses
cephalad to the brachiocephalic vein, but with a
persistent left SVC, the anomalous vessel empties
caudally, typically into the coronary sinus [38].
In a retrospective analysis of 61 patients by Greil
et al [39], the diagnostic value of gadolinium-
enhanced 3D MRV in congenital and acquired
anomalies of the pulmonary and systemic veins is
examined. In this group of patients, pulmonary
venous anomalies are found in 37 patients, systemic
venous anomalies in 17 patients, and systemic and
pulmonary anomalies in 7 patients. Compared with
available diagnostic data by other modalities, all
known or suspected anomalies are imaged by 3D
MRV. In three patients, catheterization does not
detect anomalies of pulmonary veins diagnosed by
MRV. The 3D MRV diagnoses are followed by
10 interventional catheterization procedures and
15 operations. In 74% of patients, 3D MRV
either diagnosed previously unsuspected anomalies
(28%) or added clinically new information (46%).
Gadolinium-enhanced not only was accurate, but
also a useful noninvasive alternative to diagnostic
catheterization [39].
Congenital venous malformations
Congenital vascular malformations result from
abnormal development of the primitive vascular sys-
tem in early embryonic lifebecause of unknown,
genetic, or environmental causes [40]. The malforma-
tion can affect the venous, arterial, or lymphatic
system. The most helpful classification scheme for
vascular anomalies is that by Mulliken and Glowacki
[41]. They classify vascular anomalies as either
vascular tumors with endothelial hyperplasia or vas-
cular malformations secondary to an error of embry-
onic development with normal endothelial turnover.
Vascular malformations also can be classified into
918 S. Butty et al / Radiol Clin N Am 40 (2002) 899–919
slow-flow malformations (capillary, venous, lymph-
atic, capillary-venous, or capillary-lymphatic-venous
malformations) and high-flow malformations (arterio-
venous fistulas or arteriovenous malformations).
Venous malformations (Fig. 12) are the most
common vascular malformations. Most venous mal-
formations involve the head and neck (40%), extrem-
ities (40%), and trunk (20%) [42]. Venous
malformations are usually solitary, involving the
cutaneous and subcutaneous tissues. Growth is in
proportion to the growth of the patient. They often
enlarge during puberty and pregnancy because of
hormonal influences, without involution. Symptoms
are related to the size and location. Clinical presenta-
tion varies from small strawberry-like birthmarks to
clusters of massively engorged vessels that can be
limb deforming.
MR imaging is very sensitive for identifying and
assessing the extension of venous malformations
[42 – 44]. MRV has the potential to replace conven-
tional venography because it provides information
on the vascular system and the surrounding tissues.
A standard MR imaging examination should include
T1-weighted imaging with and without fat satura-
tion. Lesions are hypointense to isointense to mus-
cle on T1-weighted images. Gadolinium-enhanced
fat-suppressed T1-weighted images are helpful in
differentiating the circulatory dynamics of the
venous malformation. Contrast enhancement distin-
guishes venous malformations from those with
lymphatic involvement. Additionally, contrast en-
hancement may be delayed or inhomogenous
[42,43]. Slow-flow lesions are differentiated from
high-flow lesions by the absence of flow voids on
spin-echo images and of high-flow channels on gra-
dient-echo imaging.
Venous malformations are readily detected on
T2-weighted images because of their bright signal
and high-contrast ratio. STIR or fat-suppressed
T2-weighted sequences are both well suited. A gra-
dient-echo T2*-weighted sequence is useful for the
evaluation of hemorrhage or thrombosis and for
the demonstration of calcifications. After treatment,
MR imaging with the same specifications as those
used for the baseline examination allows for follow-
up [42,43].
Summary
MRV offers unique diagnostic possibilities for
detection and characterization of venous disease. It
allows evaluation of perivascular and vascular ana-
tomy, evolution of thromboembolic events, and
assessment of vascular flow. MRI is a diagnostic tool
that can be tailored for a variety of clinical dilemmas,
not only DVTs. Continued improvements in hardware
and software will expand the role of MRV.
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 Radiol Clin N Am 40 (2002) 921 – 951

Technical developments in MR angiography

Timothy J. Carroll, PhDa, Thomas M. Grist, MDb,*
a
Department of Medical Physics, University of Wisconsin, Madison, WI 53792, USA
b
Department of Radiology, University of Wisconsin, Madison, WI 53792, USA

Catheter-based multistation digital subtraction
angiography (DSA) is regarded as the gold standard
for the evaluation of vascular disease. The high
incidence of morbidity associated with radiographic
DSA has placed emphasis on developing noninvasive
methods of determining whether surgical intervention
is indicated. Invasiveness, costs, and morbidity indi-
cate the need for less invasive diagnostic tools. Mag-
netic resonance angiography (MRA) is emerging as
an adjunct and, in some cases, an alternative to DSA.
The growth of MRA is the result of improvements in
image acquisition strategies and magnetic resonance
(MR) contrast agents. Contrast agent-enhanced MRA
(CE MRA) examinations result in images with high-
spatial resolution and fewer artifacts and require less
time to acquire than noncontrast methods.
This article reports on recent technical develop-
ments in this emergent technology. Many of these
acquisition strategies attempt to optimize the use of
the first pass of the bolus of contrast agent. To do so,
they coordinate image acquisition with arrival of the
contrast agent in the targeted anatomy. This may be
accomplished given prior knowledge of the transit
time of the bolus from injection site to the image
volume or by triggering the acquisition when arrival
of the contrast is detected. Triggered acquisitions are
performed either by pulse sequences, which automat-
ically detect the inflow of contrast agent, or by fluoro-
scopic acquisitions, which are triggered by an operator.
CE MRA acquisitions rely on heavily T1 weighted,
rapid images acquisition. The simplest way to speed up
an acquisition is to reduce the repetition (TR). Re-
cently, novel image reconstructions have been devel-
oped in which multicoil arrays share data to further
* Corresponding author.
E-mail address: tmgrist@facstaff.wisc.edu (T.M. Grist).
reduce acquisition time. In addition, many groups
are successfully using non-Cartesian k-space – based
data acquisitions that sample k-space along spiral or
radial trajectories.
This article discusses some of the basic physics
principles necessary to understand the limitations and
challenges of CE MRA. A short technical description
of some of the more recent technical advancements
with several illustrative examples follows. The last
section of this article describes currently available
contrast agents and some agents that are in devel-
opment or under review by the United States Food
and Drug Administration.
Basics of MRA
Localization of voxel signal in MR images is
achieved by encoding the phase and frequency of
spinning protons using magnetic field gradients.
Therefore, the raw data acquired by MR scanners
are actually a spatial-frequency representation of the
image, commonly referred to as the ‘‘k-space’’ of the
image. Images are produced when the acquired
k-space data is reconstructed using Fourier trans-
formation. An important feature of the k-space rep-
resentation of an image is that low-spatial frequencies
(ie, the central phase encoding values) contain the
information necessary to reconstruct a low-resolution
image. A low-spatial resolution image reflects the
overall image contrast. As higher spatial frequencies
are included in a reconstructed image, finer detail of
the image begins to emerge. Fig. 1 demonstrates the
effect of how low- and high-spatial frequencies
contribute to an image.
Unfortunately, in MRI, spatial resolution comes at
a cost. Generally, for a given acquisition time, as the

0033-8389/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 2 9 - 5
922 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951

spatial resolution increases, the signal-to-noise ratio Contrast mechanisms

(SNR) of the image decreases. The decrease in SNR
is a result, in part, of the decrease in the voxel size,
which results in fewer spins contributing to the signal
from the voxel. The SNR of high-spatial resolution
images may be increased by increasing scan time,
either by increasing the scan TR or signal averaging.
Signal averaging increases SNR by repeatedly acquir-
ing an image and averaging the signal intensity of
each voxel in successive images. As a rule of thumb,
for a fixed spatial resolution, SNR increases in
proportion to the square root of the imaging time.
For example, doubling the imaging time results in
roughly a 40% increase in SNR. The converse is also
true: acquiring an image in half the time will decrease
SNR by 40% relative to a standard acquisition. Low
SNR is a serious technical challenge for all rapid-
image acquisitions.
MRA may be performed using time-of-flight
(TOF) techniques, which depend on blood flow for
vessel contrast [1]. In TOF imaging, the signal from
stationary tissue within the imaging volume is sup-
pressed via application of multiple radio-frequency
(RF) pulses. When short repetition time (TR) values
are chosen, the longitudinal magnetization of the
tissue is not given sufficient time to regrow, resulting
in very low signal. Blood flowing into the image
volume, however, does not experience the same RF
excitations, and therefore appears bright (Fig. 2).
TOF examinations suffer from several sources of
artifactual signal loss [2]. In TOF, slow flowing may
become saturated, leading to a spurious thinning of the
imaged vessel. This potentially could lead to over-
estimation of the severity of a stenosis. In addition,

Fig. 1. Image formation in MRI k-space. Images of an abdominal aortic anerysm demonstrate the correspondence between spatial
frequencies and image resolution. (A) The spatial frequency, or ‘‘k-space,’’ representation of the aorta is Fourier transformed to
form an image (B). (C) If only the central k-space is used in image formation, the resulting image (D) is a low-resolution version of
the original. The Fourier transformation of the high-spatial frequencies (E) provides image detail such as delineation of edges (F).
(Courtesy of Oliver Wieben, PhD, and Frank Korosec, PhD, University of Wisconsin.)
 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951
Fig. 1 (continued ).
slice misregistration as a result of patient motion can be
problematic in TOF examinations that are acquired
over several minutes. Lengthy examination times and
a sensitivity to in-plane and retrograde flow artifacts
have prompted development of CE MRA acquisitions.
By exploiting the T1-shortening effect of para-
magnetic contrast agents to depict vessels, CE MRA
overcomes many of the limitations inherent to TOF
MRA [3]. CE MRA commonly is performed with
short TR (< 10 milliseconds) gradient-recalled echo
sequences. Fig. 3 shows how longitudinal magnet-
ization approaches its equilibrium value as multiple
short-TR RF pulses are applied to the sample. The
time available for signal regrowth between RF pulses
is TR, so that the amount of regrowth decreases as TR
is reduced, resulting in less longitudinal magnetiza-
tion (M0). Because signal intensity in MR is propor-
tional to M0, short TR provides T1 contrast by
suppressing the signal from tissues with slow re-
growth of the longitudinal magnetization (long T1).
In CE MRA, these rapid image acquisitions are
combined with an intravenous bolus injection of a
923
paramagnetic contrast agent that produces transient
shortening of the T1 of blood.
The use of short TR sequences also allows for the
rapid acquisition of high-resolution images. The time
to acquire a three-dimensional (3D) volume is given by
Time = Ny
Nz
TR, where Ny is the number of
phases-encoding values, Nz is the number of acquired
slices, and TR is the repetition time. For example, an
acquisition with 12 phase encoding values, 32 slice
partitions, and a TR of 6.0 milliseconds can be
acquired in a 24-second breath hold. The use of heavily
T1-weighted sequences introduces the problem of the
background signal from fat. The T1 of fat is approx-
imately 270 milliseconds, and therefore appears bright
in CE MRA images. Typically, a precontrast mask
image is acquired and used to subtract off the fat signal.
Mask mode subtraction is used to increase the contrast
of vessels by removing background signal but is
sensitive to patient motion. In abdominal imaging,
mask and contrast-enhanced images both must be
acquired in a breath hold. For images of the peripheral
vasculature, care must be taken to ensure that the
924 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951
Fig. 1 (continued ).
patient remains still between the acquisition of the
mask and the contrast-enhanced image.
Image contrast in CE MRA exams can be affected
by several acquisition parameters. The signal enhance-
ment provided by a bolus injection of contrast agent
depends on the flip angle of the RF excitations, the
sequence TR, and the T1 of the unenhanced blood.
Signal enhancement and overall image quality depend
strongly on intraarterial contrast concentration. Fig. 3
shows how T1 of the arterial blood depends on the
intra-arterial gadolinium ([Gd]) concentration. As
the concentration increases, blood T1 decreases. The
resulting equilibrium signal enhancement for hypo-
thetical background tissue (T1 = 700 milliseconds)
and contrast-enhanced blood (T1 = 50 milliseconds)
also is shown. The highest image contrast comes when
intra-arterial [Gd] results in blood T1 values much less
than the T1 of fat (T1(fat) = 270 milliseconds).
The first pass intra-arterial contrast concentration
depends, in turn, on injection rate and cardiac output
[4 – 6]. The role of injection rate and cardiac output
can be approximated from the relationship between
intra-arterial gadolinium concentration (IA[Gd]), injec-
tion rate (IR), cardiac output (CO), and the injected
contrast-agent concentration ([Gd]Inj),
 
IR
IA½Gd ¼
½GdInj : ð1Þ
CO
The blood T1, which results from this intra-arterial
gadolinium concentration can be determined using
1 1
¼ þ R1
IA½Gd : ð2Þ
T1 1200ms
where T1 is the resulting longitudinal relaxation rate of
the intra-arterial blood, 1200 milliseconds is the initial
T1, and R1 is the relaxivity of the particular gadolin-
ium chelate (all values assumed for a 1.5 T field).
Using equations 1 and 2 for a typical relativity of
4.5 mMolar1 sec1, a cardiac output of 5 L/min, and
[Gd]Inj of 0.5 moles/L, as the injection rate goes from
1.5 ml/second to 0.5 ml/second the intra-arterial con-
centration decreases by factor of 3, but the blood T1
 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951 925

Fig. 2. Time-of-flight MRA. (A) Blood flowing into the imaging volume is fully magnetized, and, therefore, gives a large signal
before becoming saturated by repetitive radio-frequency pulses. (B) The high flow into the imaging volume at the circle of Willis
gives high signal in the vessels, whereas background signal is suppressed as a result of saturation.

remains below 70 milliseconds for the slow injection.
This results in an arterial signal intensity that is much
brighter than the surrounding tissue. As injection rates
decrease below 0.5 ml/second, however, arterial T1
increases rapidly; therefore, lower injection rates do
not produce sufficient T1 shortening.
Centric view ordering
Optimal intravascular signal enhancement occurs
during peak arterial gadolinium concentration. There-
fore, image acquisitions that acquire the central
portion of k-space during peak gadolinium concen-

Fig. 3. Gadolinium-based contrast agents are used to decrease the spin-lattice relaxation time (T1) of blood. (A) As the
intravascular contrast agent ([Gd]) increases, the T1 of arterial blood decreases. (B) Using T1-weighted pulse sequences in
conjunction with gadolinium-based contrast agents, results in a transient increase in the intravascular signal. After steady state is
been reached by application of multiple radio-frequency pulses, the contrast-enhanced (T1 = 50 milliseconds) blood has much
higher signal than background signal (T1 = 700 milliseconds).
926 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951

tration have higher intravascular signal. For this
reason, centric-view – ordered image acquisitions are
used in widely CE MRA [7,8]. Centric view ordering
is an acquisition strategy in which the lowest spatial
frequency k-space lines are acquired firsthand; as the
scan proceeds, higher spatial frequencies are ac-
quired. Centric view ordering can be implemented
in the phase-encoding direction only or in a truly
centric manner in which k-space is sampled centri-
cally in the slice- and phase-encoding direction [8].
This means of acquiring a 3D volume is referred to as
an ‘‘elliptical centric’’ acquisition because ky-kz lines
are acquired from the center of k-spaced out in the
shape of ellipses.
Centric view ordering is beneficial in two ways.
First, the portion of k-space that contributes to the
intravascular signal is acquired at peak gadolinium
concentration. Second, in anatomic regions where the
arterial-to-venous time is rapid, centric view ordering
provides excellent suppression of venous signal. In the
renal and carotid arteries, arterial-to-venous transit
time is typically less than ten seconds. By acquiring

Fig. 4. Carotid vascular disease on centric MRA. Coronal acquisition (center) and reformatted maximum intensity projection
displays demonstrate bilateral atherosclerotic vascular disease. The high-spatial resolution in the sagitattal reformatted images
is possible by prescribing a thin-slice acquisition, with many partitions. Despite the fact that this 3D image was acquired over
54 seconds, much longer that the arterial to venous transit time, the elliptical centric acquisition provides excellent suppression of
venous signal. (Courtesy of Kevin Demarco, MD, Laurie Imaging Center.)
 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951
Fig. 4 (continued ).
the central-phase encoding values during peak arterial
enhancement and high-spatial frequencies after venous
opacification, centric-view – ordered acquisitions are
able to images with high-arterial signal and minimal
venous enhancement. Fig. 4 shows an example of a
centrically-encoded examination of the carotid bi-
furcation. Despite the fact that this 3D image was
acquired over 54 seconds, much longer than the arterial
to venous transit time, the elliptical centric acquisition
provides excellent suppression of venous signal.
927
Timing methods
The use of rapid image acquisitions introduces
some difficulties in the coordination of image acquisi-
tion and the arrival of the bolus of contrast agent. The
collection of the central lines of k-space during peak
arterial enhancement is key to the success of CE MRA
examinations. If the central lines of k-space are
acquired prior to the arrival of contrast, severe image
artifacts can limit the diagnostic use of the image [9 –
11]. Alternatively, images acquired after the passage of
the peak arterial contrast may be obscured by the
enhancement of veins. Fig. 5 shows an example of
an angiogram of the trifurcation vessels of a patient in
which the central phase-encoding values are acquired
Fig. 5. Images acquired 23, 56, and 91 seconds after the
injection of a bolus of contrast agent. The image acquired at
23 seconds has insufficient contrast enhancement during the
acquisition low-spatial frequency phase encodes resulting in
banding in the blood vessels. The trifurcation vessels are well
depicted in the properly timed image, acquired 56 seconds
after the contrast injection. The arteries are obscured in the
late phase image, acquired 96 seconds after the injection.
928 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951
Fig. 5 (continued ).
prior to the arrival of the bolus, a correctly timed
examination, and an image acquired after venous
opacification. In the image in which the central-phase
encodes are acquired too early, severe banding artifact
is evident. In the properly timed image acquisition, the
trifurcation vessels are well depicted. When an image
is acquired well after the bolus passes into the veins,
the arteries are obscured by venous overlay.
Test bolus
One means of ensuring proper timing of image
acquisition is determining transit time of the con-
trast agent from the injection site to anatomic regions
of interest with a small test bolus [12]. In test bolus
acquisitions, a small volume of contrast agent is in-
jected during the acquisition of a rapid two-dimen-
sional (2D) T1-weighted acquisition. The acquisition
is localized at the level of the anatomic region of
interest. Ideally, the 2D images are acquired at a rate
of approximately one image per second. After the
acquisition, the images are retrospectively inspected
to determine the arrival time at the targeted anatomy.
Knowledge of the arrival time is then used to syn-
chronize the image acquisition with the arrival of the
injection of the full bolus of contrast agent.
Dose-timing acquisitions are successful in ab-
dominal imaging. In this case, the operator must
coordinate not only the acquisition of the image,
but also the initiation of the breath hold. In the
example in Fig. 6, a small region of interest is placed
over the abdominal aorta, proximal to the renal
arteries. A plot of signal intensity as a function image
is produced to identify the arrival of the test bolus,
12 seconds after the injection. The patient is then
instructed to breath hold for the acquisition of the 3D
angiogram. High frame rate 2D dose-timing exams
can also be used to capture clinically relevant contrast
dynamics. Fig. 7 shows a 2D dose-timing examina-
tion that depicts the delayed filling of a dissection of
the aortic arch in a patient. Recently, 2D images have
T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951 929
930 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951

Fig. 6. Dose-timing images and data. Serial fast gradient-echo images are obtained at 1-second intervals during the intravenous
administration of 1- to 2-cc gadolinium. A region of interest place on the vessel indicates the arrival time, which is used to
determine the delay before the image acquisition.

been used to assess the severity and track the
response to treatment of intracranial arteriovenous
fistulae. Signal loss from intravoxel dephasing, how-
ever, limits these acquisitions to under 5 to 10 cm.
Fluoroscopic triggering
Fluoroscopic triggering also uses rapid 2D image
acquisition to determine when the contrast arrives in
the vessels of interest [7]. Rather than injecting a
small dose of contrast to determine the arrival time,
however, fluoroscopically triggered acquisitions use
real-time images display to monitor the targeted
anatomy. The appearance of the contrast agent in
the 2D images cues an operator to initiate the acquisi-
tion of the high-resolution 3D volume.
The rapid 2D fluoroscopic acquisition and 3D
volume images are prescribed from a set of localizers,
at which time prescan values for the 3D scan are
determined. This reduces the latency between trigger-
ing of the 3D scan and acquisition of the central

Fig. 7. Delayed filling of false lumen in aortic dissection. Dose-timing scan indicates the delayed filling of the false lumen
(arrow). The scan delay is selected to insure opacification of the false lumen (right).
 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951
Fig. 7 (continued ).
phase encodes. The 2D scan is initiated and images
are acquired and displayed on the scanner console at
roughly one image per second. An operator then
injects the full bolus of contrast agent. When signal
931
enhancement from the arrival of the contrast is
viewed, the operator manually triggers the scanner
to acquire the 3D volume image. In the case of
abdominal imaging, the patient is coached to initiate
a breath hold prior to acquisition of the 3D volume.
In later implementations of this technique, 2D images
are acquired and redisplayed in an interleaved fashion
throughout the 3D acquisition [13]. This type of 3D
acquisition embeds the acquisition and real time
display of 2D images into acquisition of the high-
spatial resolution 3D image (Fig. 8). This means of
embedding a fluoroscopic acquisition allows for
simultaneous monitoring of bolus dynamics and
acquisition of the 3D image data.
It is also possible for the MR scanner to automat-
ically detect the arrival of the bolus of contrast agent
and trigger the acquisition of the 3D scan [14]. In
automatic contrast detection, a small tracker volume
is placed in a vessel of interest. The signal level of
the tracker volume is repeatedly sampled during the
injection of the contrast agent (Fig. 9). When the
scanner detects signal level rise above a predeter-
mined threshold, the acquisition of the 3D volume
is triggered. An audible change in the scanning
sequences allows the operator to initial a breath hold
for abdominal scanning.
Moving table MRA
The detection of the bolus is combined with
automated or manual table translation to allow for
rapid full-body 3D MRA. These acquisitions are
referred to as ‘‘bolus chase acquisitions,’’ because
a single bolus is imaged at successive levels of the
anatomy. Because these acquisitions ‘‘chase’’ the
bolus as it flows from the abdomen to the distal
runoff station, they are sometimes referred to as
‘‘bolus chase’’ acquisitions [15 – 19]. A major advan-
tage of bolus chase acquisitions is that the full bolus
of contrast agent is used to image multiple anatomic
regions. This is advantageous in two respects. First,
because a large volume, typically 0.3 mmol/kg body
weight, is used at multiple imaging stations, the
intra-arterial signal is very high. Typically, in multi-
station exams, the full dose must be split between
stations, thus lowering the intra-vascular signal rel-
ative to the injection of the full contrast dose.
Second, unlike acquisitions that use a separate injec-
tion to image each station, there is no residual
intravascular gadolinium in the distal stations from
prior injections. When mask mode subtraction is
used, the residual contrast agent subtracts away from
932 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951

the arterial phase image, reducing intravascular
image contrast.
Bolus-chase MRA is performed typically with
multiple passes of the patient through the magnet.
After localization volumes are acquired, precontrast
images volumes are acquired in a first pass through
the magnet. A tracker volume is prescribed, typically
in a proximal portion of the aorta and the bolus chase
scan is initiated. When the bolus arrives in the tracker
volume, a breath hold is initiated and the abdominal
image is acquired. After the abdominal station is
acquired, the table automatically translates to a more
distal station and second image station is acquired as
the bolus fills the vasculature of the patient’s thighs.
The final arterial image is acquired after the bolus
arrives in the trifurcation vessels (Fig. 10). A third

Fig. 8. The view order for the ‘‘embedded fluoroscopy’’ technique (A) embeds a 2D real-time sequence within a high-resolution
3D CE MRA acquisition. There is a smooth transition from the high-temporal resolution real-time fluoroscopic triggering to the
embedded fluoroscopy/3D acquisition at (C) 18 seconds. The subsequent 2D images are displayed in real-time with up to 1-
second temporal resolution. Images from before contrast arrival (5 seconds), the peak arterial phase (23 seconds), and peak
venous phase (33 seconds) are shown (B). A coronal maximum intensity projection of the final high-resolution 3D result is
shown in (C). Besides bilateral disease in the carotid bifurcations, there is an occlusion of the right vertebral and a severe stenosis
at the origin of the left vertebral. (Courtesy of Sean Fain, PhD, University of Wisconsin.)
 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951
Fig. 8 (continued ).
pass of the patient and image acquisition is possible if
a late phase venous image is desired.
Angiosurf
The idea of chasing a single bolus as it flows down
the length of the body is extended to include full-body
MRA from the cranial to the caudal stations [20]. By
combining a short TR (TR = 2.1 milliseconds) 3D fast
low angle shot (FLASH) sequence with a partial
Fourier acquisition (see discussion later), a 3D image
may be acquired in 12 seconds. These rapid acquisi-
tions in combination with a dedicated moving table/
coil configuration allow five 3D volumes to be
acquired in 72 seconds, providing craniocaudal cover-
age of 1.8 meters. These scans use the dose-timing
technique to determine the arrival of contrast in a
proximal region of the descending aorta. Then the full
bolus of contrast is injected and 3D images are
acquired at the level of the carotid bifurcation/aortic
arch, abdominal aorta/renal arteries, femoral arteries,
popliteal trifurcation, and pedal arch (Fig. 11). Given
933
that atherosclerotic disease is systemic, these exami-
nations provide a means of rapidly performing full-
body screening.
Rapid imaging
The techniques introduced in the preceding section
deal primarily with optimal acquisition of standard
MR acquisitions. Although some of these techniques
acquire multiple images, they do not repeatedly image
the same anatomic region and require from 30 to 60
seconds to acquire the image. In recent years, there
has been considerable effort to reduce the time to
acquire 3D images. Rapid image acquisitions have
obvious advantages in the abdomen and thorax where
suspended respiration is required during image
acquisition. In addition to improving the reliability
for acquiring high-resolution arterial-phase images,
high frame rate examinations are able to depict filling
patterns in cases of dissections and arteriovenous
shunts. Rapid acquisitions also open up the possibility
of depicting complex contrast dynamics in 3D.
The simplest way to acquire images rapidly is to
reduce the TR of the pulse sequence. Short TR
sequences are available through the development of
high-performance gradient systems that achieve TRs
below 2 milliseconds. The availability of very short
TRs opens up the possibility of acquiring several 3D
volume images in the same time that was previously
required to acquire a single image. Many groups use
acquisitions that do not acquire or ‘‘sample’’ some or
part of the full complement of k-space points. This
method of reducing scan time is called ‘‘undersam-
pling,’’ and its result on image quality depends on
how the undersampling is applied. In some cases the
effects of undersampling can be minimized in the
image reconstruction process.
Partial Fourier acquisitions
Another approach to rapid imaging, which re-
duces the number of phase-encoding values, is partial
Fourier acquisition [21]. In an attempt to maintain
spatial resolution with rapid acquisitions, k-space
partial Fourier scans acquire k-space data asymmet-
rically about the origin, undersampling one hemi-
sphere or quadrant of k-space. As shown in Fig. 12,
partial Fourier acquisitions are similar in principle to
fractional echo acquisitions in that only high-spatial
frequencies in one quadrant are acquired. Partial
Fourier acquisition schemes have been implemented
in the phase- and slice-encoding directions to achieve
934 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951
 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951 935

Fig. 10. Bolus chase MRA acquires 3D contrast-enhanced MRA images at successive stations as the bolus of contrast agent
travels from the abdomen to the distal run-off. Automated table translation is used to track the bolus similar to computed
tomography bolus chase.

frame rates of 0.8 to 1.1 seconds. Despite the aniso-
tropic spatial resolution, 3D projection imaging
achieves much higher SNR and through-plane cov-
erage than 2D projection acquisitions. As a result,
partial Fourier acquisitions capture flow dynamics
normally not seen in 3D acquisitions, at the expense
of highly anisotropic spatial resolution.
Parallel acquisitions
The time to acquire an image in MR depends on the
number of phase-encoding steps that are required
(Ny); therefore, reducing the number of phase-
encoding steps reduces the scan time. Because the
highest k-space value sampled in any scan determines
the spatial resolution, scan time reductions result in
lower spatial resolution. Alternatively, one can reduce
the number of k-space samples while maintaining
high-spatial resolution by increasing the distance
between k-space points, as in small field-of-view
(FOV) imaging. Small FOV images may be acquired
rapidly, but normally suffer from wrap-around artifact
as a result of the undersampling.
A novel approach to rapid MR images involves
acquiring small FOV images with multi-coil arrays
[22,23]. Because the individual coil sensitivity pro-
files depend on the position of a voxel, they contain
information on the intensity of the signal that is
wrapped into a voxel from outside the FOV; there-

Fig. 9. Automated detection of gadolinium arrival. In automatic contrast detection, a small tracker volume is placed in a vessel
of interest. The signal level of the tracker volume is sampled repeatedly during the injection of the contrast agent. When the
scanner detects signal level rise above a predetermined threshold, the acquisition of the 3D volume is triggered. (Courtesy of
Martin Prince, MD, Cornell University.)
936 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951
Fig. 10 (continued ).
fore, using the individual coil sensitivity profiles,
the wrap-around artifact can be eliminated. By form-
ing linear combinations of coil sensitivities, non-
aliased full FOV images can be produced. In effect,
the coil sensitivities are used to encode the position of
a voxel. These acquisitions are called SMASH or
SENSE. The reductions in scan time (ie, ‘‘speed-up
factors’’) possible with these spatial encoding tech-
niques depends on the number of coils used and how
the sensitivities of the coils overlap. As the speed-up
factor increases, however, the SNR of the resulting
image decreases, limiting the amount of undersam-
pling or speed-up that is possible. In practice, diag-
nostic quality images are acquired with speed-up
factors of two to four.
SENSE acquisition in the abdominal station is
combined with manual table translation as part of a
three-station single injection peripheral MRA exam-
ination. This technique, termed WakiTRAK, acquires
a 3D fast field echo (FFE) dataset in the upper
(aortoiliac) station with speed-up factors of 1.5 and
2.0 in the slice- and phase-encoding directions,
respectively. This allows a 512
230
30 3D vol-
ume to be acquired in 11 seconds. This dramatically
reduces upper-station scan time such that high-res-
olution exams of the middle, and particularly the
lower, station arteries can be acquired sooner after
contrast arrival in the aorta. This makes better use of
the bolus and significantly reduces the incidence of
venous enhancement. An example of a three-station
WakiTRAK study is shown in Fig. 13. The lower
station is acquired over 71 seconds, with a true spatial
resolution of 0.9
0.9
1.0 mm and an elliptical
centric acquisition beginning approximately 31 sec-
onds after arrival of the contrast in the abdominal
station. With properly designed coils, SENSE in
theory can be applied in multiple stations.
Time-resolved acquisitions
An alternative method for acquiring angiograms
is to rapidly acquire multiple 3D volumes. By ac-
quiring images throughout the passage of the bolus of
contrast agent, multiphase techniques are inher-
ently insensitive to interpatient variability of contrast
arrival [24 – 27]. An additional benefit of time-
resolved acquisitions is the ability to depict patho-
logically delayed vessel filling.
Another approach to time-resolved image ac-
quisition relies on the fact that much of the informa-
tion forming an MR image is present in the central
region of k-space (see Fig. 1). By acquiring a
multiphase examination in which the central phase-
encoding values are acquired more often than the
outer regions of kspace, a time series of 3D image
may be reconstructed [28 – 30]. This technique
(TRICKS) retrospectively combines the central
 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951 937

Fig. 11. Angiosurf images: a 74-year-old male with peripheral vascular disease, coronary heart disease, renal insufficiency. The
images demonstrate diffuse atherosclerotic disease, including a high-grade stenosis of the carotid bifurcation right side, high-grade
stenosis common carotid artery left side, multiple wall irregularities entire aorta, occlusion of left renal artery, infrarenal abdominal
aortic aneurysm (partly thrombosed), occlusion common iliac artery left side, and occlusions of the superficial femoral artery both
sides. (Courtesy of Mathias Goyen, MD, University of Essen.)
938 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951
Fig. 11 (continued ).
phase-encoding values with high-spatial frequency
data acquired later in time. In effect, TRICKS over-
samples the central region of kspace relative to the
sampling rate of the outer regions. In this way
TRICKS is able to capture consistently an arterial
time frame, free of venous overlay even in regions of
rapid venous return, such as the carotid arteries [31].
In the distal extremities, where bolus chase tech-
niques are shown to be sensitive to contrast arrival
time and venous overlay, TRICKS is successful in
acquiring diagnostic images in patients with severe
pathology [32] (Fig. 14).
A logical extension of the oversampling of the
central phase encodes is to acquire the highest spatial
frequencies only at the end of the contrast-enhanced
scan, as in a ‘‘keyhole’’ acquisition. By acquiring the
k-space points that contribute to edge depiction only
once, at the end of the scan, the frame rate during the
arterial phase is not compromised. Because recircu-
lation of the initial bolus of contrast results in
prolonged intravascular T1-shortening, sampling the
highest k-space lines up to 3 to 4 minutes after first
pass the contrast is possible. Fig. 15 shows a signal
enhancement curve acquired in the femoral arteries of
a volunteer after 0.1 mmol/kg of a gadolinium-
based contrast agent, showing that prolonged signal
enhancement persists for several minutes. The in-
creased spatial resolution that is possible is demon-
strated in an image of the carotid bifurcation.
Non-Cartesian acquisitions
Despite the recent advances in rapid image
acquisitions presented in the preceding sections,
the use of conventional Fourier spin-warp imaging
is limited in its ability to meet the demands of high-
resolution MRA. The dependence of spatial resolu-
tion on image acquisition time will ultimately limit
the spatial resolution at which images are acquired.
Novel approaches, however, to MR image acquis-
itions are beginning to show promise as a means to
address some of the technical challenges facing the
development of conventional MRA.
Undersampled PR
Radial projections reconstruction (PR) k-space
trajectories were introduced as the first technique for
doing spatial localization in MR. Rather than sampling
k-space on a rectilinear grid, as with conventional MR
 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951 939

acquisitions, PR acquisitions sample k-space on radial
trajectories. An example of radial k-space sampling is
shown in Fig. 16. Unlike conventional MRA acqui-
sitions, radial k-space trajectories sample the center
and periphery of k-space on each echo.
Reducing the image acquisition time with Fourier
encoding can be achieved by acquiring fewer phase-
encoding values. Undersampling in Fourier-encoded
MRI usually requires the acquisition of low-spatial
resolution images, small FOVs, or highly anisotropic
spatial resolution. Undersampling in PR acquisitions is
achieved by decreasing the number of angular samples
and does not decrease spatial resolution or FOV [33].
Rather, decreasing the number of radial samples results
in a low intensity streak artifact, similar to that seen in
computed tomographic (CT) examinations. The PR
undersampling artifact has not proven to be less
problematic in CE MRA, because blood vessels are
the dominant signal source, unlike in CT, where
artifact from bone can confound diagnosis.
Fig. 17 shows a comparison between a con-
ventional Fourier and undersampled PR contrast-
enhanced examination of a resolution phantom. In
the PR image (center), small structures are visualized

Fig. 12. Partial Fourier acquisition. Image acquisitions can be accelerated by acquiring a portion of the full compliment of
k-space points. (A) A k-space image prior to Fourier transformation with frequency (v) and phase-encoding (Ky) directions
indicated. (B) Fractional-echo acquisitions can be used to reduce echo time as well as repetition time resulting in a more rapid
acquisition of images. (C) Similarly, by acquiring a subset of the total number of phase-encoding values, a proportionate decrease
in scanning time is achieved.
940 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951
Fig. 12 (continued ).
more accurately than the Fourier encoded image
acquired in the same time (left). In order for Fourier
encoding to acquire the same spatial resolution, four
times the imaging time is required (right). This is
demonstrated in vivo in a contrast-enhanced exam-
ination of the pulmonary arteries (Fig. 18). The many
more distal branches of the pulmonary vasculature
are visible in the undersampled PR acquisition as
compared to the Fourier-encoded image acquired in
the same time.
PR-TRICKS
The short imaging times that are possible with
undersampled PR acquisitions are ideal for time-
resolved examinations. By combining an under-
sampled PR k-space trajectory to sample k-space in
the kx-ky plane with a TRICKS-encoding in the slice
direction, the frame rate of TRICKS examinations may
be increased [34]. Using a combined PR-TRICKS
acquisition, it is possible to acquire high resolution
(0.5 mm
0.76
2.4 mm) 3D volumes with a frame
rate equal to 2.5 seconds per frame. An example of a
time frame from a PR-TRICKS examination of the
trifurcation vessels in Fig. 10. In this example, the
bolus of contrast arrives in the right leg several seconds
after the left. The high frame rate afforded by PR-
TRICKS allows for optimal sampling of the central
phase-encoding values to depict both legs.
PR-hyperTRICKS
As described previously, TRICKS encoding is able
to increase the frame rate over the normal multiphase
examination by resampling the center of k-space at a
higher rate than the higher spatial frequencies. The
resampling of the center of k-space, however, results in
TRICKS examinations having lower spatial resolution
than single-image acquisitions acquired in the same
time. In elliptical centric acquisitions of the renal and
carotid arteries, the high-spatial frequency phase-
encoding values are acquired several seconds after
venous opacification. Motivated by the excellent
venous suppression afforded by elliptical-centric
examinations, further improvements in the spatial
resolution of TRICKS have been achieved. By slight-
ly modifying the TRICKS acquisition schedule, it
is possible to double the slice resolution without
sacrificing frame rate during the first pass of the
bolus of contrast agent. These acquisitions, called
hyperTRICKS acquisitions, perform a conventional
TRICKS examination during the first pass of the
contrast agent, then acquire the high-spatial frequen-
cies slice encodes only at the end of the acquisition,
similar in principle to keyhole imaging (Fig. 19). In
this way, dynamic information on filling patterns and
contrast arrival are available to the clinician. In addi-
tion, the spatial resolution of the arterial image is
increased to recover the loss in spatial resolution
normally associated with time-resolved acquisitions.
Fig. 19 also shows an example of the improve-
ments in spatial resolution that hyperTRICKS ac-
quisitions are capable of in an extremely low-spatial
resolution TRICKS examination. The spatial resolu-
tion of a single slice through the carotid bulb
acquired at peak arterial enhancement is improved
by including high-spatial frequencies acquired after
venous opacification. As in elliptical-centrically en-
coded examinations, edge depiction of the artery
is improved with minimal venous overlay. When
hyperTRICKS is combined with undersampled PR
(ie, PR-hyperTRICKS), further improvements in spa-
 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951 941

Fig. 13. WakiTRACK peripheral MRA examination. A multicoil SENSE acquisition in the abdominal station is combined with
manual table translation as part of a three-station single injection peripheral MRA examination. The third station ± 45° oblique view
and coronal. Also, a zoomed image of the trifurcation vessels demonstrates diffuse occlusive disease. (Courtesy of Jeffrey Maki,
MD, PhD, University of Washington.)

tial and temporal resolution are possible. In exami-
nations of the distal extremities, PR-hyperTRICKS
is used to improve the spatial resolution and coverage
of these examinations.
VIPR
Motivated by the scan time reductions achieved
with undersampled PR, radial undersampling is
extended to 3D acquisitions [35]. Previous imple-
mentations of undersampling relied on traditional
Fourier encoding in the slice direction. The VIPR
(Vastly undersampled Isotropic Projection Recon-
struction) acquisition samples k-space using 3D
radial trajectories (Fig. 20). The low-intensity streaks
associated with 2D undersampling appear as low
intensity correlated noise distribution.
There are several advantages to the VIPR sam-
pling strategy. First, because radial sampling is per-
942 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951

Fig. 14. Time-resolved imaging of vascular malformation in 2-month-old child. Sequential 3D volumes were reconstructed
every 2 seconds using the 3D TRICKS technique. Images show early arterial filling of the vascular malformation (A),
followed by the blush (B), and then the venous drainage is demonstrated (C). Time-resolved imaging allows the use of a small
2-cc bolus in this infant, without a timing scan.
T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951 943
944 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951
Fig. 15. HyperTRICKS schematic. Time-resolved images
are acquired during the first pass of contrast agent, then
high-resolution steady state imaging is performed beginning
120 seconds after the start of the scan. The curve (A) shows
signal enhancement in the femoral arteries of a volunteer
after 0.1 mmol/kg of a gadolinium-based contrast agent,
showing that prolonged signal enhancement persists for
several minutes. The image resolution of the carotid study
(B – D) increases (left to right) as high-spatial frequencies
are acquired and used in the reconstruction.
formed in 3D, the spatial resolution and coverage of
these examinations are isotropic. This is useful par-
ticularly in abdominal imaging. The isotropic 3D
coverage eliminates the need for volumetric selection.
In addition, reprojection at any angle of obliquity
does not result in degraded spatial resolution. Second,
the ability to undersample in 3D without a loss in
coverage or spatial resolution allows for high-spatial
resolution images to be acquired in a comfortable
breath hold.
By interleaving sets of projection angles, it
becomes possible to acquire high-spatial resolution
and isotropic 3-D volumes. Time-resolved VIPR
acquisition of 256
256
256 volumes in less than
4 seconds is possible. Fig. 20 shows a coronal view
of an early time frame that depicts the pulmonary
arteries. A coarctation of the aorta from a later frame
in the same acquisition is best viewed in the sagittal
plane. The large coverage and isotropic spatial res-
olution allow reprojection of these time-resolved
acquisitions in any plane.
Contrast agents
Gadolinium chelates have proved safe and effec-
tive for CE MRA in many clinical trials. These
agents, however, are used primarily during the first
pass of contrast-enhancement, as there is relatively
high leakage of contrast through the vascular capil-
lary network into the interstitial space. The distri-
bution of standard gadolinium contrast agents results
in enhancement of the soft tissues following intra-
venous injection of gadolinium contrast agent. Sev-
eral gadolinium-based contrast agents are approved
for use in the United States, and additional agents
have met approval in Europe [36]. None of the three
gadolinium-based contrast agents used in the United
States, however, are in fact approved for use in CE
MRA. MRA using gadolinium contrast agents is
shown to be safe and effective in multiple clinical
trials published in the literature. The pharmaceutical
manufacturers, however, have not yet performed the
clinical trials necessary for Food and Drug Adminis-
tration approval of gadolinium agents for the MRA
indication. Therefore, use of extracellular gadolinium
contrast agents represents an ‘‘off-label’’ use of the
pharmaceutical as established by clinical need under
the guidance of a licensed physician.
Many advances in the development of improved
contrast agents aimed specifically at MRA have been
made. Two general categories of contrast media are
being developed, including extracellular and blood
pool contrast agents. Extracellular contrast agents are
similar to existing gadolinium chelates; however,
some compounds are designed to enhance the T1
relaxivity of the gadolinium chelate [37]. For example,
the weak protein binding of gadobenate dimeglumine
(Multihance, Bracco, Milan, Italy) results in improved
relaxivity (R1); therefore, injection of the contrast
agent results in a shorter T1 relaxation time and
improved signal intensity relative to standard gadolin-
ium chelates [37,38]. In addition, formulations of
gadobutrol (Gadovist, Schering, Berlin, Germany)
 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951 945

Fig. 16. (A) Spin-warp MR image acquisitions sample the k-space representation of an image on a rectilinear grid. (B) Projection
reconstruction acquisitions sample k-space on radial trajectories that pass through the center of k-space and resemble the spoke of
a bicycle tire. These trajectories sample both the low-spatial frequencies (responsible for image contrast) and high-spatial
frequencies (responsible for image detail) in every repetition time. Undersampling in the radial dimension does not cause wrap-
around artifact or reduced spatial resolution as in spin-warp imaging. (Courtesy of Karl Vigen, PhD, Stanford University.)

are prepared using a higher molar concentration of The second general category of contrast agents
gadolinium per cubic centimeter (1.0 M versus the includes blood pool contrast agents, which are in-
current standard of 0.5 M), which is shown to improve tended to stay within the intravascular space. As
vessel SNR in one study of pelvic MRA [39]. described previously, one of the difficulties with

Fig. 17. Comparison between a conventional Fourier and undersampled projections reconstruction (PR) resolution. In the PR
image (center), small structures are visualized more accurately than the Fourier encoded image acquired in the same time (left).
In order for Fourier encoding to acquire the same spatial resolution, four times the imaging time is required (right). Acquiring a
fewer number of projections than are required to full sample k-space results in a low-level streak artifact that emanates out from
objects within an image. Undersampling radial projections, however, allows for rapid acquisition of high-spatial resolution
images, where the streak artifacts are relatively minor. (Courtesy of Dana Peters, PhD, National Institutes of Health.)
946 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951

Fig. 18. (A) A Fourier-encoded examination of the pulmonary vasculature is compared with (B) an undersampled projections
reconstruction (PR) examination in the same patient. The acquisitions time was the same for both examinations; however, the in-
plane spatial resolution of the undersampled PR image (0.7 mm
0.7 mm) is greater than the Fourier encoded image (0.7 mm

2.0 mm). (Courtesy of Dana C. Peters, PhD, National Institutes of Health.)

extracellular contrast agents is leakage of the contrast
agent into the extracellular space, which results in
reduced contrast between the intravascular signal and
the soft tissues. In theory, blood pool contrast agents
could reduce this leakage and thereby improve the
contrast between the vascular phase and stationary
tissues. More importantly, several of the blood pool
contrast agents are designed so that there is prolonged
intravascular signal associated with the contrast
agent, thereby allowing the acquisition of high-res-
olution images [40]. Improved signal intensity and
spatial resolution can be provided by the prolonged
arterial phase of the blood pool contrast agents [41].
The prolonged arterial phase also comes at a disadvan-
tage, however, because of the associated enhancement
of venous structures surrounding the arteries. These
techniques undoubtedly will require improved proc-
essing algorithms to segment the arteries or veins
[42]. The success of these segmentation methods,
however, needs to be demonstrated in large-scale
clinical trials.
Several different blood pool contrast agents have
been proposed. One agent, MS-325, uses a principal of
strong protein binding to ensure that the gadolinium-
based contrast agent stays within the vascular phase
[31,41,45]. MS-325 binds to serum albumin, which
results in a prolonged blood half-life [40]. In addition,
the protein binding results in improved (R1), thus
leading to improved SNR at a lower dose.
Gadomer-17 represents a dendrimer compound
with multiple gadolinium atoms per molecule [43].
This contrast agent also is shown to have high
relaxivity. The molecule is designed to ensure that
the size is large enough to stay in the vessel, but small
enough to be filtered renal filtration. The contrast
agent has several potentially desirable properties for
MRA, including high relaxivity and the fact that it
stays within the blood pool. In addition, it has a
relatively short blood-pool half-life, thus allowing
repeated injections if clinically indicated.
Finally, investigators have proposed the use of
iron-based contrast agents to provide prolonged

Fig. 19. Projections reconstruction hypertricks scan of the distal lower extremities. Serial time frames demonstrate delayed filling
of the right infrapopliteal vessels. The total examination time is 216, but images are reconstructed every 2 seconds (A – D). Image
resolution is 0.7
0.7
2 mm. The high-resolution study provides excellent depiction of the small distal vessels. (Courtesy of
Jiang Du, MS, University of Wisconsin.)
T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951 947
948 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951

blood pool enhancement for MRA [44]. The iron-
based agents effect T1 and T2, because the particulate
compounds have an effect on R1 and R2 relaxivity.
At low doses, however, the effect is primarily on
the R1, resulting in T1 shortening for MRA. These
agents have potential merit because of the long blood
pool residence time, and the high relaxivity. Limita-
tions of the iron-based agents, however, are related to
the fact that the also shortened T2 relaxivity, thereby
lowering signal intensity at high doses.
Summary
CE MRA has evolved rapidly since the early
studies by Prince et al [3]. Whereas many of the

Fig. 20. VIPR (Vastly undersampled Isotropic Projection Reconstruction) acquisition samples k-space using in 3D radial
trajectories (A). Pulmonary phase (B) and aortic phase (C) images may be reconstructed from a single breath-hold examination
by weighting the k-space data differently. Image in (C) demonstrates coarctation of the aorta. High frame rates allow capture of
an arterial phase, while simultaneously providing isotropic resolution and broad coverage. (Courtesy of Walter Block, PhD,
University of Wisconsin.)
 T.J. Carroll, T.M. Grist / Radiol Clin N Am 40 (2002) 921–951
Fig. 20 (continued ).
procedures in clinical use today rely heavily on the
use of gadolinium contrast agents and standard Four-
ier transform acquisition techniques, advances will
have a significant impact on MRA by shortening the
acquisition time, improving the reproducibility of the
image-acquisition techniques, and improving spatial
resolution or SNR. From a technical basis, shorter
acquisition times associated with fast gradients are
likely to improve spatial resolution and allow for
acquisition of MR images over large FOVs. In
addition, alternative k-space sampling techniques,
such as parallel imaging and PR, are expected to
further reduce acquisition time, while maintaining or
improving spatial resolution. The approval and sub-
sequent use of new contrast agents will also have a
beneficial impact on the image quality of contrast-
enhanced MRA applications. It is likely that these
contrast agents will be coupled with advanced
acquisition techniques to improve spatial resolution
and technical success rates of MRA examinations.
References
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Carpenter JP, et al. Multi-center trial to evaluate vas-
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 Radiol Clin N Am 40 (2002) 953 – 963

Catheter-directed gadolinium-enhanced MR angiography

Reed A. Omary, MD, MSa,*, Jordin Green, BSb, J. Paul Finn, MDb,
Debiao Li, PhDb
a
Department of Radiology, Northwestern University Medical School, 676 North Saint Clair, Suite 800, Chicago, IL 60611, USA
b
Department of Radiology, Northwestern University, Suite 700, 448 East Ontario Street, Chicago, IL 60611, USA

Magnetic resonance imaging (MRI) guidance for
endovascular procedures offers several important
advantages over conventional x-ray guidance. These
advantages include (1) lack of ionizing radiation
exposure, which benefits not only the patient, but
the operator and team who perform a lifetime of
procedures; (2) lack of iodinated contrast agents, with
their attendant risks of nephrotoxicity and allergic
reactions; (3) the ability to detect blood vessels and
three-dimensional (3D) anatomy at the same time, an
important feature for performing procedures such as
transjugular intrahepatic portosystemic shunt (TIPS)
placement; and (4) the ability to detect changes in end-
organ (eg, kidney, heart, or brain) function at the time
of an endovascular intervention, a capacity that is not
readily available with x-ray – guided techniques.
MRI-guided procedures are still early in their
development. Most studies have occurred in animals,
with little published about these procedures in humans.
In animal models, published applications of MRI-
guided endovascular interventions include inferior
vena cava filter placement [1,2], percutaneous trans-
luminal angioplasty (PTA) of the aorta [3 – 5] and renal
artery [6,7], stent placement within the iliac artery
[8,9] and aorta [9,10], coronary angiography [11,12],
TIPS [13], and carotid artery aneurysm embolization
[14]. In humans, MRI-guided hemodialysis, Brescia-
Cimino arteriovenous and loop graft fistulagraphy
R.A. Omary was supported in part by NIH K08
DK60020.
* Corresponding author.
E-mail address: romary@radiology.northwestern.edu
(R.A. Omary).
[15], and iliac artery stent placement [16] also have
been performed.
Whether performed under x-ray or MRI guidance,
these endovascular procedures require multiple con-
trast-agent injections to define baseline vascular
anatomy, to confirm intraluminal position of endo-
vascular devices, and to document changes in vascular
anatomy following an intervention. Direct catheter-
based injections of gadolinium (Gd) chelates under
MRI guidance can be used in the same manner as
injections of iodinated contrast material under x-ray
guidance. The primary rationale for using catheter-
directed rather than conventional intravenous (IV)
injections under MRI is to conserve contrast agent.
Because multiple injections are required during an
MRI-guided endovascular intervention, the Food and
Drug Administration (FDA)-mandated daily dose
limit of Gd, 0.3 mmol/kg, is easily exceeded using
IV injections. Catheter -directed injections use smaller
volumes of dilute contrast agent. These smaller Gd
doses not only should help the operator remain below
the FDA dose limits, but also should reduce back-
ground tissue enhancement. A secondary benefit of
these catheter-based injections is that only the artery
of interest is enhanced. Other adjacent vascular beds
remain suppressed, which facilitates artery visualiza-
tion and disease detection.
This article reviews catheter-directed Gd-enhanced
MR angiography (MRA), with special focus on intra-
arterial (IA) injections. Catheter-directed IA Gd-
enhanced MRA has been used in animals in the aorta
[12,17 – 19], carotid arteries [12,14,18,20], renal arter-
ies [6,12,19,21], iliac arteries [18,19,21], and coronary
arteries [12,22]. The authors present background
theory; discuss IA injection protocols, MRA se-
quences, and methods to limit contrast agent dose;

0033-8389/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 1 4 - 3
954 R.A. Omary et al / Radiol Clin N Am 40 (2002) 953–963

and describe how to perform IA injections. Finally, the
authors discuss the accuracy, advantages, and limita-
tions of IA injections.
Theory of local Gd injections
Gd-enhanced MRA is based on the T1 shortening
effect of Gd in blood. T1 shortening increases MR
signal. Gd, however, also shortens blood T2*, which
results in MR signal loss with a gradient-echo
sequence. Consequently, there is an optimal Gd
concentration ([Gd]), where the T1 shortening signal
gain is balanced with the competing T2 signal loss,
and the blood signal is maximal. Fig. 1 compares T1
and T2* shortening effects during selective renal-
artery injections.
If dilute Gd is required, then what is the optimal
concentration? This question has been addressed
using (1) theoretic expressions [18,19], (2) static
[12,17] and dynamic [21] phantoms, and (3) in vivo
[12,18,19,21] experiments. Using complex theoretic
expressions, Frayne et al [18] derive 2% Gd as the
optimal concentration for MR vascular signal for
typical MRA acquisition parameters. Bos et al [19]
find that 3% to 6% is optimal. In initial static
phantom experiments, Omary et al [17] show that
optimal arterial [Gd] range between 1% and 6%,
depending on the selected imaging parameters. In
subsequent static phantom experiments, Serfaty et al
[12] find 6% [Gd] to be optimal. In vivo optimal
arterial Gd concentrations range from 1% to 5%
[18,21].
This spectrum of optimal values reinforces a key
point: satisfactory vascular depiction occurs over a
relatively broad range of arterial [Gd] [12,18,19].
There is little practical difference in vessel enhance-
ment or signal-to-noise ratio (SNR) between Gd sol-
utions ranging in concentrations between 1% and 6%.
Regarding nomenclature, dilute Gd solutions are
generally presented in one of three ways: (1) dilution
ratios (eg, 1:20, which is equivalent to 1 part Gd and
20 parts saline); (2) millimolar concentration (eg, 50
mM); and (3) percentage concentration (eg, 4% Gd).
While all these methods are equivalent, they have
varying degrees of scientific validity and practicality.
The dilution ratio and percentage concentration meth-
ods are clearly the most intuitive; one need not be
familiar with the standard molar concentration of Gd
(500 mM) to recognize how to produce these dilu-
tions. The mM method is scientifically most correct
because full-strength contrast agent within the dis-
pensing bottle is itself a solution of Gd chelate. The
mM method is limited in practice because it requires
a priori knowledge of this concentration and is not
readily intuitive to most radiologists.

Fig. 1. Coronal 2D MRA using selective Gd injection in swine right renal artery. (A) Injected [Gd] = 1.8%, injection rate = 1 mL/
second, arterial [Gd] = 1%, total injected Gd dose = 0.13 mL. (B) Injected [Gd] = 14%, injection rate = 2 mL/second, arterial
[Gd] = 10%, total injected Gd dose = 2.0 mL. The injection in (A) shows optimal signal-to-noise ratio, with T1 shortening effects
predominating over T2* effects. The injection in (B) shows signal loss due to T2* effects. (From Omary RA, Henseler KP, Unal
O, Smith RJ, Ryu RK, Resnick SA, et al. Validation of injection parameters for catheter-directed intraarterial gadolinium-
enhanced MR angiography. Acad Radiol 2002;9:172 – 85; with permission.)
 R.A. Omary et al / Radiol Clin N Am 40 (2002) 953–963
Intra-arterial injection protocol
Knowledge of the optimal arterial Gd concentra-
tion is only the first step in performing an IA
injection. It is paramount to recognize that the desired
arterial [Gd] differs in most instances from the
injected [Gd]. The difference between injected and
arterial Gd concentrations results from further dilu-
tion of injected Gd by inflowing blood. Arterial [Gd]
is based on three factors: injected [Gd], injection rate,
and arterial blood flow rate. Frayne et al [18] and Bos
et al [19] postulate relationships between these injec-
tion parameters by assuming that all injected Gd is
diluted by inflowing blood. Their injection relation-
ships are similar, except that Frayne et al [18] account
for the influence of injection rate on overall arterial
blood flow rates.
The IA injection protocol proposed by Frayne et al
[18] is:
Qartery
½Gdinj ¼ ð1 þ Þ  ½Gdartery (Equation 1)
Qinj
where [Gd]inj = injected [Gd] (%), Qartery = blood
flow rate in vessel of interest (mL/s), Qinj = injection
rate of Gd agent (mL/s), and [Gd]artery = desired
arterial concentration of Gd (%). By substituting
injection parameters into Equation 1, interventional
radiologists can devise injection protocols for IA
Gd-enhanced MRA.
This injection protocol has been validated in
dynamic flow phantoms and in swine [21]. Accord-
ing to the injection protocol, there is an inverse
relationship between injected [Gd] and injection rate.
To obtain a desired arterial [Gd], either (1) increase
the injection rate and reduce the injected [Gd] or (2)
increase the injected [Gd] and reduce the injection
rate. This trade-off occurs because both techniques
deliver the same local Gd mass flux [18] to the
blood vessel.
MRA sequences
The selection of MRA sequences should be
based on the intended purpose of an IA injection.
If a rapid vascular roadmap is desired and the blood
vessels are located within a defined thin-imaging slab,
then a standard two-dimensional (2D) time-resolved
sequence should be used. With tortuous vessels, it is
better to use a thicker 2D-imaging slab, arbitrarily
called ‘‘projection MRA.’’ The term ‘‘projection’’
refers to 2D imaging over a thick-imaging slab, gen-
955
erally 5 to 20 cm, similar to 2D x-ray fluoroscopy.
Projection MRA emphasizes a larger imaging slab at
the expense of vessel signal. If greater accuracy and the
ability to perform multiplanar volumetric reconstruc-
tions are desired, then three-dimensional (3D) se-
quences should be used. Potential problems with 3D
imaging are that the temporal resolution will be com-
promised and more contrast agent will be required. In
general, short repetition time (TR)/short echo time
(TE) T1-weighted sequences, similar to conventional
IV-Gd – enhanced MRA, can be used for 2D and 3D
MRA. Electrocardiographic (ECG) gating may be
used for some vascular distributions, such as the heart
(Fig. 2). Typical imaging parameters for each sequence
are shown in Table 1.
According to Equation 1, knowledge of the local
blood flow rate adjacent to the catheter is necessary to
use the injection protocol relationship. This blood
flow rate is empirically estimated based on experience
or estimates from the literature. To be more accurate,
however, a 2D cine-phase contrast sequence [18,21,
23,24] is used to measure the local blood flow rate.
There are several methods to suppress background
for IA-Gd – enhanced MRA. One involves subtraction
of source-imaging data obtained prior to the admin-
Fig. 2. Coronal 3D coronary MRA in canine using selective
left circumflex artery Gd injection. Electrocardiographic-
triggering was used. Injection parameters included injected
[Gd] = 6%, injection rate = 0.3 mL/second, injection vol-
ume = 10 mL, slice thickness = 16 mm (interpolated to
32 mm), and temporal resolution = 0.5 frames/second.
956 R.A. Omary et al / Radiol Clin N Am 40 (2002) 953–963

Table 1
Typical imaging parameters used for Gd-enhanced MRA
Technique Parameters
2D cine-phase contrast TR (repetition time)/TE (echo time)/flip = 10.1 ms/4.7 ms/45°;
field of view (FOV) = 24  11 cm; acquisition matrix = 256  128;
reconstruction matrix = 256  256; slice thickness = 5 mm;
velocity-encoding value = 300 cm/s; duration = 18 s
Time-resolved 2D TR/TE/flip = 5.8 ms/1.4 ms/ 30°; FOV = 24  18 cm;
acquisition matrix = 256  160; reconstruction matrix = 256  256;
slice thickness = 20 mm; scan duration = 7 s
Single-phase 3D TR/TE/flip = 8.3 ms/ 1.6 ms/ 45°; FOV = 24  18 cm;
acquisition matrix = 512  192; reconstruction matrix = 512  512;
slice thickness = 2.6 mm with 16 partitions (acquired) and 1.3 mm
with 32 partitions (reconstructed); scan duration = 26 s

istration of contrast agent [25]. This method is limited
because it requires additional image processing.
Motion between data acquisitions also causes image
artifacts after subtraction. A gradient dephaser has
been used in the slice direction to suppress signals
from the thick, homogeneous background [26,27].
The effectiveness of this scheme, however, depends
on the anatomical structure of the imaging slice.
Recently, magnetization preparation has been used
to suppress background in contrast-enhanced MRA
[20,22,28,29]. This method may be a useful approach
for 2D projection MRA.
Limiting contrast-agent dose
Because MRI-guided endovascular interventions
require at least as many separate injections as x-ray
guided procedures, it is essential to limit contrast-
agent dose during each injection. Limiting injected-
Gd dose not only reduces the likelihood of exceeding
FDA Gd-dose limitations during an intervention, but
it also has the added imaging advantage of minimiz-
ing background tissue enhancement.
There are several techniques available to limit
contrast-agent dose. These can be categorized as

Fig. 3. Coronal 2D MRA using selective Gd injection in swine right-iliac artery. (A) Injected [Gd] = 10%, injection rate = 1 mL/
second, arterial [Gd] = 4%. (B) Injected [Gd] = 2.5%, injection rate = 1 mL/second, arterial [Gd] = 1%. There is no significant
difference in arterial depiction between images. The selective injection, however, depicted in (A) required a total of 0.70 mL of
undiluted Gd, while the injection depicted in (B) required only 0.18 mL. (From Omary RA, Henseler KP, Unal O, Smith RJ, Ryu
RK, Resnick SA, et al. Validation of injection parameters for catheter-directed intraarterial gadolinium-enhanced MR angiography.
Acad Radiol 2002;9:172 – 85; with permission.)
 R.A. Omary et al / Radiol Clin N Am 40 (2002) 953–963 957

injection parameters, imaging techniques, and cath-
eter location.
Injection parameters
These techniques use arterial [Gd] equal to 1%.
Whereas optimal SNR is obtained with arterial [Gd]
ranging from 1% to 6%, aiming for 1% reduces
contrast agent dose six-fold over 6%. This reduction
is a result of the direct relationship between arterial
[Gd] and injected dose (Equation 1). Fig. 3 depicts
selective iliac artery injections in a pig. Images show
how aiming for arterial [Gd] of 1% rather than 4%
reduces injected-Gd dose without appreciably affect-
ing vascular depiction.
Imaging techniques
1. Tailor injections toward imaging goal. Early
experience with IA injections [17] suggests that
injection duration should cover at least a
substantial portion of the image acquisition
period. Because image acquisition time is much
faster for 2D rather than 3D techniques, 2D IA-
MRA uses considerably less contrast agent than
3D IA-MRA. Roadmaps using 2D projection
methods thus save considerable contrast agent
over 3D IA-MRA. Reserve 3D methods for
occasions when high diagnostic accuracy or
multiplanar volumetric reconstructions are re-
quired. Fig. 4 shows how image quality differs
between 2D projection and 3D techniques for
catheter-directed MR aortography.
2. Reduce imaging times. This can be accom-
plished by: (1) shortening the TR, (2) using
partial Fourier acquisitions, or (3) reducing the
number of phase encoding steps.
3. Reduce injection duration. For 3D IA-MRA,
Hwang et al [30] show that injection duration
can be reduced to 50% of the image acquisition

Fig. 4. Catheter-based Gd injections in aorta of same pig. (A) 2D coronal projection MRA using injected [Gd] = 4%, injection
rate = 5 mL/second, injection duration = 1 second, total undiluted Gd dose = 0.2 mL, slice thickness = 50 mm, and temporal
resolution approximately 2 frames/second. (B) 3D coronal MRA (maximum intensity projection) using injected [Gd] = 4%,
injection rate = 5 mL/second, injection duration = 8 seconds, total undiluted Gd dose = 1.6 mL, slice thickness = 48 mm (after
interpolation), and temporal resolution = one image every 6 second. The 3D acquisition has better image quality than the 2D
projection acquisition but uses more contrast agent and requires a longer acquisition time.
958 R.A. Omary et al / Radiol Clin N Am 40 (2002) 953–963

time without significant loss of SNR in the
aorta and iliac arteries. For smaller vessels,
such as the renal arteries, injection duration can
be reduced to 75% of the image acquisition
time without significant loss of SNR. Hwang
et al [30] found no difference in SNR between
elliptical centric and conventional sequential
linear encoding schemes for IA-MRA. Fig. 5
depicts sample 3D IA-Gd – enhanced images
from a dynamic arterial flow phantom using
both encoding schemes at the different in-
jection durations.
Catheter location
Place catheters as selectively as possible. Major
reductions in contrast-agent dose occur when cathe-
ters are positioned within smaller vessels. This effect
on dose reduction can be seen from Equation 1:
smaller vessels have reduced blood flow rates com-
pared to larger vessels. Consequently, performing a
selective renal artery injection uses substantially less
contrast agent than an abdominal aortic injection.
For example, the selective 2D renal MRA shown in
Fig. 1a uses only 0.13 mL of undiluted Gd. In a 25-kg
pig, 115 separate similar injections can be per-
formed without exceeding the FDA Gd-dose limit of
0.3 mmol/kg/day.
How to perform an IA injection
Equation 1 describes the relationship between
three pertinent injection parameters: injection rate,
injected [Gd], and blood flow rate. Although Equa-
tion 1 can be used to establish an injection protocol
for IA-Gd – enhanced MRA, it still leaves many
injection parameter choices available to the operator.
The authors present the following method of
approaching an IA injection:
1. Place catheter selectively into vessel of interest.
2. Measure or estimate blood flow rate (Q) in
mL/second in the catheterized vessel. To meas-

Fig. 5. Coronal 3D MRA using aortic catheter-based injections in a dynamic aortorenal-iliac flow phantom. Two series of images
acquired with aortic blood flow rate of 29 mL/second and an injection rate of 4 mL/second, using elliptical (a – d) and sequential
(e – h) encoding. Both series are shown with decreasing injection coverage: 100% (a,e), 75% (b,f ), 50% (c,g), and 30% (d,h). No
statistical difference ( P > 0.05) in signal-to-noise ratio (SNR) is present between the two encoding schemes. When injection
coverage is dropped to 30%, there is a statistically significant drop in SNR for all vessel segments ( P < 0.05). (From Hwang KP,
Green JD, Li D, Simonetti OP, Resnick SA, Finn JP, et al. Minimizing contrast-agent dose during intraarterial gadolinium-
enhanced MR angiography: in vitro assessment. J Magn Reson Imaging 2002;15:55 – 61; with permission.)
 R.A. Omary et al / Radiol Clin N Am 40 (2002) 953–963 959

ure blood flow rates directly, use 2D cine-
phase contrast MRA [18,21,23,24]. Estimates
of blood flow rate can be obtained from the
literature or from operator experience. Esti-
mates are often sufficient, given the wide
variation in acceptable arterial [Gd]. This is not
unlike the case with x-ray digital subtraction
angiography (DSA). Significant vascular pa-
thology, however, might introduce more varia-
tion into estimates and potentially limit the
effectiveness of IA injections.
3. Select an injection rate. Injection rates might
range from 1 to 10 mL/second, given the
availability/preference of automated injectors
versus hand injections. A smaller injection rate
is beneficial because it uses smaller volumes of
dilute contrast agent. Smaller injection rates
might result in suboptimal mixing of contrast

Fig. 6. Pig following surgical induction of bilateral renal artery stenosis. (A) X-ray digital substration angiography shows 70%
right renal artery stenosis and 53% left renal artery stenosis; (B) IV-Gd – enhanced 3D MRA shows 68% right renal artery
stenosis and 65% left renal artery stenosis. (C) IA-Gd – enhanced 3D MRA shows 65% right renal artery stenosis and 75% left
renal artery stenosis. Both MR images are coronal-maximum intensity projections obtained with same 3D-fast spoiled gradient
echo acquisition. (From Omary RA, Henseler KP, Unal O, Maciolek LJ, Finn JP, Li D, et al. Comparison of intraarterial and
intravenous gadolinium-enhanced MR angiography with x-ray digital subtraction angiography for the detection of renal artery
stenosis in pigs. AJR Am J Roentgenol 2002;178:119 – 27; with permission.)
960 R.A. Omary et al / Radiol Clin N Am 40 (2002) 953–963

agent and blood. Faster injection rates should
improve mixing in large vessels. Use of
injection rate of 1 mL/second, however, will
simplify the math underlying Equation 1. This
injection rate works in most vessels, especially
if they are smaller.
4. Select desired arterial-Gd concentration
([Gd] artery ). The authors suggest using
[Gd] artery = 1%, which should minimize
injected contrast dose and still provide ade-
quate images.
5. Determine injected-Gd concentration ([Gd]inj).
Assuming use of [Gd]artery = 1%, [Gd]inj = 1 +
(blood flow rate/injection rate)%. As an
example, for blood flow rate = 12 mL/second
and injection rate = 4 mL/second, substitution
yields [Gd]inj = 4%. Injecting at 1 ml/second,
requires [Gd]inj = 13%. To produce this injected
[Gd], dilute full-strength Gd (500 mM) with
normal saline.
6. Determine purpose of injection. Use 2D MRA to
verify catheter positioning, to confirm intra-
luminal catheter location, or to perform rapid
vascular roadmaps. These images can be pro-
jectional (5 – 20 cm slab) for tortuous vessels.
Use 3D MRA for its improved diagnostic ac-
curacy at the beginning and end of MRI-guided
endovascular procedures.
7. Determine injection duration. For fast time-
resolved 2D MRA, injection can coincide with
image acquisition and continue for the desired
number of arterial-phase imaging frames. For
3D MRA, injection should begin two seconds
prior to image acquisition, which will facilitate
adequate mixing of injected contrast agent with
inflowing blood. To minimize injected contrast
agent, injection duration can be reduced to the
first 50% of the image acquisition time in
medium or large vessels without loss of SNR.
For instance, injection duration should be
10 seconds for a 3D selective iliac artery
acquisition that lasts 16 seconds (2 second lead
time plus 8 seconds). In smaller vessels, such
as renal or coronary arteries, injection duration
should cover the first 75% of image acquisition
time. A similar 3D injection in a renal artery
might require injection duration of 14 seconds
(2 second lead time plus 12 seconds).

Fig. 7. Scatter plot shows swine renal artery stenosis measurements obtained for IV- and intraarterial (IA)-3D MRA using x-ray
digital substration angiography as reference standard. Stenoses were induced using reverse cable ties. IA MRA has slightly
greater scatter than IV MRA. (From Omary RA, Henseler KP, Unal O, Maciolek LJ, Finn JP, Li D, et al. Comparison of
intraarterial and intravenous gadolinium-enhanced MR angiography with x-ray digital subtraction angiography for the detection
of renal artery stenosis in pigs. AJR Am J Roentgenol 2002;178:119 – 27; with permission.)
 R.A. Omary et al / Radiol Clin N Am 40 (2002) 953–963 961

To simplify Equation 1, substitute [Gd]artery = 1%
and injection rate = 1 ml/second [21]. This substi-
tution leads to:
½Gdinj ¼ ð1 þ QÞ  1%; (Equation 2)
where [Gd]inj = injected [Gd] (%) and Q = blood
flow rate in vessel of interest (mL/second).
provides a more compact immediate input bolus.
Fourth, IA injections are required for projection
imaging when there are other overlapping vascular
beds near the artery of interest, such as with the
coronary circulation (Fig. 8). Finally, IA injections
have reduced contrast-agent dispersion compared with
IV injections.

Using Equation 2, the injected [Gd] in percent

equals one plus the estimated blood flow rate in Limitations to IA injections
mL/second.
There are several important limitations to IA
injections of Gd. First, the FDA has not approved
Accuracy of IA injections catheter-directed injections for MRA. These injec-
tions represent an off-label use and unapproved route
The accuracy of IA injections are theoretically at of administration of contrast agent. Second, the
least as effective as, if not better than, conventional safety of IA-Gd injections is not proven. Because
IV-Gd – enhanced MRA because both rely on T1 the major use of IA injections will be during MRI-
shortening by contrast agent to produce bright vas- guided endovascular interventions, there is little
cular signal. There are limited data available to
confirm this accuracy. In a reverse-cable tie-swine
model of renal artery stenosis; however, Omary et al
[24] compare the accuracy of IV and IA MRA
methods using x-ray DSA as a reference standard.
In this study, the same 3D MRA sequence is used to
compare an IA injection protocol, using Equation 1,
with conventional IV double-dose (0.2 mmol/kg) Gd -
enhanced MRA. Fig. 6 shows sample images from
their experiments. Their results indicate that there is
no significant difference ( P >0.05) in accuracy
between IA- and IV-Gd – enhanced MRA. Both injec-
tion methods also have similar accuracy to x-ray DSA.
IA stenosis measurements have slightly greater varia-
tion than IV measurements (Fig. 7). The IA injections,
however, use approximately 38% less Gd dose than
IV injections.

Advantages to IA injections

During MRI-guided endovascular procedures, IA

injections offer several advantages over conventional
IV administration of contrast agent. The most impor-
tant advantage is reduced contrast-agent dosage. Sec-
ond, the local delivery of contrast agent is much more
efficient than IV administration. Instead of waiting for
first-pass arterial passage of Gd, there is immediate
Fig. 8. Coronal electrocardiographic-triggered 2D MRA in
contrast-agent delivery into the vessel of interest,
canine using selective left circumflex artery Gd injection.
analogous to x-ray DSA. IA injections thereby avoid
Injection parameters were: injected [Gd] = 6%, injection
the need for a dose-timing test bolus [31] or other rate = 1.5 mL/second, injection duration = 4 seconds, slice
complex schemes [25,32,33] to synchronize the arrival thickness = 20 mm, and temporal resolution = 0.5 frames/
of contrast agent with image acquisition. Third, per- second. Direct contrast-agent injection into the left circumflex
fusion assessment, although not yet proven, should be artery prevents overlap with the left anterior descending
superior with IA injections because the local delivery artery distribution during 2D projection imaging.
962 R.A. Omary et al / Radiol Clin N Am 40 (2002) 953–963
incremental risk for each injection. Gd as an alterna-
tive contrast agent for x-ray DSA has achieved
widespread use by interventional radiologists. Sev-
eral publications document its safety for DSA [34,35]
and endovascular interventions [36,37] performed
under x-ray guidance, particularly in patients with
underlying renal insufficiency. Third, there is limited
experience in humans. The expanded use of IA injec-
tions in humans is tied directly to increased use of MRI
guidance for endovascular interventions. There may
be, however, a role for IA injections as a problem-
solving tool in selected diagnostic applications [38].
Finally, more research needs to be performed to
confirm its diagnostic accuracy for detecting stenoses
in multiple vascular distributions.
Summary
In the setting of MRI-guided endovascular inter-
ventions, catheter-directed Gd-enhanced MRA offers
many of the same capabilities as conventional x-ray
DSA. Local injections permit rapid depiction of
blood vessels and help guide interventions. The
primary benefit of IA injections is significant reduc-
tion of administered contrast-agent dose compared
with conventional IV injections. Another major bene-
fit is facilitated background suppression, including
that of adjacent vascular beds. As MRI guidance
methods improve, catheter-based Gd injections
should gain expanded use in clinical practice.
Acknowledgments
The authors thank Toye Spencer and David Botos
for assistance with manuscript preparation and Richard
Tang for expert help with the animal experiments.
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 Radiol Clin N Am 40 (2002) 965 – 970

Index

Note: Page numbers of article titles are in boldface type.

A three-dimensional multiple overlapping thin-slab,

Abdominal aortic aneurysms of carotid plaque, 891 – 892
postoperative imaging of, 799 – 833 visceral, gadolinium in, 704
catheter-based MR angiography in, 814 – 815 Aorta, CT angiography of, 737 – 742, 744
CT angiography in, 800, 804 – 805, 807 – 809
ferromagnetism in, 813 Aortic dissection, and mesenteric ischemia, MR
for device-related failures, 826 angiography of, 875
for endoleaks and endotension, 813, 818 – 822,
824 – 826 Aortic plaque, in atherosclerotic disease, MR imaging
for graft infections, 828 of, 890 – 891
for graft thrombosis, 826 – 828 Aortography, gadolinium in, 704
for stent-graft and artifacts, 811 – 813
for stent-grafts, available devices, 815 – 818 Arterial system, CT angiography of, 729 – 749
heating in, 813 – 814 aorta, 737 – 742, 744
MR angiography in, 809 – 811 peripheral vascular system, 744 – 745
limitations of, 814 principles of, 729 – 730
plain films in, 801 – 802 renal arteries, 745 – 747
rationale and goals for, 799 – 801 techniques for, 730 – 737
ultrasonography in, 802 – 803 choosing scan parameters, 730 – 732
three-dimensional angiography of, 726 – 727 contrast issues, 732 – 734
image reconstruction and postprocessing,
Acetylcysteine, before angiography, 693 734 – 737
Anaphylactoid reactions, to gadolinium, 694
Arteriovenous malformations, cerebral and spinal,
Aneurysms three-dimensional angiography of, 726
abdominal aortic. See Abdominal
aortic aneurysms. Atheromatous disease, CT and MR angiography
aortic, CT angiography of, 737 – 739 of, 793
cerebral, three-dimensional angiography of, Atherosclerotic aortic ulcer, with intramural
726 – 727 hematoma, CT angiography of, 740 – 741
renal artery, MR angiography of, 858
Atherosclerotic disease
Angio SURF system, technique for, 842, 933
mesenteric, MR angiography of, 875 – 878
Angiography MR imaging of, 887 – 898
CT. See CT angiography. advantages of, 888
gadolinium in. See Gadolinium. aortic plaques in, 890 – 891
MR. See MR angiography. carotid plaque in, 891 – 892
of pulmonary embolism, 752 contrast agents in, 894 – 896
of thromboembolic disease, versus CT, 753 – 754 coronary and coronary wall imaging in,
three-dimensional. See Three- 892 – 894
dimensional angiography. interventional imaging in, 894

0033-8389/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 0 3 3 - 8 3 8 9 ( 0 2 ) 0 0 0 3 9 - 8
966 Index / Radiol Clin N Am 40 (2002) 965–970

plaque characterization in, 888 – 890
to monitor therapy, 896
vulnerable plaques in, 887 – 888
renal artery, MR angiography of, 853 – 855, 857
Atherosclerotic plaques, characterization of
CT in, 779 – 780
MR imaging in, 888 – 890
B
Biliary studies, gadolinium angiography in, 706
Blood oxygen saturation, in superior mesenteric
vein, 872
Blood pool contrast agents, in MR angiography,
944 – 946
C Thromboembolic disease.
Calcifications, coronary, CT of, 774 – 777
Central venous anomalies, MR venography of, 913,
915 – 917
Central venous occlusion, MR venography of,
911 – 913
Cerebral aneurysms, three-dimensional angiography
of, 722, 724, 726
Cerebral arteriovenous malformations,
three-dimensional angiography of, 726
Cerebrovascular disease, CT and MR angiography of,
784 – 785, 787
Collateral arteries, mesenteric, MR angiography
of, 870
Computed tomography
of coronary arteries. See Coronary arteries.
of thromboembolic disease. See
of vascular disease, 690 – 691

Carbon dioxide, as contrast agent, 693 – 694 Congenital venous malformations

MR imaging of, 918
Carcinoma, renal cell, MR venography of, 909 – 911 MR venography of, 917 – 918
Carotid plaque, in atherosclerotic disease, MR Contrast agents. See also Gadolinium.
imaging of, 891 – 892 in CT and MR angiography, 732 – 734, 788 – 789,
Catheter-based MR angiography, 689 – 692 836 – 840, 848 – 850, 871 – 872, 921 – 950
advances in, 690 Angio SURF system in, 842, 933
drug delivery, 690 basics of angiography in, 921 – 922
embolization, 690 blood pool agents, 944 – 946
endograft placement, 690 centric view ordering in, 925 – 927
percutaneous revascularization, 690 extracellular agents, 944
current applications for, 689 – 690 fluoroscopic triggering in, 930 – 931
current status of, 690 – 691 future directions in, 842 – 844
future of, 691 gadobenate dimeglumine, 944
implications for interventionists, 691 gadolinium. See Gadolinium.
gadolinium in, 951 – 961 gadomer-17, 946
accuracy of, 959 hyper-TRICKS algorithm in, 941 – 942
advantages of, 959 iron-based, 946
angiographic sequences in, 953 – 954 mechanisms of, 922 – 925
catheter location in, 956 moving table angiography in, 931 – 933
imaging techniques in, 955 – 956 MS-325, 946
injection parameters in, 955 non-Cartesian acquisitions in, 938
limitations of, 959 – 960 parallel acquisitions in, 935 – 937
limiting dose of, 954 – 956 partial Fourier acquisition in, 933, 935
protocol for, 953 rapid imaging in, 933
rationale for, 952 test bolus in, 928, 930
technique for, 956 – 959 timed-resolved acquisitions in, 937 – 938
postoperative, of abdominal aortic aneurysms, timing methods in, 927 – 928
814 – 815 TRICKS algorithm in, 361, 940 – 941
undersampled radial projection
Celiac artery, MR angiography of, 867
reconstruction in, 938 – 940
Central vein evaluation, interventional radiology for, vastly undersampled isotropic projection
gadolinium in, 703 – 704 reconstruction in, 942, 944
 Index / Radiol Clin N Am 40 (2002) 965–970
in MR imaging, 894 – 896
in MR venography, 901, 905
Coronary arteries, CT of, 773 – 782
electron-beam CT, 773
for calcifications, 774 – 777
future directions in, 780
radiation dose in, 774
retrospective multislice ECG gating in, 774
to characterize atherosclerotic plaques, 779 – 780
with angiography, 777 – 779
Coronary plaque, MR imaging of, 892 – 894
CT angiography
contrast agents in. See Contrast agents.
of arterial system. See Arterial system.
of cerebrovascular disease, 784 – 785, 787
of coronary arteries, 777 – 779
of extracranial carotid vascular disease. See
Extracranial carotid vascular disease.
of kidney transplant donors, 745 – 747
postoperative, of abdominal aortic aneurysms,
800, 804 – 805, 807 – 809
CT venography, of thromboembolic disease. See
Thromboembolic disease.
D
D-dimer test, for thromboembolic disease, 752
Deep venous thrombosis. See
Thromboembolic disease.
Dialysis access, interventional radiology for,
gadolinium in, 703 – 704
Direct volume rendering, in MR venography, 907
Dissection, renal artery, MR angiography of, 858
Duplex ultrasonography, postoperative, of abdominal
aortic aneurysms, 803
E in MR angiography, 836 – 840, 944
ECG gating, retrospective multislice, in CT, of
coronary arteries, 774
Electron-beam CT, of coronary arteries, 773
Embolism, superior mesenteric artery, MR
angiography of, 873 – 875
Endoleaks, abdominal aortic aneurysm surgery and,
813, 818 – 822, 824 – 826
Extracellular contrast agents, in MR
angiography, 944
Extracranial carotid vascular disease, CT and MR
angiography of, 783 – 798
967
advantages and disadvantages of, 785 – 787,
789 – 792
atheromatous disease, 793
cerebrovascular disease, 784 – 785, 787
contrast agents in, 788 – 789
nonatheromatous disease, 793, 795
versus other imaging methods, 793
Extra-slice spin-tagging perfusion-weighted imaging,
of renal arteries, 852 – 853
F
Femoral artery occlusion, interventional radiology
for, gadolinium in, 702 – 703
Fenoldopam, before angiography, 693
Ferromagnetism, in MR angiography, 813
Fibromuscular dysplasia, renal artery, MR
angiography of, 857 – 858
Fluoroscopy, MR, of renal arteries, 850
Fourier acquisitions, partial, in MR angiography,
933, 935
G
Gadobenate dimeglumine, in MR angiography, 944
Gadolinium, 693 – 710. See also Contrast agents.
adverse effects of, 694
applications for, 705 – 706
in angiography and interventional radiology, 699
of central veins and dialysis access, 703 – 704
of peripheral vascular disease, 702 – 703
of renal vascular disease, 699, 701 – 702
in aortography and visceral angiography, 704
in catheter-based MR angiography. See
Catheter-based MR angiography.
in genitourinary and biliary studies, 706
in MR imaging, 894
in MR venography, 902, 904 – 905
premedication for, 693 – 694
properties of, 694 – 697
technical issues for, 697 – 699
Gadomer-17, in MR angiography, 946
Gastrointestinal hemorrhage, MR angiography
of, 883
Genitourinary studies, gadolinium angiography
in, 706
Graft infection, abdominal aortic aneurysm surgery
and, 828
968 Index / Radiol Clin N Am 40 (2002) 965–970

Graft thrombosis, abdominal aortic aneurysm surgery of congenital venous malformations, 917 – 918
and, 826 – 828 of renal cell carcinoma, 910
Maximum intensity projection, in MR
venography, 907
H
Hemodynamics, of renal arteries, MR angiography May-Thurner syndrome, MR venography of, 915
of, 850
Mesenteric vasculature, MR angiography of,
Hemorrhage, gastrointestinal, MR angiography 867 – 886
of, 883 blood oxygen saturation in, 872
Hyper-TRICKS algorithm, in MR angiography, bolus tracking in, 872
941 – 942 celiac artery in, 867
collateral arteries in, 870
contrast agents in, 871 – 872
I for aortic dissection, 875
for arterial embolism, 873 – 875
Iliac vein compression syndrome, MR venography
for arterial thrombosis, 875
of, 915
for atherosclerotic ischemia, 875 – 878
Infection, of graft, abdominal aortic aneurysm for gastrointestinal hemorrhage, 883
surgery and, 828 for ischemia, 873
Inferior mesenteric artery, MR angiography of, 869 for nonatherosclerotic ischemia, 878
for nonocclusive ischemia, 875
Inferior vena cava anomalies, MR venography for pancreatic cancer resectability, 881
of, 913 for portomesenteric venous system, 879 – 881
Inferior vena cava syndrome, MR venography of, for venous thrombosis, 875
911 – 912 in liver transplant recipients, 883
in living related liver transplant donors,
Interventional radiology 881 – 883
for atherosclerotic disease, 894 inferior mesenteric artery in, 869
gadolinium in. See Gadolinium. phase contrast in, 871
Iron-based contrast agents, in MR angiography, 946 post-processing imaging in, 872 – 873
superior mesenteric artery in, 867 – 869
time-of-flight imaging in, 871
K venous anatomy in, 871
Kidney transplant donors Motion artifacts, on CT, of thromboembolic
CT angiography of, 745 – 747 disease, 762
MR angiography of, 858 – 859
MR angiography
Kidney transplant recipients
catheter-based. See Catheter-based
interventional radiology for, gadolinium in,
MR angiography.
701 – 702
contrast agents in. See Contrast agents.
stenosis in, MR angiography of, 859 – 861
of extracranial carotid vascular disease. See
Extracranial carotid vascular disease.
of kidney transplant donors, 858 – 859
L
of mesenteric vasculature. See
Liver transplant donors, MR angiography of, Mesenteric vasculature.
881 – 883 of peripheral vascular disease. See Peripheral
Liver transplant recipients, MR angiography of, 883 vascular disease.
of renal arteries. See Renal arteries.
postoperative, of abdominal aortic aneurysms,
M 809 – 811, 813 – 814
Magnetic resonance imaging MR fluoroscopy, of renal arteries, 850
of atherosclerotic disease. See
Atherosclerotic disease. MR portography, of mesenteric vasculature, 879 – 881
 Index / Radiol Clin N Am 40 (2002) 965–970 969

MR venography, 899 – 919 Phase contrast MR venography, technique for,

contrast agents in, 901, 905 900 – 901
and appearance of thrombosed veins, 902,
Plain films
904 – 905
of pulmonary embolism, 751 – 752
direct thrombus imaging in, 902
postoperative, of abdominal aortic aneurysms,
direct volume rendering in, 907
801 – 802
image reconstruction in, 906 – 907
in venous mapping, 912 Portography, MR, of mesenteric vasculature,
maximum intensity projection in, 907 879 – 881
multiplanar reconstruction in, 907 PR-TRICKS algorithm, in MR angiography,
of central vein anomalies, 913, 915 – 917 940 – 941
of central vein occlusion, 911 – 913
of congenital venous malformations, 917 – 918 Pulmonary embolism. See Thromboembolic disease.
of deep vein thrombosis, 907 – 908 Pulmonary venous anomalies, MR venography of,
of ovarian vein thrombosis, 911 915 – 917
of renal vein thrombosis, 908 – 911
of thromboembolic disease, 752 R
phase contrast in, 900 – 901
Renal arteries
time-of-flight in, 899 – 900
CT angiography of, 745 – 747
MS-325, in MR angiography, 946 MR angiography of, 847 – 865
contrast administration and bolus timing in,
Multiplanar reconstruction, in MR venography, 907
849 – 850
extra-slice spin-tagging perfusion weighting in,
N 852 – 853
Nonatheromatous disease, CT and MR angiography flow measurements in, 851 – 852
of, 793, 795 for aneurysms, 858
for atherosclerotic disease, 853 – 855, 857
O for dissection, 858
Ovarian vein thrombosis, MR venography of, 911 for fibromuscular dysplasia, 857 – 858
for stenosis, 853
in transplant recipients, 859 – 861
P
hardware in, 848
Pancreatic cancer, resectability of, MR angiography hemodynamic significance in, 850
of, 881 image analysis in, 850
Parallel acquisitions, in MR angiography, 935 – 937 in transplant donors, 858 – 859
normal findings and anatomic variants in, 853
Paramagnetic contrast agents pulse sequence in, 848 – 849
in MR angiography, 836 – 837 renal anatomy in, 853
in MR imaging, 895 techniques for, 848 – 853
Peripheral vascular disease three-dimensional contrast enhancement
CT angiography of, 744 – 745 in, 848
interventional radiology for, gadolinium in, three-dimensional phase contrast in, 850 – 851
702 – 703 Renal cell carcinoma
MR angiography of, 835 – 846 MR imaging of, 910
contrast agents in, 836 – 840 MR venography of, 909 – 911
future directions in, 840 – 844
new contrast agents, 842 – 844 Renal vascular disease, interventional radiology for,
sensitivity encoding data-collection gadolinium in, 699, 701 – 702
strategies, 840, 936 – 937 Renal vein thrombosis, MR venography of, 908 – 911
whole-body imaging, 841 – 842
noncontrast, 836 S
Phase contrast MR angiography, of mesenteric Sensitivity encoding data-collection strategies, in MR
vasculature, 871 angiography, 840, 936 – 937
970 Index / Radiol Clin N Am 40 (2002) 965–970

Septic puerperal ovarian vein thrombosis, MR Thrombosis

venography of, 911 graft, abdominal aortic aneurysm surgery and,
826 – 828
Spinal arteriovenous malformations,
mesenteric artery, MR angiography of, 875
three-dimensional angiography of, 726
mesenteric vein, MR angiography of, 875
Stenosis, renal artery, MR angiography of, 853
Time-of-flight MR angiography, of mesenteric
in transplant recipients, 859 – 861
vasculature, 871
Stent-grafts, for abdominal aortic aneurysms,
Time-of-flight MR venography, technique for,
postoperative imaging of, 811 – 813, 815 – 818
899 – 900
Streak artifacts, on CT, of thromboembolic
Transesophageal MR imaging, of atherosclerotic
disease, 762
disease, 894
Superior mesenteric artery, MR angiography of,
Transjugular intrahepatic portosystemic shunts,
867 – 869, 873 – 875
gadolinium angiography in, 706
Superior vena cava syndrome, MR venography of,
Trauma, to aorta, CT angiography of, 742, 744
911 – 912
TRICKS algorithm, in MR angiography, 841,
Superparamagnetic iron oxides
937 – 938
in MR imaging, 895 – 896
in MR venography, 905
U
T Ultrasonography
Three-dimensional angiography, 711 – 727 of deep venous thrombosis, 752
applications for, 722, 724, 726 – 727 postoperative, of abdominal aortic aneurysms,
future directions in, 727 802 – 803
historical aspects of, 711
Upper extremity occlusion, interventional radiology
techniques for, 711, 713, 715 – 722
for, gadolinium in, 703
Three-dimensional multiple overlapping thin-slab
Ureteropelvic junction obstruction, CT angiography
angiography, of carotid plaque, 891 – 892
of, 745 – 747
Three-dimensional phase contrast MR angiography,
of renal arteries, 850 – 851
V
Thromboembolic disease
Vascular disease, CT of, 690 – 691
CT of
algorithm for, 754 Vascular opacification, CT angiography of, 744 – 745
findings on, 759 – 768 Venography
acute pulmonary embolism, 759 – 760 contrast, of deep venous thrombosis, 752
artifacts and pitfalls, 760 – 763 CT, of thromboembolic disease. See
chronic pulmonary embolism, 764 – 766 Thromboembolic disease.
deep venous thrombosis, 766 – 768 MR. See MR venography.
historical aspects of, 753
sensitivity and specificity of, 753 – 754 Venous mapping, MR venography in, 912
technique for, 754 – 756 Ventilation-perfusion imaging, of pulmonary
contrast agents, 756 embolism, 752
scanning parameters, 754 – 755
timing of imaging, 756 Visceral angiography, gadolinium in, 704
versus other imaging methods, 751 – 754
CT venography of, 756 – 759 W
image viewing in, 758
WakiTRAK technique, in MR angiography, 937
post-processing technique for, 758 – 759
technique for, 756 – 757 Whole-body MR angiography, technique for,
MR venography of, 902, 904 – 905, 907 – 908 841 – 842