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From the RSNA Refresher Courses

MR Imaging of Aortic and Peripheral Vascular Disease¹

¹ From the Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115 (S.T., M.J.L., B.D.D., R.B.S., E.K.Y.); and the Department of Radiology, Beth Israel Deaconess Hospital, Harvard Medical School, Boston (M.J.L.). Presented as a refresher course at the 2002 RSNA scientific assembly. Received March 6, 2003; revision requested May 7 and received June 17; accepted July 11. Address correspondence to S.T. (e-mail: statli@partners.org).

View larger version (137K): [in a new window]   Figure 1.  Black-blood imaging of the aorta. Axial image shows the ascending (black arrowhead) and descending (white arrowhead) aorta at the level of the right pulmonary artery (RPA). Note the excellent suppression of the luminal blood signal and demonstration of the vessel wall. The image was obtained in 13 seconds with cardiac gating and breath holding.

View larger version (96K): [in a new window]   Figure 2a.  Phase-contrast imaging of the aorta. Magnitude (a) and phase (b) axial images show the ascending (white arrowhead) and descending (black arrowhead) aorta at the level of the main pulmonary artery (MPA in a). Flow encoding was superior to inferior. On the phase image (b), the ascending aorta and main pulmonary artery appear black and the descending aorta appears white due to the opposite directions of flow in these arteries.

View larger version (170K): [in a new window]   Figure 2b.  Phase-contrast imaging of the aorta. Magnitude (a) and phase (b) axial images show the ascending (white arrowhead) and descending (black arrowhead) aorta at the level of the main pulmonary artery (MPA in a). Flow encoding was superior to inferior. On the phase image (b), the ascending aorta and main pulmonary artery appear black and the descending aorta appears white due to the opposite directions of flow in these arteries.

View larger version (110K): [in a new window]   Figure 3a.  TOF MR angiography of the right calf. Axial source (a) and coronal maximum intensity projection (MIP) (b) images show pulsation artifacts (arrows) along the phase-encoding direction.

View larger version (84K): [in a new window]   Figure 3b.  TOF MR angiography of the right calf. Axial source (a) and coronal maximum intensity projection (MIP) (b) images show pulsation artifacts (arrows) along the phase-encoding direction.

View larger version (119K): [in a new window]   Figure 4a.  Contrast-enhanced MR angiography of the aorta. Source (a), subtracted (b), and MIP (c) coronal images show the aortic arch. The subtracted image (b) was obtained by subtracting the mask image from the source image (a) and demonstrates better suppression of the background signal from the body in comparison with the source image. On the MIP image (c), note the significant focal stenosis of the left subclavian artery (arrowhead). Also note the focal signal loss in the midportion of the left subclavian artery (arrows in c), which was due to concentrated gadolinium contrast material in the adjacent vein.

View larger version (135K): [in a new window]   Figure 4b.  Contrast-enhanced MR angiography of the aorta. Source (a), subtracted (b), and MIP (c) coronal images show the aortic arch. The subtracted image (b) was obtained by subtracting the mask image from the source image (a) and demonstrates better suppression of the background signal from the body in comparison with the source image. On the MIP image (c), note the significant focal stenosis of the left subclavian artery (arrowhead). Also note the focal signal loss in the midportion of the left subclavian artery (arrows in c), which was due to concentrated gadolinium contrast material in the adjacent vein.

View larger version (104K): [in a new window]   Figure 4c.  Contrast-enhanced MR angiography of the aorta. Source (a), subtracted (b), and MIP (c) coronal images show the aortic arch. The subtracted image (b) was obtained by subtracting the mask image from the source image (a) and demonstrates better suppression of the background signal from the body in comparison with the source image. On the MIP image (c), note the significant focal stenosis of the left subclavian artery (arrowhead). Also note the focal signal loss in the midportion of the left subclavian artery (arrows in c), which was due to concentrated gadolinium contrast material in the adjacent vein.

View larger version (121K): [in a new window]   Figure 5a.  Contrast-enhanced MR angiography of the lower extremity performed with the hybrid method. Imaging of the calf was performed first with 20 mL of gadolinium contrast material, and MIP images of each side were produced separately to prevent superimposition on the lateral projections. After the calf study, imaging of the pelvis and thigh was performed with 40 mL of gadolinium contrast material and the moving-table technique (from the pelvis to the thigh). Coronal MIP images show the arteries of the pelvis (a), thigh (b), right calf (c), and left calf (d). Note the short segmental occlusion of the right superficial femoral artery with reconstitution (arrows in b) and the high origin of the right posterior tibial artery (arrowhead in c).

View larger version (116K): [in a new window]   Figure 5b.  Contrast-enhanced MR angiography of the lower extremity performed with the hybrid method. Imaging of the calf was performed first with 20 mL of gadolinium contrast material, and MIP images of each side were produced separately to prevent superimposition on the lateral projections. After the calf study, imaging of the pelvis and thigh was performed with 40 mL of gadolinium contrast material and the moving-table technique (from the pelvis to the thigh). Coronal MIP images show the arteries of the pelvis (a), thigh (b), right calf (c), and left calf (d). Note the short segmental occlusion of the right superficial femoral artery with reconstitution (arrows in b) and the high origin of the right posterior tibial artery (arrowhead in c).

View larger version (40K): [in a new window]   Figure 5c.  Contrast-enhanced MR angiography of the lower extremity performed with the hybrid method. Imaging of the calf was performed first with 20 mL of gadolinium contrast material, and MIP images of each side were produced separately to prevent superimposition on the lateral projections. After the calf study, imaging of the pelvis and thigh was performed with 40 mL of gadolinium contrast material and the moving-table technique (from the pelvis to the thigh). Coronal MIP images show the arteries of the pelvis (a), thigh (b), right calf (c), and left calf (d). Note the short segmental occlusion of the right superficial femoral artery with reconstitution (arrows in b) and the high origin of the right posterior tibial artery (arrowhead in c).

View larger version (34K): [in a new window]   Figure 5d.  Contrast-enhanced MR angiography of the lower extremity performed with the hybrid method. Imaging of the calf was performed first with 20 mL of gadolinium contrast material, and MIP images of each side were produced separately to prevent superimposition on the lateral projections. After the calf study, imaging of the pelvis and thigh was performed with 40 mL of gadolinium contrast material and the moving-table technique (from the pelvis to the thigh). Coronal MIP images show the arteries of the pelvis (a), thigh (b), right calf (c), and left calf (d). Note the short segmental occlusion of the right superficial femoral artery with reconstitution (arrows in b) and the high origin of the right posterior tibial artery (arrowhead in c).

View larger version (173K): [in a new window]   Figure 6a.  Ascending aortic aneurysm in a 34-year-old man. (a) Sagittal oblique contrast-enhanced MR angiogram shows marked dilatation of the aortic root (arrow) and the proximal portion of the ascending aorta. This type of aneurysm is typical of Marfan syndrome, but the patient did not have other features of that disease. (b) Axial oblique steady-state free precession cine image of the left ventricular outflow tract shows a markedly dilated aortic root (large arrow) with regurgitant flow (small arrow).

View larger version (147K): [in a new window]   Figure 6b.  Ascending aortic aneurysm in a 34-year-old man. (a) Sagittal oblique contrast-enhanced MR angiogram shows marked dilatation of the aortic root (arrow) and the proximal portion of the ascending aorta. This type of aneurysm is typical of Marfan syndrome, but the patient did not have other features of that disease. (b) Axial oblique steady-state free precession cine image of the left ventricular outflow tract shows a markedly dilated aortic root (large arrow) with regurgitant flow (small arrow).

View larger version (146K): [in a new window]   Figure 7.  Saccular atherosclerotic aneurysm in a 75-year-old man. Sagittal oblique MIP image from contrast-enhanced MR angiography shows a saccular aneurysm of the aortic arch (arrow).

View larger version (144K): [in a new window]   Figure 8a.  Stanford type A aortic dissection in a 60-year-old man. (a) Axial T1-weighted black-blood image shows nearly circumferential compression of the true aortic lumen by a false lumen (arrow). High signal intensity in the false lumen makes it difficult to differentiate thrombosis from flowing blood. (b) Axial reformatted image from contrast-enhanced MR angiography shows an intimal flap (black arrow) with flow in the false lumen (white arrow).

View larger version (64K): [in a new window]   Figure 8b.  Stanford type A aortic dissection in a 60-year-old man. (a) Axial T1-weighted black-blood image shows nearly circumferential compression of the true aortic lumen by a false lumen (arrow). High signal intensity in the false lumen makes it difficult to differentiate thrombosis from flowing blood. (b) Axial reformatted image from contrast-enhanced MR angiography shows an intimal flap (black arrow) with flow in the false lumen (white arrow).

View larger version (154K): [in a new window]   Figure 9.  Intramural hematoma in an 87-year-old man with chest pain. Axial T1-weighted black-blood image shows eccentric circumferential thickening of the wall of the descending aorta with increased signal intensity (arrow), findings consistent with intramural hematoma.

View larger version (164K): [in a new window]   Figure 10.  Penetrating atherosclerotic ulcer in a 61-year-old man with high blood pressure. Sagittal oblique contrast-enhanced MR angiogram shows a diffusely aneurysmal descending aorta with a large outpouching in the medial anterior region (arrow), an appearance consistent with penetrating atherosclerotic ulcer. Prior studies showed development of a focal aneurysm 2 years earlier.

View larger version (157K): [in a new window]   Figure 11.  Takayasu arteritis in a 41-year-old woman. Coronal MIP image from contrast-enhanced MR angiography shows occlusive disease involving the major arteries of the aortic arch. The left subclavian artery is occluded just beyond its origin (large white arrow). The left vertebral artery originates from the aortic arch and is stenotic at its origin (small white arrow). The right common carotid artery has a long stenotic segment (small black arrows). The left common carotid artery is stenotic in its proximal segment (large black arrow).

View larger version (165K): [in a new window]   Figure 12.  Aortic wall thickening in a 67-year-old man with clinically suspected vasculitis. Axial gadolinium-enhanced T1-weighted black-blood image obtained with fat suppression shows significant enhancement of the wall of the aorta at the level of the aortic arch (arrows). Contrast-enhanced MR angiography showed occlusive disease of the distal right subclavian artery.

View larger version (121K): [in a new window]   Figure 13.  Severe atherosclerotic disease of the aorta in a 60-year-old man. Coronal MIP image from contrast-enhanced MR angiography shows an occluded infrarenal aorta with marked atherosclerotic contour irregularities (large arrows). Note the high-grade focal stenosis of the right renal artery (small arrows).

View larger version (179K): [in a new window]   Figure 14.  Fibromuscular dysplasia in a 61-year-old woman with high blood pressure. Coronal MIP image from contrast-enhanced MR angiography shows that the right renal artery has a string-of-beads appearance (arrows), which is typical of fibromuscular dysplasia. The diagnosis was confirmed with conventional angiography and pressure measurements. The patient was treated with angioplasty.

View larger version (173K): [in a new window]   Figure 15.  Renal artery aneurysm in a 38-year-old woman with hypertension who was previously treated for an aneurysm of the right renal artery. Coronal contrast-enhanced MR angiogram shows a saccular aneurysm of the left renal artery (arrows).

View larger version (175K): [in a new window]   Figure 16a.  Dissection of the SMA in a 50-year-old man with acute onset of abdominal pain during weight lifting. (a) Coronal contrast-enhanced MR angiogram shows an intimal flap in the proximal segment of the SMA (arrow). (b) Sagittal MIP image shows a dilated SMA (white arrows). The intimal flap is not well seen; however, occlusion of the SMA after the origin of the ileocolic branch is clearly demonstrated (black arrow).

View larger version (148K): [in a new window]   Figure 16b.  Dissection of the SMA in a 50-year-old man with acute onset of abdominal pain during weight lifting. (a) Coronal contrast-enhanced MR angiogram shows an intimal flap in the proximal segment of the SMA (arrow). (b) Sagittal MIP image shows a dilated SMA (white arrows). The intimal flap is not well seen; however, occlusion of the SMA after the origin of the ileocolic branch is clearly demonstrated (black arrow).

View larger version (105K): [in a new window]   Figure 17.  Atherosclerotic disease of the iliac arteries in a 66-year-old woman with left-sided claudication. Coronal MIP image from contrast-enhanced MR angiography of the first station runoff shows mild atherosclerotic disease of the distal aorta with aneurysmal dilatation (large arrow). The right common iliac artery is moderately narrowed with a weblike stenosis at the iliac bifurcation (arrowheads). The left common iliac artery is severely stenosed at its origin (small arrow).

View larger version (136K): [in a new window]   Figure 18a.  Reconstitution of the calf arteries in a 55-year-old woman with left-sided claudication. (a) Coronal MIP image from contrast-enhanced MR angiography performed with dedicated calf injection shows focal occlusion of the left popliteal artery just above the trifurcation (large arrow) with reconstitution of the calf arteries. Note the collateral vessel feeding the anterior tibial artery (small arrows). (b) Sagittal MIP image from high-resolution TOF angiography shows a patent posterior tibial artery feeding the plantar arteries (large arrows). The patent anterior tibial artery continues as the dorsalis pedis artery (small arrows).

View larger version (134K): [in a new window]   Figure 18b.  Reconstitution of the calf arteries in a 55-year-old woman with left-sided claudication. (a) Coronal MIP image from contrast-enhanced MR angiography performed with dedicated calf injection shows focal occlusion of the left popliteal artery just above the trifurcation (large arrow) with reconstitution of the calf arteries. Note the collateral vessel feeding the anterior tibial artery (small arrows). (b) Sagittal MIP image from high-resolution TOF angiography shows a patent posterior tibial artery feeding the plantar arteries (large arrows). The patent anterior tibial artery continues as the dorsalis pedis artery (small arrows).

View larger version (149K): [in a new window]   Figure 19a.  Peripheral arterial disease in a 65-year-old man with ischemic symptoms in the left leg. (a) Coronal MIP image from contrast-enhanced MR angiography of the thigh station shows diffuse disease of both superficial femoral arteries with a totally occluded left popliteal artery (arrow). (b) Coronal image from contrast-enhanced MR angiography performed with dedicated calf injection shows the occluded popliteal artery (large arrow) with a reconstituted posterior tibial artery (small arrows) and significantly diseased peroneal and anterior tibial arteries. (c) Coronal MIP image from TOF imaging of the same calf shows that the distal posterior tibial artery is widely patent (large arrows) and the anterior tibial artery is diminutive (small arrows). (d) Coronal TOF image of the left foot shows a patent plantar arch (small arrows) supplied by the posterior tibial artery (large arrow). The dorsalis pedis artery is absent.

View larger version (90K): [in a new window]   Figure 19b.  Peripheral arterial disease in a 65-year-old man with ischemic symptoms in the left leg. (a) Coronal MIP image from contrast-enhanced MR angiography of the thigh station shows diffuse disease of both superficial femoral arteries with a totally occluded left popliteal artery (arrow). (b) Coronal image from contrast-enhanced MR angiography performed with dedicated calf injection shows the occluded popliteal artery (large arrow) with a reconstituted posterior tibial artery (small arrows) and significantly diseased peroneal and anterior tibial arteries. (c) Coronal MIP image from TOF imaging of the same calf shows that the distal posterior tibial artery is widely patent (large arrows) and the anterior tibial artery is diminutive (small arrows). (d) Coronal TOF image of the left foot shows a patent plantar arch (small arrows) supplied by the posterior tibial artery (large arrow). The dorsalis pedis artery is absent.

View larger version (82K): [in a new window]   Figure 19c.  Peripheral arterial disease in a 65-year-old man with ischemic symptoms in the left leg. (a) Coronal MIP image from contrast-enhanced MR angiography of the thigh station shows diffuse disease of both superficial femoral arteries with a totally occluded left popliteal artery (arrow). (b) Coronal image from contrast-enhanced MR angiography performed with dedicated calf injection shows the occluded popliteal artery (large arrow) with a reconstituted posterior tibial artery (small arrows) and significantly diseased peroneal and anterior tibial arteries. (c) Coronal MIP image from TOF imaging of the same calf shows that the distal posterior tibial artery is widely patent (large arrows) and the anterior tibial artery is diminutive (small arrows). (d) Coronal TOF image of the left foot shows a patent plantar arch (small arrows) supplied by the posterior tibial artery (large arrow). The dorsalis pedis artery is absent.

View larger version (94K): [in a new window]   Figure 19d.  Peripheral arterial disease in a 65-year-old man with ischemic symptoms in the left leg. (a) Coronal MIP image from contrast-enhanced MR angiography of the thigh station shows diffuse disease of both superficial femoral arteries with a totally occluded left popliteal artery (arrow). (b) Coronal image from contrast-enhanced MR angiography performed with dedicated calf injection shows the occluded popliteal artery (large arrow) with a reconstituted posterior tibial artery (small arrows) and significantly diseased peroneal and anterior tibial arteries. (c) Coronal MIP image from TOF imaging of the same calf shows that the distal posterior tibial artery is widely patent (large arrows) and the anterior tibial artery is diminutive (small arrows). (d) Coronal TOF image of the left foot shows a patent plantar arch (small arrows) supplied by the posterior tibial artery (large arrow). The dorsalis pedis artery is absent.

View larger version (134K): [in a new window]   Figure 20.  Pseudoaneurysm after aortobifemoral bypass in a 75-year-old man. Coronal MIP image shows a patent aortobifemoral bypass graft (small arrows) with a contrast material-filled outpouching in the region of the left femoral artery (large arrow), a finding consistent with a postsurgical pseudoaneurysm. The left renal artery is absent due to prior nephrectomy.

View larger version (172K): [in a new window]   Figure 21a.  Lower-extremity aneurysms in a 60-year-old man with deep vein thrombosis. (a, b) Coronal MIP images from contrast-enhanced MR angiography of the aortoiliac (a) and thigh (b) stations show aneurysms of both common iliac arteries (arrows in a), the left common femoral artery, and both popliteal arteries (arrows in b). (c) Coronal contrast-enhanced MR angiogram of the thigh shows disappearance of the aneurysms after treatment with bilateral bypass grafts. Note the clip artifacts in the grafts (arrows).

View larger version (125K): [in a new window]   Figure 21b.  Lower-extremity aneurysms in a 60-year-old man with deep vein thrombosis. (a, b) Coronal MIP images from contrast-enhanced MR angiography of the aortoiliac (a) and thigh (b) stations show aneurysms of both common iliac arteries (arrows in a), the left common femoral artery, and both popliteal arteries (arrows in b). (c) Coronal contrast-enhanced MR angiogram of the thigh shows disappearance of the aneurysms after treatment with bilateral bypass grafts. Note the clip artifacts in the grafts (arrows).

View larger version (163K): [in a new window]   Figure 21c.  Lower-extremity aneurysms in a 60-year-old man with deep vein thrombosis. (a, b) Coronal MIP images from contrast-enhanced MR angiography of the aortoiliac (a) and thigh (b) stations show aneurysms of both common iliac arteries (arrows in a), the left common femoral artery, and both popliteal arteries (arrows in b). (c) Coronal contrast-enhanced MR angiogram of the thigh shows disappearance of the aneurysms after treatment with bilateral bypass grafts. Note the clip artifacts in the grafts (arrows).

View larger version (73K): [in a new window]   Figure 22.  Graft stenosis in a 75-year-old man with diabetes and peripheral vascular disease. He presented with gangrenous changes in the left toes after placement of a bypass graft. Coronal contrast-enhanced MR angiogram obtained with calf injection shows significant stenosis at the origin of a popliteal-to-distal artery bypass graft (arrow). The distal portion of the graft is widely patent.

View larger version (105K): [in a new window]   Figure 23.  Contrast-enhanced MR angiography of the foot in a 33-year-old man with numbness and coldness of the left foot. Sagittal contrast-enhanced MR angiogram obtained with foot injection shows the main arterial anatomy of the foot. The anterior tibial artery feeds the dorsalis pedis artery (large arrow), which constitutes the plantar arch (small arrows) along with the lateral plantar artery from the posterior tibial artery (medium-sized arrow).