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Dynamic MR Angiography of Upper Extremity Vascular Disease: Pictorial Review¹

¹ From the Department of Radiology, 560 First Avenue, TCH-HW-202, New York University Medical Center, New York, NY 10016 (F.S., E.M.H., R.R., B.T., M.K., V.S.L.), and Huntingdon Valley Orthopedics, Meadowbrook, Pa (L.E.H.). Presented as an education exhibit at the 2006 RSNA Annual Meeting. Received July 16, 2007; revision requested September 12; revision received and accepted September 27.

View larger version (42K): [in this window] [in a new window] [Download PPT slide]   Figure 1.  Common upper extremity arterial anatomy: The ulnar artery supplies the superficial palmar arch, the major source of blood flow to the digits. The radial artery supplies the deep palmar arch, which in turn supplies the dorsal arches of the hand. (Reprinted with permission from reference 13.)

 

View larger version (68K): [in this window] [in a new window] [Download PPT slide]   Figure 2.  Upper extremity venous drainage. Superficial system: The cephalic vein ascends the anterolateral forearm and courses in the deltopectoral groove to drain into the axillary vein. The basilic vein ascends the medial forearm, pierces the deep fascia, and joins the brachial vein to form the axillary vein. Deep system: This is composed of the venae comitantes, or veins that accompany corresponding arteries. (Reprinted with permission of Wesley Norman, PhD, from The Anatomy Lesson.)

 

View larger version (107K): [in this window] [in a new window] [Download PPT slide]   Figure 3.  The superficial palmar arch is formed mainly by the ulnar artery and is completed by the superficial branch of the radial artery. A complete arch is not always present. The superficial palmar arch provides the arterial supply to the digits via the digital palmar arteries. (Reprinted with permission of Wesley Norman, PhD, from The Anatomy Lesson.)

 

View larger version (104K): [in this window] [in a new window] [Download PPT slide]   Figure 4.  The deep palmar arch is supplied by the radial artery as it passes under the "snuff box" tendons and gives rise to the princeps pollicis and deep palmar arch. The deep palmar arch is more often complete than the superficial palmar arch. (Reprinted with permission of Wesley Norman, PhD, from The Anatomy Lesson.)

 

View larger version (95K): [in this window] [in a new window] [Download PPT slide]   Figure 5a.  Subclavian steal syndrome. (a) TOF sequence with a saturation band above the section demonstrates absence of signal in the left vertebral artery (arrow). (b) TOF sequence with a saturation band below the section demonstrates signal corresponding to retrograde flow in the left vertebral artery (arrow). (c) Coronal maximum intensity projection (MIP) image from contrast-enhanced MR angiographic study demonstrates occlusion of the proximal subclavian artery (arrow), with reconstitution distal to the origin of a patent left vertebral artery.

 

View larger version (74K): [in this window] [in a new window] [Download PPT slide]   Figure 5b.  Subclavian steal syndrome. (a) TOF sequence with a saturation band above the section demonstrates absence of signal in the left vertebral artery (arrow). (b) TOF sequence with a saturation band below the section demonstrates signal corresponding to retrograde flow in the left vertebral artery (arrow). (c) Coronal maximum intensity projection (MIP) image from contrast-enhanced MR angiographic study demonstrates occlusion of the proximal subclavian artery (arrow), with reconstitution distal to the origin of a patent left vertebral artery.

 

View larger version (90K): [in this window] [in a new window] [Download PPT slide]   Figure 5c.  Subclavian steal syndrome. (a) TOF sequence with a saturation band above the section demonstrates absence of signal in the left vertebral artery (arrow). (b) TOF sequence with a saturation band below the section demonstrates signal corresponding to retrograde flow in the left vertebral artery (arrow). (c) Coronal maximum intensity projection (MIP) image from contrast-enhanced MR angiographic study demonstrates occlusion of the proximal subclavian artery (arrow), with reconstitution distal to the origin of a patent left vertebral artery.

 

View larger version (77K): [in this window] [in a new window] [Download PPT slide]   Figure 6a.  Takayasu arteritis. (a) Coronal MIP image from contrast-enhanced MR angiographic study reveals a normal aortic arch, brachiocephalic trunk, and left common carotid artery, with bilateral long-segment subclavian and axillary artery stenoses. (b) Magnified image of the right subclavian artery again demonstrates high-grade stenoses and occlusions (arrows), with collateral reconstitution of the axillary artery. Note that patient was injected with contrast agent on the right, accounting for mild venous opacification. (c) Coronal-oblique MIP image of the aortic arch and left subclavian artery proximal to the vertebral artery origin demonstrates mild and moderate stenoses (arrow), but the more distal subclavian and axillary arteries demonstrate severe long-segment stenoses.

 

View larger version (140K): [in this window] [in a new window] [Download PPT slide]   Figure 6b.  Takayasu arteritis. (a) Coronal MIP image from contrast-enhanced MR angiographic study reveals a normal aortic arch, brachiocephalic trunk, and left common carotid artery, with bilateral long-segment subclavian and axillary artery stenoses. (b) Magnified image of the right subclavian artery again demonstrates high-grade stenoses and occlusions (arrows), with collateral reconstitution of the axillary artery. Note that patient was injected with contrast agent on the right, accounting for mild venous opacification. (c) Coronal-oblique MIP image of the aortic arch and left subclavian artery proximal to the vertebral artery origin demonstrates mild and moderate stenoses (arrow), but the more distal subclavian and axillary arteries demonstrate severe long-segment stenoses.

 

View larger version (117K): [in this window] [in a new window] [Download PPT slide]   Figure 6c.  Takayasu arteritis. (a) Coronal MIP image from contrast-enhanced MR angiographic study reveals a normal aortic arch, brachiocephalic trunk, and left common carotid artery, with bilateral long-segment subclavian and axillary artery stenoses. (b) Magnified image of the right subclavian artery again demonstrates high-grade stenoses and occlusions (arrows), with collateral reconstitution of the axillary artery. Note that patient was injected with contrast agent on the right, accounting for mild venous opacification. (c) Coronal-oblique MIP image of the aortic arch and left subclavian artery proximal to the vertebral artery origin demonstrates mild and moderate stenoses (arrow), but the more distal subclavian and axillary arteries demonstrate severe long-segment stenoses.

 

View larger version (99K): [in this window] [in a new window] [Download PPT slide]   Figure 7.  Giant cell arteritis. Coronal MIP image from a contrast-enhanced MR angiographic study demonstrates multifocal beading, with alternating segments of stenosis and normal luminal caliber (arrows) involving the entire length of the subclavian artery bilaterally.

 

View larger version (70K): [in this window] [in a new window] [Download PPT slide]   Figure 8a.  Thoracic outlet syndrome (venous subtype). (a) Coronal MIP images from a contrast-enhanced MR angiographic study performed with arms up positioning demonstrate normal-caliber patent subclavian arteries bilaterally in the arterial phase image on the left and stenosis of the distal right subclavian vein (arrow) in the venous phase image on the right. (b) Axial MIP image from contrast-enhanced MR angiographic study performed with arms up positioning again demonstrate a severe distal right subclavian vein stenosis (arrow). (c) Coronal MIP image from the same study performed with patient’s arms in neutral position shows that the right subclavian vein has returned to normal caliber (arrow), demonstrating the dynamic changes at the thoracic outlet that can elicit clinical symptoms and different imaging findings.

 

View larger version (76K): [in this window] [in a new window] [Download PPT slide]   Figure 8b.  Thoracic outlet syndrome (venous subtype). (a) Coronal MIP images from a contrast-enhanced MR angiographic study performed with arms up positioning demonstrate normal-caliber patent subclavian arteries bilaterally in the arterial phase image on the left and stenosis of the distal right subclavian vein (arrow) in the venous phase image on the right. (b) Axial MIP image from contrast-enhanced MR angiographic study performed with arms up positioning again demonstrate a severe distal right subclavian vein stenosis (arrow). (c) Coronal MIP image from the same study performed with patient’s arms in neutral position shows that the right subclavian vein has returned to normal caliber (arrow), demonstrating the dynamic changes at the thoracic outlet that can elicit clinical symptoms and different imaging findings.

 

View larger version (110K): [in this window] [in a new window] [Download PPT slide]   Figure 8c.  Thoracic outlet syndrome (venous subtype). (a) Coronal MIP images from a contrast-enhanced MR angiographic study performed with arms up positioning demonstrate normal-caliber patent subclavian arteries bilaterally in the arterial phase image on the left and stenosis of the distal right subclavian vein (arrow) in the venous phase image on the right. (b) Axial MIP image from contrast-enhanced MR angiographic study performed with arms up positioning again demonstrate a severe distal right subclavian vein stenosis (arrow). (c) Coronal MIP image from the same study performed with patient’s arms in neutral position shows that the right subclavian vein has returned to normal caliber (arrow), demonstrating the dynamic changes at the thoracic outlet that can elicit clinical symptoms and different imaging findings.

 

View larger version (72K): [in this window] [in a new window] [Download PPT slide]   Figure 9.  Thoracic outlet syndrome (arterial subtype). Coronal MIP images from a 3D T1-weighted spoiled gradient-echo MR angiographic sequence. In the left image, during the arterial phase of enhancement with the patient’s arms elevated, severe stenosis of the right subclavian artery (arrow) and mild stenosis of the left subclavian artery (arrowhead) are seen. In the right image, the stenoses resolve after the patient’s arms are placed in the neutral position.

 

View larger version (91K): [in this window] [in a new window] [Download PPT slide]   Figure 10a.  Paget-Schroetter syndrome in young weightlifter. (a) Coronal postcontrast 3D T1-weighted fat-suppressed spoiled gradient-echo images with dynamic positioning (arm up in left image and down in right image) demonstrate a long segment of occlusive venous thrombus extending from the basilic vein into the right subclavian vein (arrowheads), with wall enhancement. (b) Axial postcontrast 3D T1-weighted fat-suppressed spoiled gradient-echo image again demonstrates that the right axillary and subclavian veins are completely occluded and distended with thrombus. (c) Sagittal unenhanced T1-weighted turbo spin-echo image supplements the angiographic images and demonstrates the severely compressed subclavian vein (solid arrow) in the costoclavicular space, interposed between the clavicle (black arrowhead) and the anterior scalene muscle (white arrowhead). The subclavian artery (open arrow) is seen as a flow void posterior to the anterior scalene muscle.

 

View larger version (83K): [in this window] [in a new window] [Download PPT slide]   Figure 10b.  Paget-Schroetter syndrome in young weightlifter. (a) Coronal postcontrast 3D T1-weighted fat-suppressed spoiled gradient-echo images with dynamic positioning (arm up in left image and down in right image) demonstrate a long segment of occlusive venous thrombus extending from the basilic vein into the right subclavian vein (arrowheads), with wall enhancement. (b) Axial postcontrast 3D T1-weighted fat-suppressed spoiled gradient-echo image again demonstrates that the right axillary and subclavian veins are completely occluded and distended with thrombus. (c) Sagittal unenhanced T1-weighted turbo spin-echo image supplements the angiographic images and demonstrates the severely compressed subclavian vein (solid arrow) in the costoclavicular space, interposed between the clavicle (black arrowhead) and the anterior scalene muscle (white arrowhead). The subclavian artery (open arrow) is seen as a flow void posterior to the anterior scalene muscle.

 

View larger version (99K): [in this window] [in a new window] [Download PPT slide]   Figure 10c.  Paget-Schroetter syndrome in young weightlifter. (a) Coronal postcontrast 3D T1-weighted fat-suppressed spoiled gradient-echo images with dynamic positioning (arm up in left image and down in right image) demonstrate a long segment of occlusive venous thrombus extending from the basilic vein into the right subclavian vein (arrowheads), with wall enhancement. (b) Axial postcontrast 3D T1-weighted fat-suppressed spoiled gradient-echo image again demonstrates that the right axillary and subclavian veins are completely occluded and distended with thrombus. (c) Sagittal unenhanced T1-weighted turbo spin-echo image supplements the angiographic images and demonstrates the severely compressed subclavian vein (solid arrow) in the costoclavicular space, interposed between the clavicle (black arrowhead) and the anterior scalene muscle (white arrowhead). The subclavian artery (open arrow) is seen as a flow void posterior to the anterior scalene muscle.

 

View larger version (63K): [in this window] [in a new window] [Download PPT slide]   Figure 11.  Diagrams of the three types of upper arm arteriovenous fistulas used for hemodialysis. A, Normal anatomy of the right antecubital fossa, showing the cephalic vein (CV), median antecubital vein (MACV), basilic vein (BV), brachial artery (BA), radial artery (RA), and ulnar artery (UA). B, Brachiocephalic arteriovenous fistula. C, Brachiobasilic arteriovenous fistula. D, Brachial artery–to–median antecubital vein arteriovenous fistula (36).

 

View larger version (141K): [in this window] [in a new window] [Download PPT slide]   Figure 12a.  Hemodialysis arteriovenous fistula complications. (a) Time-resolved contrast-enhanced MR angiographic images at 6 seconds per frame demonstrate a left-side brachiobasilic hemodialysis fistula with multiple venous stenoses(arrows). (b) Coronal postcontrast 3D T1-weighted fat-suppressed spoiled gradient-echo images reveal an additional significant finding: multiple intraluminal venous thrombi (arrowheads). (c) Time-resolved contrast-enhanced MR angiograms in two patients with arteriovenous hemodialysis fistula complications; the patient in the left image has two venous aneurysms (arrows), and the patient in the right image has complete venous occlusion with collateral vessels present (arrowhead).

 

View larger version (72K): [in this window] [in a new window] [Download PPT slide]   Figure 12b.  Hemodialysis arteriovenous fistula complications. (a) Time-resolved contrast-enhanced MR angiographic images at 6 seconds per frame demonstrate a left-side brachiobasilic hemodialysis fistula with multiple venous stenoses(arrows). (b) Coronal postcontrast 3D T1-weighted fat-suppressed spoiled gradient-echo images reveal an additional significant finding: multiple intraluminal venous thrombi (arrowheads). (c) Time-resolved contrast-enhanced MR angiograms in two patients with arteriovenous hemodialysis fistula complications; the patient in the left image has two venous aneurysms (arrows), and the patient in the right image has complete venous occlusion with collateral vessels present (arrowhead).

 

View larger version (123K): [in this window] [in a new window] [Download PPT slide]   Figure 12c.  Hemodialysis arteriovenous fistula complications. (a) Time-resolved contrast-enhanced MR angiographic images at 6 seconds per frame demonstrate a left-side brachiobasilic hemodialysis fistula with multiple venous stenoses(arrows). (b) Coronal postcontrast 3D T1-weighted fat-suppressed spoiled gradient-echo images reveal an additional significant finding: multiple intraluminal venous thrombi (arrowheads). (c) Time-resolved contrast-enhanced MR angiograms in two patients with arteriovenous hemodialysis fistula complications; the patient in the left image has two venous aneurysms (arrows), and the patient in the right image has complete venous occlusion with collateral vessels present (arrowhead).

 

View larger version (97K): [in this window] [in a new window] [Download PPT slide]   Figure 13.  Congenital arteriovenous malformation. Time-resolved MR angiography of the left arm in a young child demonstrates a high-flow arteriovenous malformation characterized by a dilated, ectatic arterial system, a complex vascular nidus in the hand and forearm (arrow), and early filling of markedly dilated and tortuous basilic and cephalic veins (arrowheads). Associated hypertrophy of the left arm is seen, as well as diffuse infiltration of the muscular and subcutaneous compartments by the vascular nidus, which was best seen on T2-weighted images (not shown).

 

View larger version (80K): [in this window] [in a new window] [Download PPT slide]   Figure 14.  Ulnar artery occlusion. Time-resolved MR angiography of the hand demonstrates occlusion of the distal ulnar artery (arrow) 8 cm proximal to the wrist. The radial artery is patent and the superficial palmar arch and common digital arteries of the third to fifth fingers are filled via deep palmar arch collateral vessels (arrowheads).

 

View larger version (126K): [in this window] [in a new window] [Download PPT slide]   Figure 15.  Posttraumatic pseudoaneurysm. Time-resolved MR angiography of the hand demonstrates a pseudoaneurysm (arrow) at the level of the fifth metacarpophalangeal joint, arising from a branch of the third common palmar artery. In addition to the clinical history of prior trauma, the absence of a draining vein indicates that this is unlikely to represent a hemangioma.

 

View larger version (84K): [in this window] [in a new window] [Download PPT slide]   Figure 16a.  Distal extremity embolic disease. (a) Time-resolved MR angiography of the hand in a patient presenting with sudden onset pallor and paresthesias of the digits demonstrates an abrupt occlusion of the second digital palmar artery (arrow) without collateral vessels, consistent with an acute distal arterial embolism. (b) Coronal MIP image from a contrast-enhanced MR angiographic study demonstrates a normal-caliber aortic arch and bilateral subclavian, axillary, and brachial arteries without any evidence of atherosclerosis or other vascular disease. Since no arterial embolic source was demonstrated, a cardiac source must be considered, which was the cause in this case.

 

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 16b.  Distal extremity embolic disease. (a) Time-resolved MR angiography of the hand in a patient presenting with sudden onset pallor and paresthesias of the digits demonstrates an abrupt occlusion of the second digital palmar artery (arrow) without collateral vessels, consistent with an acute distal arterial embolism. (b) Coronal MIP image from a contrast-enhanced MR angiographic study demonstrates a normal-caliber aortic arch and bilateral subclavian, axillary, and brachial arteries without any evidence of atherosclerosis or other vascular disease. Since no arterial embolic source was demonstrated, a cardiac source must be considered, which was the cause in this case.

 

View larger version (84K): [in this window] [in a new window] [Download PPT slide]   Figure 17.  Scleroderma. Coronal MIP images from a contrast-enhanced MR angiographic study of the left hand reveal a patent radial artery from the proximal forearm to the wrist. At the level of the wrist, the radial artery becomes severely stenotic (arrowhead). Severe ulnar artery stenosis is also noted at the level of the wrist. The superficial palmar arch is not visualized. The deep arch is supplied by a collateral vessel from the radial artery (arrow). The second digit is hyperemic relative to the other digits. (The patient is status post resection of the distal phalanx of the third digit.)

 

View larger version (78K): [in this window] [in a new window] [Download PPT slide]   Figure 18.  Subclavian artery pseudostenosis. Coronal MIP images from a contrast-enhanced MR angiographic study demonstrate apparent stenosis of the distal right subclavian artery (arrow) ipsilateral to the side of contrast agent injection. Delayed imaging demonstrates a normal-caliber subclavian artery, indicating that the finding was artifactual and secondary to signal loss caused by the high concentration of gadolinium in the adjacent vein.

 

View larger version (163K): [in this window] [in a new window] [Download PPT slide]   Figure 19a.  Metallic stent artifact: (a) Coronal MIP image from a time-resolved contrast-enhanced MR angiographic study demonstrates an arteriovenous fistula with two apparent severe stenoses involving the left brachiocephalic vein (arrow) and axillary vein (arrowheads). The margins of these stenoses are unusually abrupt and collateral vessels are present in the upper arm. (b) Axial (left) and coronal (right) reformations of the 3D T1-weighted fat-suppressed spoiled gradient-echo data demonstrate blooming artifacts at the sites of the two indwelling stents. The presence of the collateral vessels still raised the suspicion of possible stent occlusion, and DSA was recommended, which confirmed patency of the venous system. (c) Anteroposterior chest radiograph shows the presence of two stents (arrows) corresponding to the regions of suspected venous stenoses.

 

View larger version (63K): [in this window] [in a new window] [Download PPT slide]   Figure 19b.  Metallic stent artifact: (a) Coronal MIP image from a time-resolved contrast-enhanced MR angiographic study demonstrates an arteriovenous fistula with two apparent severe stenoses involving the left brachiocephalic vein (arrow) and axillary vein (arrowheads). The margins of these stenoses are unusually abrupt and collateral vessels are present in the upper arm. (b) Axial (left) and coronal (right) reformations of the 3D T1-weighted fat-suppressed spoiled gradient-echo data demonstrate blooming artifacts at the sites of the two indwelling stents. The presence of the collateral vessels still raised the suspicion of possible stent occlusion, and DSA was recommended, which confirmed patency of the venous system. (c) Anteroposterior chest radiograph shows the presence of two stents (arrows) corresponding to the regions of suspected venous stenoses.

 

View larger version (129K): [in this window] [in a new window] [Download PPT slide]   Figure 19c.  Metallic stent artifact: (a) Coronal MIP image from a time-resolved contrast-enhanced MR angiographic study demonstrates an arteriovenous fistula with two apparent severe stenoses involving the left brachiocephalic vein (arrow) and axillary vein (arrowheads). The margins of these stenoses are unusually abrupt and collateral vessels are present in the upper arm. (b) Axial (left) and coronal (right) reformations of the 3D T1-weighted fat-suppressed spoiled gradient-echo data demonstrate blooming artifacts at the sites of the two indwelling stents. The presence of the collateral vessels still raised the suspicion of possible stent occlusion, and DSA was recommended, which confirmed patency of the venous system. (c) Anteroposterior chest radiograph shows the presence of two stents (arrows) corresponding to the regions of suspected venous stenoses.

 

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