Original Article
Magnetic Resonance Imaging of Angiographically Occult Runoff Vessels in Peripheral Arterial Occlusive Disease
N Engl J Med 1992; 326:1577-1581June 11, 1992
- Abstract
- Abstract
Background.
Bypass grafting to arteries of the lower leg has become standard surgical management of advanced peripheral vascular disease. Its success depends on identifying suitable distal vessels. Preoperative preparation includes imaging of the arteries of the lower leg, usually by conventional contrast arteriography. An alternative procedure, magnetic resonance (MR) angiography, has been successfully employed in patients with various cardiovascular diseases, but its possible value in patients with peripheral vascular disease has received little attention.
Methods.
We used both conventional and MR angiography in preoperative studies of the lower-leg vessels of 23 patients (25 legs) with peripheral arteriosclerosis and arterial insufficiency, and developed independent therapeutic plans based on the information provided by each technique. When the plans differed, the interventional procedure judged more likely to save the limb was performed. The findings of conventional and MR angiography were verified by intraoperative arteriography, postinterventional arteriography, or direct operative exploration.
Results.
MR angiography detected all vessels identified by conventional angiography, whereas conventional arteriography failed to detect 22 percent of the runoff vessels identified by MR angiography. The detection by MR angiography of vessels not identified by conventional angiography altered the surgical management of the disorders of four patients (17 percent) and guided successful bypass procedures.
Conclusions.
MR angiography is a noninvasive technique with greater sensitivity than conventional contrast arteriography for detecting distal runoff vessels in patients with peripheral arterial occlusive disease.
Media in This Article
Figure 1
Numbers of Runoff Vessels Shown to Be Patent on MR Angiography and Conventional Angiography.Figure 2
Conventional, MR, and Intraoperative Angiograms of a Patient with Severe Foot Ischemia.Article Activity
- Article
With improvements in the techniques of vascular surgery, bypass grafting to very small distal vessels to save a limb has become possible. Grafts to the arteries of the foot are now standard vascular surgical practice. As the options for salvaging limbs have expanded, the need for detailed imaging of the distal lower extremities has increased.
Since the introduction of safe iodinated contrast materials in the 1950s, contrast arteriography has served as the standard diagnostic technique for evaluating peripheral arterial disease. However, conventional contrast arteriography fails to demonstrate distal vessels suitable for reconstructive surgery in up to 70 percent of patients with severe disease.1 2 3 4 In addition, conventional angiography is not without risk. Although the vast majority of angiographic complications are minor, the overall complication rate for transfemoral angiography remains nearly 8 percent.5 Intravascular ionic contrast mediums are responsible for severe reactions in 0.22 percent of patients, and nonionic mediums for reactions in 0.04 percent.6 A more sensitive and noninvasive technique for identifying target vessels for reconstructive operations in advanced peripheral occlusive disease would be of great clinical value.
The ability of magnetic resonance to image flowing blood (magnetic resonance [MR] angiography) without the injection of contrast material is well documented.7 8 9 10 11 12 MR angiography has been successfully used to evaluate arterial disease affecting most anatomical regions; it was the subject of a recent review.13 Less attention has been directed to the evaluation of occlusive peripheral arterial disease, especially involvement below the knee. In this study, we investigated the use of MR angiography in the preoperative evaluation of patients with symptomatic peripheral vascular disease and compared the findings of MR angiography with those of conventional angiography.
Methods
We studied 25 legs of 23 patients by both MR and conventional arteriography; 15 patients were men, and 8 were women, with a mean age of 67 years. The indications for vascular evaluation included rest pain (15 patients), nonhealing ulcers or gangrene (11), severe claudication (4), and a failing vascular graft (1); 6 patients had two indications. Concomitant conditions included hypertension, diabetes mellitus, coronary artery disease, and renal insufficiency (creatinine concentration, >133 μmol per liter). Twenty of the 23 patients studied subsequently underwent direct visualization at surgery or intraoperative or postinterventional arteriography of the lower-leg vessels studied.
MR angiography was performed with a standard 1.5-tesla superconducting system (Signa; General Electric Medical Systems, Milwaukee) with a transmit–receive extremity coil and commercially available pulse sequences. Only two-dimensional time-of-flight techniques were used. Inferior saturation pulses were used to suppress signal from venous blood flow. The scanning variables were a 16-cm field of view, 2-mm–thick sections, a flip angle of 60 degrees, a repetition time of 33 to 45 msec, an echo time of 7.7 msec, and 128-phase encoding steps with no signal averaging (1 NEX [number of excitations]). One hundred axial images covering 20 cm were obtained at three or four stations, for a total of 300 or 400 axial images. At all examinations the lower leg was imaged from the level of the adductor canal to the dorsum of the foot. The examination time ranged from 40 to 80 minutes, for an average of approximately 60 minutes.
Conventional contrast arteriography was performed according to the standard approach with a femoral catheter, with either diatrizoate (370 mg of iodine per milliliter; Hypaque-76) or iohexol (350 mg of iodine per milliliter; Omnipaque 350). Ninety milliliters of contrast medium was injected into the distal abdominal aorta (15 patients), 40 ml into the iliac artery (7), or 30 ml into the femoral artery (3). Filming was continued for 40 seconds after the end of the injection. Blood flow to the ischemic extremity was augmented by the administration of an intraarterial vasodilator (10 to 25 mg of tolazoline) in five limbs and by the induction of reactive hyperemia in three limbs. Intraarterial digital-subtraction arteriography supplemented conventional arteriography in three patients. Angiographic studies were considered to be of adequate quality only if one or more distal runoff vessels were identified or an angiographic blush was seen within the soft tissues or in the very small unnamed peripheral arteries.
Three radiologists reviewed both the MR and conventional arteriograms. The MR angiograms were interpreted without knowledge of the findings on conventional arteriography. Both the axial images and the computer-reconstructed angiograms7 were reviewed before a final opinion was rendered. The conventional angiograms were then reviewed by the same three radiologists. Finally, intraoperative angiograms, postinterventional angiograms, and intraoperative findings from direct surgical exploration were reviewed; these were considered the gold standard.
The investigation was limited to the major arteries of the lower leg — i.e., the popliteal, posterior tibial, anterior tibial, peroneal, and dorsalis pedis arteries and the tibioperoneal trunk. For the purpose of comparison, the popliteal, posterior tibial, anterior tibial, and peroneal arteries were each divided into three equal segments, which were described as the proximal, middle, and distal thirds. Because of their relatively short length, the tibioperoneal trunk and dorsalis pedis arteries were each considered as a single segment. Each segment was classified as either patent or occluded. Fourteen arterial segments were evaluated in each of the 25 legs, for a total of 350 segments.
After review of these studies, the surgeons developed two independent therapeutic plans, one based on the clinical and MR-angiographic findings and the other on the clinical and conventional-arteriographic findings. When the two plans differed, the intervention judged more likely to save the limb was attempted (Table 1Table 1
Procedures Performed in 23 Patients with Peripheral Arterial Disease.).Results
Twenty-five limbs of 23 patients with symptomatic peripheral arterial occlusive disease were studied by both conventional and MR angiography. Discrepancies between the two techniques were identified in 18 of the 25 limbs studied (72 percent). For the purpose of comparison, the vessels of the lower leg were divided into segments and classified as patent or occluded. The results are shown in Figure 1Figure 1
Numbers of Runoff Vessels Shown to Be Patent on MR Angiography and Conventional Angiography.. In 77 of the 350 vascular segments studied (22 percent), MR angiography demonstrated flow in vascular segments that were not identified as patent by conventional arteriography (Fig. 2Figure 2Conventional, MR, and Intraoperative Angiograms of a Patient with Severe Foot Ischemia.). This phenomenon was most apparent in the infrapopliteal vessels. MR angiography demonstrated 48 percent more patent vascular segments overall (236 vs. 159), but demonstrated only 24 percent more popliteal segments (57 vs. 46), as compared with 62 percent more midtibial and distal tibial segments (89 vs. 55). In no instance did MR angiography fail to demonstrate flow in a segment of a vessel that was seen on a conventional preoperative, postinterventional, or intraoperative arteriogram. No vessel found to be patent at surgery was undetected by MR angiography. Therefore, the sensitivity of this technique in detecting distal runoff vessels was 100 percent.Two independent interventional plans were developed for each patient in the light of the clinical setting, one based on the MR angiogram and the other on the conventional angiogram. In four patients (17 percent), the MR angiogram detected target vessels that were suitable for bypass grafting but were not detected on the conventional arteriogram (Fig. 2). In these patients, a limb-salvage procedure was successfully performed and the findings of MR angiography were confirmed. The interventional plan based on the conventional angiogram had been blind exploration of runoff vessels and intraoperative arteriography with subsequent amputation if no suitable target vessel was identified. Retrospective review of the preoperative contrast angiograms revealed all four to be of good quality. Contrast medium had been injected into the distal abdominal aorta in two patients and into iliac vessels in two patients. For all four patients, conventional angiograms demonstrated the presence of contrast medium in small unnamed vessels of the lower leg (Fig. 2A). In the remaining 19 patients (83 percent), the interventional plans based on the MR and conventional contrast arteriograms were identical.
Discussion
The therapeutic options available to patients with symptomatic peripheral arterial occlusive disease depend on the underlying anatomy. In patients with long segmental occlusions and adequate distal runoff vessels, bypass grafting is usually the therapy of choice. However, in patients with complete absence of distal runoff arteries, amputation is often the only option. The optimal management of their disorder requires vascular imaging that discloses the full extent of vascular occlusions and reveals all distal runoff vessels suitable for bypass grafting.
In the present investigation, 25 legs of 23 patients with symptomatic disease were studied with both conventional contrast angiography and MR angiography. Discrepancies between the results of these two techniques were found in 18 of the 25 limbs studied. They were in all cases due to superior detection of distal runoff vessels by MR angiography.
The demonstration of vascular patency by contrast arteriography requires the opacification of a vascular lumen with radiopaque material. Contrast material is injected at a proximal site and flows toward the distal extremity, opacifying branch vessels along the way. In the presence of multisegmental occlusions, contrast medium diluted by blood may pool in dependent soft tissues and fail to opacify patent distal vessels. On the other hand, MR angiography directly images flowing blood and does not rely on the upstream injection of contrast material. Under the protocol of MR angiography described here, flow velocities of 2 cm per second or greater are easily detected.
The increased sensitivity of MR angiography in detecting distal runoff vessels suitable for limb-salvage procedures appears to be clinically useful. MR-angiographic findings altered the preoperative surgical plan of 4 of the 23 patients studied (17 percent). In each of these four patients, the use of MR angiography led to a procedure for limb salvage that had not been regarded as possible on the basis of the preoperative contrast arteriogram. These patients would either have undergone amputation or at best blind exploration of potential target vessels and intraoperative arteriography before bypass grafting.
The availability of cross-sectional images (Fig. 2C) and three-dimensional reconstructions (Fig. 2B) allowed definitive identification of distally reconstituted vessels, which is often difficult or impossible with a single projection from a contrast arteriogram. Since cortical bone yields no appreciable MR signal, it did not obscure the vessels of the lower leg, a common problem with conventional arteriography. Because MR angiography does not require the injection of contrast medium, the use of this technique eliminated the risk of renal failure induced by contrast medium; six patients in this study (26 percent) had preoperative evidence of renal insufficiency (serum creatinine concentration, >133 μmol per liter).
MR angiography can measure flow velocities in the lower extremity noninvasively14 15; combining such measurement with imaging may produce a more complete vascular assessment of the lower limb than can be achieved by imaging alone.
The appropriate indications for MR angiography and its effects on the cost of the care of patients with peripheral vascular disease are not yet established. At present, the principal indication for peripheral MR angiography is the preoperative evaluation of patients in whom contrast arteriography fails to identify a distal target vessel suitable for bypass surgery. Although MR angiography incurs additional costs, this expense may well be offset by savings in operating room time if each vascular compartment does not have to be explored. MR angiography appears to be a potentially valuable technique for assessing the lower limbs of patients with peripheral vascular disease. Its increased sensitivity in detecting distal runoff vessels may improve the overall rate of limb salvage among such patients.
We are indebted to Drs. Henry D. Berkowitz, Michael A. Golden, and Clyde F. Barker of the vascular-surgery section for allowing us to enroll their patients in this investigation; to Drs. Michael Soulen, John B. Weigele, Martin Sheline, and Richard Shlansky-Goldberg of the vascular-radiology section for their numerous helpful suggestions and encouragement; to Dr. Stanley Baum for his insightful guidance; and to all the MR technicians for filming and archiving the vast number of images produced by this investigation.
Source Information
From the Departments of Radiology (R.S.O., R.A.B., C.C.) and Vascular Surgery (J.P.C., L.J.P.), University of Pennsylvania School of Medicine, Philadelphia. Address reprint requests to Dr. Cope at the Department of Radiology, Hospital of the University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104.
- References
References
1
Patel
CrossRef | Web of Science | Medline2
Ricco
CrossRef | Web of Science | Medline3
Scarpato
Web of Science | Medline4
Flanigan
Web of Science | Medline5
Waugh
Web of Science | Medline6
Katayama
Web of Science | Medline7
Keller
Web of Science | Medline8
Lenz
Web of Science | Medline9
Axel
CrossRef | Web of Science | Medline10
Wehrli
CrossRef | Web of Science | Medline11
Dumoulin
CrossRef | Web of Science | Medline12
Spritzer
Web of Science | Medline13
Edelman
Web of Science | Medline14
Kerr
CrossRef | Web of Science | Medline15
Dousset
Web of Science | Medline
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1
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CrossRef2
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W. Gregory Hundley, David A. Bluemke, J. Paul Finn, Scott D. Flamm, Mark A. Fogel, Matthias G. Friedrich, Vincent B. Ho, Michael Jerosch-Herold, Christopher M. Kramer, Warren J. Manning, Manesh Patel, Gerald M. Pohost, Arthur E. Stillman, Richard D. White, Pamela K. Woodard. (2010) ACCF/ACR/AHA/NASCI/SCMR 2010 Expert Consensus Document on Cardiovascular Magnetic Resonance. Journal of the American College of Cardiology 55:23, 2614-2662
CrossRef4
Robert R. Edelman, James W. Goldfarb, Agnes E. Holland. 2010. Cardiovascular Magnetic Resonance Angiography. , 463-479.
CrossRef5
William D Adair, Amman Bolia. (2009) Recanalization of infrapopliteal occlusions. Interventional Cardiology 1:2, 225-235
CrossRef6
Maya J. Salameh, Elizabeth V. Ratchford. (2009) Update on Peripheral Arterial Disease and Claudication Rehabilitation. Physical Medicine and Rehabilitation Clinics of North America 20:4, 627-656
CrossRef7
Andrew R. Owen, Iain R. Robertson, Ganesan Annamalai, Giles H. Roditi, Richard D. Edwards, Lilian S. Murray, Jon G. Moss. (2009) Critical Lower-limb Ischemia: The Diagnostic Performance of Dual-phase Injection MR Angiography (Including High-resolution Distal Imaging) Compared with Digital Subtraction Angiography. Journal of Vascular and Interventional Radiology 20:2, 165-172
CrossRef8
M.ªD. Ferrer, A.J. Revert, Y. Pallardó, E. Esteban, J. Jornet, E. Mollá. (2006) Evaluación de la arteriopatía de los miembros inferiores por tomografía computarizada multidetector comparada con la angiografía por sustracción digital. Radiología 48:6, 369-374
CrossRef9
Chun Yuan. 2006. Magnetic Resonance Angiography. .
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Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, Society of Interventional Radiology, and the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Develop Guidelines for the Management of Patients With Peripheral Arterial Disease). Journal of the American College of Cardiology 47:6, e1-e192
CrossRef11
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CrossRef12
A.J. Edwards, I.P. Wells, C.A. Roobottom. (2005) Multidetector row CT angiography of the lower limb arteries: a prospective comparison of volume-rendered techniques and intra-arterial digital subtraction angiography. Clinical Radiology 60:1, 85-95
CrossRef13
E INSKO. (2004) Magnetic resonance angiography. Seminars in Vascular Surgery 17:2, 83-101
CrossRef14
T. Leiner. (2004) Contrast-Enhanced MRA in the Workup of Peripheral Arterial Occlusive Disease. Imaging Decisions MRI 8:1, 20-28
CrossRef15
Albert D Sam, Mark D Morasch, Jeremy Collins, Gina Song, Richard Chen, F.Scott Pereles. (2003) Safety of gadolinium contrast angiography in patients with chronic renal insufficiency. Journal of Vascular Surgery 38:2, 313-318
CrossRef16
K Visser, S.O de Vries, P.J.E.H.M Kitslaar, J.M.A van Engelshoven, M.G.M Hunink. (2003) Cost-effectiveness of Diagnostic Imaging Work-up and Treatment for Patients with Intermittent Claudication in The Netherlands. European Journal of Vascular and Endovascular Surgery 25:3, 213-223
CrossRef17
Kenneth S. Rholl. (2003) Physiologic Arterial Testing for PVD: Advantages over Duplex/MRA/CTA and Pitfalls in Diagnosis. Journal of Vascular and Interventional Radiology 14:2, P255-P258
CrossRef18
Keith M. Sterling. (2003) Noninvasive Evaluation of PAD: What I Like and Why. Journal of Vascular and Interventional Radiology 14:2, P19-P28
CrossRef19
C. N. Cronberg, S. Sjoberg, U. Albrechtsson, P. Leander, M. Lindh, L. Norgren, P. Danielsson, B. Sonesson, E.-M. Larsson. (2003) Peripheral Arterial Disease. Contrast-Enhanced 3D Mr Angiography of the Lower Leg and Foot Compared with Conventional Angiography. Acta Radiologica 44:1, 59-66
CrossRef20
Vincent B Ho, William R Corse. (2003) MR angiography of the abdominal aorta and peripheral vessels. Radiologic Clinics of North America 41:1, 115-144
CrossRef21
William B Morrison, Hans Peter Ledermann. (2002) Work-up of the diabetic foot. Radiologic Clinics of North America 40:5, 1171-1192
CrossRef22
Mathias Goyen, Stefan G Ruehm, Jölrg F Debatin. (2002) MR angiography for assessment of peripheral vascular disease. Radiologic Clinics of North America 40:4, 835-846
CrossRef23
M SHARAFUDDIN, A STOLPEN, S SUN, C LEUSNER, A SAFVI, J HOBALLAH, W SHARP, J CORSON. (2002) High-resolution Multiphase Contrast-enhanced Three-dimensional MR Angiography Compared with Two-dimensional Time-of-Flight MR Angiography for the Identification of Pedal Vessels. Journal of Vascular and Interventional Radiology 13:7, 695-702
CrossRef24
Jonathan L Halperin. (2002) Evaluation of patients with peripheral vascular disease. Thrombosis Research 106:6, V303-V311
CrossRef25
Jan Thorsten Winterer, Oliver Schaefer, Peter Uhrmeister, Gesine Zimmermann-Paul, Stefan Lehnhardt, C Altehoefer, J Laubenberger. (2002) Contrast enhanced MR angiography in the assessment of relevant stenoses in occlusive disease of the pelvic and lower limb arteries: diagnostic value of a two-step examination protocol in comparison to conventional DSA. European Journal of Radiology 41:2, 153-160
CrossRef26
M. Gregor, B. Tombach, A. Hentsch, P. Reimer. (2002) Peripheral Run-off CE-MRA with a 1.0 Molar Gadolinium Chelate (Gadovist) with Intraarterial DSA Comparison. Academic Radiology 9:2, S398-S400
CrossRef27
Kenneth S. Rholl. (2002) How to Perform and Interpret Lower Extremity PVRs. Journal of Vascular and Interventional Radiology 13:2, P19-P22
CrossRef28
J.P Eiberg, E Lundorf, C Thomsen, T.V Schroeder. (2001) Peripheral Vascular Surgery and Magnetic Resonance Arteriography – a Review. European Journal of Vascular and Endovascular Surgery 22:5, 396-402
CrossRef29
Mathias Goyen, Jörg F. Debatin, Stefan G. Ruehm. (2001) Peripheral Magnetic Resonance Angiography. Topics in Magnetic Resonance Imaging 12:5, 327-335
CrossRef30
Konstantin Nikolaou, Armin Huber, Andreas Knez, Jürgen Scheidler, Rainer Petsch, Maximilian Reiser. (2001) Navigator Echo-Based Respiratory Gating for Three-Dimensional MR Coronary Angiography: Reduction of Scan Time Using a Slice Interpolation Technique. Journal of Computer Assisted Tomography 25:3, 378-387
CrossRef31
Stefan G Ruehm, Mathias Goyen, Jörg Barkhausen, Knut Kröger, Silke Bosk, Mark E Ladd, Jörg F Debatin. (2001) Rapid magnetic resonance angiography for detection of atherosclerosis. The Lancet 357:9262, 1086-1091
CrossRef32
Geetha Pandian, Mark E. Huang, Daniel A. Duffy. (2001) Acquired limb deficiencies. 2. Perioperative management. Archives of Physical Medicine and Rehabilitation 82:3, S9-S16
CrossRef33
S REID, H PAGANMARIN, J MENZOIAN, J WOODSON, E YUCEL. (2001) Contrast-enhanced Moving-Table MR Angiography: Prospective Comparison to Catheter Arteriography for Treatment Planning in Peripheral Arterial Occlusive Disease. Journal of Vascular and Interventional Radiology 12:1, 45-53
CrossRef34
Nancy A. Obuchowski, Michael L. Lieber, Kimerly A. Powell. (2000) Data analysis for detection and localization of multiple abnormalities with application to mammography. Academic Radiology 7:7, 516-525
CrossRef35
(2000) Amputation. European Journal of Vascular and Endovascular Surgery 19, S225-S230
CrossRef36
(2000) Evaluation. European Journal of Vascular and Endovascular Surgery 19, S150-S157
CrossRef37
R. Thomas Bonk, Udo P. Schmiedl, Chun Yuan, James A. Nelson, Chris D.V. Black, David L. Ladd. (2000) Time-of-flight MR angiography with Gd-DTPA hexamethylene diamine co-polymer blood pool contrast agent: Comparison of enhanced MRA and conventional angiography for arterial stenosis induced in rabbits. Journal of Magnetic Resonance Imaging 11:6, 638-646
CrossRef38
M SHARAFUDDIN, J WROBLICKA, S SUN, M ESSIG, S SCHOENBERG, W YUH. (2000) Percutaneous Vascular Intervention Based on Gadolinium-enhanced MR Angiography. Journal of Vascular and Interventional Radiology 11:6, 739-746
CrossRef39
M KALINOWSKI, J HEVERHAGEN, H ALFKE, K KLOSE, H WAGNER. (2000) Mid-term Follow-up after Percutaneous Hydrodynamic Thrombectomy in Lower Limb Ischemia: Initial Experience with Two-dimensional MR Imaging and Three-dimensional MR Angiography. Journal of Vascular and Interventional Radiology 11:6, 747-753
CrossRef40
George G. Hartnell. (2000) IMAGING IN BLOOD STASIS. Hematology/Oncology Clinics of North America 14:2, 299-323
CrossRef41
Thomas M. Grist. (2000) MRA of the abdominal aorta and lower extremities. Journal of Magnetic Resonance Imaging 11:1, 32-43
CrossRef42
(2000) Clinical evaluation of critical limb ischemia. Journal of Vascular Surgery 31:1, S176-S183
CrossRef43
(2000) Amputation. Journal of Vascular Surgery 31:1, S267-S274
CrossRef44
Vincent B. Ho, Peter L. Choyke, Thomas K.F. Foo, Maureen N. Hood, Donald L. Miller, Julianna M. Czum, Alex M. Aisen. (1999) Automated bolus chase peripheral MR angiography: Initial practical experiences and future directions of this work-in-progress. Journal of Magnetic Resonance Imaging 10:3, 376-388
CrossRef45
John R. Bartholomew, Bruce H. Gray. (1999) LARGE ARTERY OCCLUSIVE DISEASE. Rheumatic Disease Clinics of North America 25:3, 669-686
CrossRef46
Jan Thorsten Winterer, Joerg Laubenberger, Klaus Scheffler, Klaus Neumann, Yilmaz R. Bayraktarli, Karl-Heinz Allmann, Peter Uhrmeister, Mathias Langer. (1999) Contrast-Enhanced Subtraction MR Angiography in Occlusive Disease of the Pelvic and Lower Limb Arteries: Results of a Prospective Intraindividual Comparative Study with Digital Subtraction Angiography in 76 Patients. Journal of Computer Assisted Tomography 23:4, 583-589
CrossRef47
Louis Allard, Guy Cloutier, Zhenyu Guo, Louis-Gilles Durand. (1999) Review of the assessment of single level and multilevel arterial occlusive disease in lower limbs by duplex ultrasound. Ultrasound in Medicine & Biology 25:4, 495-502
CrossRef48
S.A Ray, T.M Buckenham, A.-M Belli, R.S Taylor, J.A Dormandy. (1999) The Association Between Laser Doppler Reactive Hyperaemia Curves and the Distribution of Peripheral Arterial Disease. European Journal of Vascular and Endovascular Surgery 17:3, 245-248
CrossRef49
Priscilla A. Winchester, Howard M. Lee, Neil M. Khilnani, Yi Wang, David W. Trost, Harry L. Bush Jr, Thomas A. Sos. (1998) Comparison of Two-dimensional MR Digital Subtraction Angiography of the Lower Extremity with X-Ray Angiography
. Journal of Vascular and Interventional Radiology 9:6, 891-899
CrossRef50
VIVIAN S. LEE, HOWARD M. LEE, NEIL M. ROFSKY. (1998) Magnetic Resonance Angiography of the Hand. Investigative Radiology 33:9, 687-698
CrossRef51
Klaus Scholz, Robin Wegener, Stefan Lundt. (1998) Cost-effectiveness contribution of contrast media: A discussion of perspectives. Academic Radiology 5, S385-S388
CrossRef52
Omaida C. Velázquez, Richard A. Baum, Jeffrey P. Carpenter. (1998) MAGNETIC RESONANCE ANGIOGRAPHY OF LOWER-EXTREMITY ARTERIAL DISEASE. Surgical Clinics of North America 78:4, 519-537
CrossRef53
John R. Leyendecker, Kelcey D. Elsass, Stephen P. Johnson, Daniel C. Diffin, David L. Cull, Jerry T. Light, David L. Dawson. (1998) The Role of Infrapopliteal MR Angiography in Patients Undergoing Optimal Contrast Angiography for Chronic Limb-threatening Ischemia
CrossRef54
H.J.M. Verhagen, J.D. Blankensteijn, Ph. G. de Groot, G.J. Heijnen-Snyder, A. Pronk, Th. M. Vroom, H.J. Muller, K. Nicolay, Th. J.M.V. van Vroonhoven, J.J. Sixma, B.C. Eikelboom. (1998) In Vivo experiments with mesothelial cell seeded ePTFE vascular grafts. European Journal of Vascular and Endovascular Surgery 15:6, 489-496
CrossRef55
David B. Stafford Johnson, Martin R. Prince, Thomas L. Chenevert. (1998) Magnetic resonance angiography: A review. Academic Radiology 5:4, 289-305
CrossRef56
Zhenyu Guo, Louis-Gilles Durand, Louis Allard, Guy Cloutier, Aaron Fenster. (1998) In vitro evaluation of multiple arterial stenoses using three-dimensional power Doppler angiography. Journal of Vascular Surgery 27:4, 681-688
CrossRef57
A. Albäck, F. Biancari, O. Saarinen, M. Lepäntalo. (1998) Prediction of the immediate outcome of femoropopliteal saphenous vein bypass by angiographic runoff score. European Journal of Vascular and Endovascular Surgery 15:3, 220-224
CrossRef58
Thomas S. Huber, Martin R. Back, R.James Ballinger, William C. Culp, Timothy C. Flynn, Paul S. Kubilis, James M. Seeger. (1997) Utility of magnetic resonance arteriography for distal lower extremity revascularization. Journal of Vascular Surgery 26:3, 415-424
CrossRef59
Thomas S. Huber, Martin R. Back, Timothy C. Flynn, Timothy R.S. Harward, William C. Culp, Lori M. Carlton, James M. Seeger. (1997) Intraoperative prebypass arteriography for infrageniculate revascularization. The American Journal of Surgery 174:2, 205-209
CrossRef60
Elisabeth Larch, Erich Minar, Ramazanali Ahmadi, Gerald Schnüder, Barbara Schneider, Andreas Stümpflen, Herbert Ehringer. (1997) Value of color duplex sonography for evaluation of tibioperoneal arteries in patients with femoropopliteal obstruction: A prospective comparison with anterograde intraarterial digital subtraction angiography. Journal of Vascular Surgery 25:4, 629-636
CrossRef61
Richard P. Cambria, John A. Kaufman, Gilbert J. L'Italien, Jonathan P. Gertler, Glenn M. LaMuraglia, David C. Brewster, Stuart Geller, Susan Atamian, Arthur C. Waltman, William M. Abbott. (1997) Magnetic resonance angiography in the management of lower extremity arterial occlusive disease: A prospective study. Journal of Vascular Surgery 25:2, 380-389
CrossRef62
Kenneth S. Rholl. (1997) Noninvasive Diagnosis of Peripheral Vascular Disease. Journal of Vascular and Interventional Radiology 8:1, 265-268
CrossRef63
M ALSON, E LANG, J KAUFMAN. (1997) Pedal Arterial Imaging
CrossRef64
John R. Hoch, Michael J. Tullis, Todd W. Kennell, John McDermott, Charles W. Acher, William D. Turnipseed. (1996) Use of magnetic resonance angiography for the preoperative evaluation of patients with infrainguinal arterial occlusive disease. Journal of Vascular Surgery 23:5, 792-801
CrossRef65
AUGUSTINUS LUDWIG JACOB, KLAUS WILHELM STOCK, MICHAEL PROSKE, WOLFGANG STEINBRICH. (1996) Lower Extremity Angiography: Improved Image Quality and Outflow Vessel Detection with Bilaterally Antegrade Selective Digital Subtraction Angiography. Investigative Radiology 31:4, 184-193
CrossRef66
Jeffrey P. Carpenter, Michael A. Golden, Clyde F. Barker, George A. Holland, Richard A. Baum. (1996) The fate of bypass grafts to angiographically occult runoff vessels detected by magnetic resonance angiography. Journal of Vascular Surgery 23:3, 483-489
CrossRef67
Jean-Pierre Laissy, Elisabeth Schouman-Claeys. (1996) Time-of-flight magnetic resonance angiography of aorta and renal arteries: state-of-the-art. European Journal of Radiology 21:3, 201-211
CrossRef68
Kenneth S. Rholl. (1996) Noninvasive Testing in Peripheral Vascular Disease. Journal of Vascular and Interventional Radiology 7:1, 116-120
CrossRef69
Richard A. Baum. (1996) Peripheral Vascular MR Angiography. Journal of Vascular and Interventional Radiology 7:1, 120-123
CrossRef70
Thomas K.P. Egglin, Paul V. O'Moore, Alvan R. Feinstein, Arthur C. Waltman. (1995) Complications of peripheral arteriography:A new system to identify patients at increased risk. Journal of Vascular Surgery 22:6, 787-794
CrossRef71
J. Shannon Swan, Frank R. Korosec, Dennis M. Heisey, Thomas M. Grist. (1995) Evaluation of Presaturation Pulse Thickness and Gap for Lower Extremity Peripheral Two-dimensional Time-of-Flight MR Angiography with a Signa 1.5-T Unit
CrossRef72
V.G. McDermott, T.J. Meakem, J.P. Carpenter, R.A. Baum, A.H. Stolpen, G.A. Holland, M.D. Schnall. (1995) Magnetic resonance angiography of the distal lower extremity. Clinical Radiology 50:11, 741-746
CrossRef73
B Dupas, D El Kouri, P de Faucal, B Planchon, P Peltier, J-J Lejeune. (1995) Angiomagnetic resonance imaging of iliofemorocaval venous thrombosis. The Lancet 346:8966, 17-19
CrossRef74
Rachel F. Oser, Daniel Picus, Marshall E. Hicks, Michael D. Darcy, David M. Hovsepian. (1995) Accuracy of DSA in the Evaluation of Patency of Infrapopliteal Vessels
CrossRef75
John J. Snidow, Veronica J. Harris, Scott O. Trerotola, Dolores F. Cikrit, Stephen G. Lalka, Kenneth A. Buckwalter, Matthew S. Johnson. (1995) Interpretations and Treatment Decisions Based on MR Angiography versus Conventional Arteriography in Symptomatic Lower Extremity Ischemia
CrossRef76
Gerald G. Blackwell, Gerald M. Pohost. (1995) The evolving role of MRI in the assessment of coronary artery disease. The American Journal of Cardiology 75:11, D74-D78
CrossRef77
Frank B. Pomposelli, Edward J. Marcaccio, Gary W. Gibbons, David R. Campbell, Dorothy V. Freeman, Anne M. Burgess, Arnold Miller, Frank W. LoGerfo. (1995) Dorsalis pedis arterial bypass: Durable limb salvage for foot ischemia in patients with diabetes mellitus. Journal of Vascular Surgery 21:3, 375-384
CrossRef78
Barbara Krug, Harald Kugel, Urs Harnischmacher, Walter Heindel, Roman Fischbach, Alexander Altenburg, Friedrich Krings. (1995) Diagnostic performance of digital subtraction angiography (DSA) and magnetic resonance angiography (MRA): preliminary results in vascular occlusive disease of the abdominal and lower-extremity arteries. European Journal of Radiology 19:2, 77-85
CrossRef79
Jeffrey P. Carpenter, Richard A. Baum, George A. Holland, Clyde F. Barker. (1994) Peripheral vascular surgery with magnetic resonance angiography as the sole preoperative imaging modality. Journal of Vascular Surgery 20:6, 861-871
CrossRef80
Steven M. Hertz, George A. Holland, Richard A. Baum, Ziv J. Haskal, Jeffrey P. Carpenter. (1994) Evaluation of renal artery stenosis by magnetic resonance angiography. The American Journal of Surgery 168:2, 140-143
CrossRef81
Jeffrey P. Carpenter, George A. Holland, Richard A. Baum, Rodney S. Owen, Judith T. Carpenter, Constantin Cope. (1993) Magnetic resonance venography for the detection of deep venous thrombosis: Comparison with contrast venography and duplex Doppler ultrasonography. Journal of Vascular Surgery 18:5, 734-741
CrossRef82
Joseph R. Durham, Craig A. Hackworth, J. Chadwick Tober, J.G. Bova, William F. Bennett, Petra Schmalbrock, Michael E. Van Aman, John D. Horowitz, J. Gordon Wright, William L. Smead. (1993) Magnetic resonance angiography in the preoperative evaluation of abdominal aortic aneurysms. The American Journal of Surgery 166:2, 173-178
CrossRef83
Steven M. Hertz, Richard A. Baum, Rodney S. Owen, George A. Holland, Donald R. Logan, Jeffrey P. Carpenter. (1993) Comparison of magnetic resonance angiography and contrast arteriography in peripheral arterial stenosis. The American Journal of Surgery 166:2, 112-116
CrossRef84
J. Shannon Swan, Todd W. Kennel, Myron M. Wojtowycz, Thomas M. Grist. (1993) Increased Presaturation Pulse Gaps in Two-dimensional Time-of-Flight MR Angiography: A Pitfall in Diseased Lower Extremities
CrossRef85
Richard P. Cambria, E. Kent Yucel, David C. Brewster, Gilbert L'Italien, Jonathan P. Gertler, Glenn M. Lamuraglia, John A. Kaufman, Arthur C. Waltman, William M. Abbott. (1993) The potential for lower extremity revascularization without contrast arteriography: Experience with magnetic resonance angiography. Journal of Vascular Surgery 17:6, 1050-1057
CrossRef86
Edelman, Robert R.Warach, Steven. (1993) Magnetic Resonance Imaging. New England Journal of Medicine 328:11, 785-791
Full Text87
Jeffrey P. Carpenter, Rodney S. Owen, Richard A. Baum, Constantin Cope, Clyde F. Barker, Henry D. Berkowitz, Michael A. Golden, Leonard J. Perloff. (1992) Magnetic resonance angiography of peripheral runoff vessels. Journal of Vascular Surgery 16:6, 807-815
CrossRef88
(1992) Magnetic Resonance versus Conventional Angiography in Peripheral Arterial Occlusive Disease. New England Journal of Medicine 327:18, 1319-1320
Full Text89
Higgins, Charles B., . (1992) The Potential Role of Magnetic Resonance Imaging in Ischemic Vascular Disease. New England Journal of Medicine 326:24, 1624-1626
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