Lower extremity stepping-table magnetic resonance angiography with multilevel contrast timing and segmented contrast infusion

Objectives: Standard lower extremity contrast-enhanced magnetic resonance angiography (LE-CEMRA) with single injection bolus-chase methods on the basis of a single pelvis timing run can be accurate for depicting most vascular occlusive lesions but may fall short of catheter-based angiography when imaging tibial and pedal vessels. Magnetic resonance angiography techniques with a second contrast timing bolus and separate acquisitions for the calves and the pelvis greatly improve reliability and reduce venous contamination to levels that may render conventional angiography obsolete. Methods: From July to December 2001, 60 consecutive patients underwent LE-CEMRA of the calves with separate stepping-table acquisitions of the pelvis and thighs. Forty-five (75%) had complete or partial angiographic correlation during an endoluminal intervention or operative completion study. Lower extremity vessels were divided into anatomic segments (aortoiliac, femoropopliteal, tibial-pedal) for review. Three blinded observers assessed magnetic resonance source partitions, maximum-intensity projections, and volume-rendered images. Disease per segment was graded from insignificant (<20%) to occluded (100%) in 10% increments. Segments were also scored for venous contamination (scale, 0 to 3) and diagnostic quality (scale, 1 to 5). Digital subtraction angiograms were assessed similarly but separately. Results: The combination dual-timing/dual-injection technique had an overall sensitivity, specificity, and accuracy of 99%, 97%, and 98%. Venous contamination and artifact were virtually eliminated with combined technique LE-CEMRA. Diagnostic quality of calf and foot vessels was significantly superior to conventional bolus-chase magnetic resonance techniques (P < .01). Conclusion: Hybrid dual-acquisition LE-CEMRA allows complete timing specification that consistently produces high-quality, artifact-free images of the calf and pedal vessels. These techniques may be accurate enough to replace conventional digital subtraction angiogram for evaluation of lower extremity vascular occlusive disease.