Ferumoxytol-enhanced MRI in the peripheral vasculature

E D Lehrman, A N Plotnik, T Hope, D Saloner, E D Lehrman, A N Plotnik, T Hope, D Saloner

Abstract

Ferumoxytol is a promising non-gadolinium-based contrast agent with numerous varied magnetic resonance imaging applications. Previous reviews of vascular applications have focused primarily on cardiac and aortic applications. After considering safety concerns and technical issues, the objective of this paper is to explore peripheral applications for ferumoxytol-enhanced magnetic resonance angiography (MRA) and venography (MRV) in the upper and lower extremities. Separate searches for each of the following keywords were performed in pubmed: "ferumoxytol," "ultrasmall superparamagnetic iron oxide," and "USPIO." All studies pertaining to MRA or MRV in humans are included in this review. Case-based examples of various peripheral applications are used to supplement a relatively scant literature in this space. Ferumoxytol's unique properties including high T1 relaxivity and prolonged intravascular half-life make it the optimal vascular imaging contrast agent on the market and one whose vast potential has only begun to be tapped.

Conflict of interest statement

Conflict of interest

None.

Copyright © 2018 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Figures

Figure 1
Figure 1
MIP of the abdominal aorta and bilateral lower extremity run-off generated from first-pass acquisition after bolus intravenous injection of ferumoxytol. Note the excellent definition of vascular structures and virtually complete lack of enhancement of non-vascular structures.
Figure 2
Figure 2
Atherosclerotic plaque resulting in right superficial femoral artery (SFA) stenoses. (a) High-resolution steady-state FE-MRA curved multiplanar reformatted (CMPR) image of the right SFA demonstrating significant atherosclerotic plaque diffusely distributed in the proximal segment (straight line) and focally distributed in the distal segment (dashed line) with relatively minimal disease in the intervening segment (dotted line). (b–d). Orthogonal axial reformatted images showing the cross-sectional patency of the SFA at each location from part (a). (e) MIP from the first-pass acquisition during the same examination appears to overestimate the degree of disease proximally (white arrow) and underestimate it distally (dashed arrow). (f,g) Pre-and post-stent angiograms in the proximal SFA respectively.
Figure 3
Figure 3
Mid-to-distal SFA with multifocal dissection and focal occlusion. (a) CMPR image from a steady-state FE-MRA of the SFA (arrowheads), demonstrating multifocal dissections (white line and dotted line) as well as a complex lesion distally (dashed line) with a combination of dissection and occlusion. (b–d) Orthogonal axial reformatted images at each level showing the dissection flaps (solid arrow and dotted arrow) as well as the occluded true lumen and surrounding false lumen of the complex lesion (dashed arrow).
Figure 4
Figure 4
Distal right SFA occlusion. (a) First-pass FE-MRA MIP demonstrates patent proximal SFA (arrowheads) and the occlusion (bracket) with distal reconstitution of the popliteal artery (star) by profunda femoris artery collaterals. (b) Steady-state CMPR image shows the patent proximal SFA (arrowheads) as well as the low signal intensity occlusion (bracket) and reconstituted popliteal artery (star). The orthogonal axial reformatted images show patent SFA (c), occluded SFA (d) and patent reconstituted popliteal artery (e), respectively (arrows).
Figure 5
Figure 5
Large SFA aneurysm. (a) First-pass FE-MRA MIP demonstrating the flow channel of the aneurysm. (b) Steady-state CMPR image demonstrates the flow channel and mural thrombus of the aneurysm. (c) Orthogonal axial reformatted images show the true diameter of the aneurysm (arrows); (d) a section of relatively normal artery that could accept a stent graft (dotted arrow); and (e) an incidental irregular eccentric plaque (dashed arrow).
Figure 6
Figure 6
FE-MRA evaluation of the tibial vessels prior to fibular flap reconstructive surgery. (a) First-pass MIP showing normal arterial anatomy and patent vessels. (b–d) Steady-state CMPR images through each of the tibial arteries confirming patency. (e) Steady-state axial reformatted image in the calf showing a typical configuration of each tibial artery between two adjacent veins: posterior tibial artery (carat), peroneal artery (arrowhead), and anterior tibial artery (arrow).
Figure 7
Figure 7
Femoral vein normal valve leaflets visualised in axial (a) and oblique coronal (b) planes (arrows).
Figure 8
Figure 8
Chronic femoropopliteal DVT. (a) Steady-state FE-MRV CMPR image shows chronic retracted eccentric thrombus (short arrows). (b,c) Orthogonal axial reformatted images at the levels indicated in (a) showing web formation (dashed arrow) (b), and non-occlusive eccentric thrombus (dotted arrow) (c). (d) Extent of residual clot is more completely demonstrated than on corresponding longitudinal greyscale ultrasound image from 1 day prior.
Figure 9
Figure 9
A 23-year-old women with multiple abdominal surgeries for short gut syndrome requiring central venous access for total parenteral nutrition and difficulty with prior attempts at venous access. (a) Volume-rendered and (b) coronal MIP FE-MRV, which demonstrates bilateral subclavian vein and internal jugular vein occlusion with collateralisation (dashed arrows) via anterior chest wall and paravertebral plexus and a 6 mm non-occlusive thrombus in SVC (solid arrow). (c) A Hickman catheter was placed in the right external jugular vein.
Figure 10
Figure 10
FE-MRV in a patient with pelvic congestion syndrome. (a) Coronal MIP shows numerous collaterals throughout the pelvis (arrowheads). Connection is identified to both internal iliac veins (white arrows). (b) Coronal MIP shows enlarged complex bilateral ovarian vein networks bilaterally (dashed white arrows and prominent vulvar varices (carats).

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Source: PubMed

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