Skip to main content
SpringerLink
Log in

Diagnostic accuracy of non-contrast quiescent-interval slice-selective (QISS) MRA combined with MRI-based vascular calcification visualization for the assessment of arterial stenosis in patients with lower extremity peripheral artery disease

  • Cardiac
  • Published:
European Radiology Aims and scope Submit manuscript

Abstract

Objectives

The proton density–weighted, in-phase stack-of-stars (PDIP-SOS) MRI technique provides calcification visualization in peripheral artery disease (PAD). This study sought to investigate the diagnostic accuracy of a combined non-contrast quiescent-interval slice-selective (QISS) MRA and PDIP-SOS MRI protocol for the detection of PAD, in comparison with CTA and digital subtraction angiography (DSA).

Methods

Twenty-six prospectively enrolled PAD patients (70 ± 8 years) underwent lower extremity CTA and 1.5-T or 3-T PDIP-SOS/QISS MRI prior to DSA. Two readers rated image quality and graded stenosis (≥ 50%) on QISS MRA without/with calcification visualization. Sensitivity, specificity, and area under the curve (AUC) were calculated against DSA. Calcification was quantified and compared between MRI and non-contrast CT (NCCT) using paired t test, Pearson’s correlation, and Bland-Altman analysis.

Results

Image quality ratings were significantly higher for CTA compared to those for MRA (4.0 [3.0–4.0] and 3.0 [3.0–4.0]; p = 0.0369). The sensitivity and specificity of QISS MRA, QISS MRA with PDIP-SOS, and CTA for ≥ 50% stenosis detection were 85.4%, 92.2%, and 90.2%, and 90.3%, 93.2%, and 94.2%, respectively, while AUCs were 0.879, 0.928, and 0.923, respectively. A significant increase in AUC was observed when PDIP-SOS was added to the MRA protocol (p = 0.0266). Quantification of calcification showed significant differences between PDIP-SOS and NCCT (80.6 ± 31.2 mm3 vs. 88.0 ± 29.8 mm3; p = 0.0002) with high correlation (r = 0.77, p < 0.0001) and moderate mean of differences (− 7.4 mm3).

Conclusion

QISS MRA combined with PDIP-SOS MRI provides improved, CTA equivalent, accuracy for the detection of PAD, although its image quality remains inferior to CTA.

Key Points

• Agreement in stenosis detection rate using non-contrast quiescent-interval slice-selective MRA compared to DSA improved when calcification visualization was provided to the readers.

• An increase was observed in both sensitivity and specificity for the detection of ≥ 50% stenosis when MRI-based calcification assessment was added to the protocol, resulting in a diagnostic accuracy more comparable to CTA.

• Quantification of calcification showed statistical difference between MRI and non-contrast CT; however, a high correlation was observed between the techniques.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

Abbreviations

ABI:

Ankle brachial index

CI:

Confidence interval

ICC:

Intraclass correlation coefficient

MIP:

Maximum intensity projection

NCCT:

Non-contrast computed tomography

PAD:

Peripheral artery disease

PDIP-SOS:

Proton density–weighted, in-phase stack-of-stars

PETRA:

Point-wise encoding time reduction with radial acquisition

QISS:

Quiescent-interval slice-selective

UTE:

Ultra-short echo time

VNC:

Virtual non-contrast

References

  1. Criqui MH, Aboyans V (2015) Epidemiology of peripheral artery disease. Circ Res 116:1509–1526

    Article  CAS  Google Scholar 

  2. Hiatt WR, Hoag S, Hamman RF (1995) Effect of diagnostic criteria on the prevalence of peripheral arterial disease. The San Luis Valley Diabetes Study. Circulation 91:1472–1479

    Article  CAS  Google Scholar 

  3. Pollak AW, Norton PT, Kramer CM (2012) Multimodality imaging of lower extremity peripheral arterial disease: current role and future directions. Circ Cardiovasc Imaging 5:797–807

    Article  Google Scholar 

  4. Ouwendijk R, Kock MC, van Dijk LC, van Sambeek MR, Stijnen T, Hunink MG (2006) Vessel wall calcifications at multi-detector row CT angiography in patients with peripheral arterial disease: effect on clinical utility and clinical predictors. Radiology 241:603–608

    Article  Google Scholar 

  5. Davenport MS, Khalatbari S, Cohan RH, Dillman JR, Myles JD, Ellis JH (2013) Contrast material-induced nephrotoxicity and intravenous low-osmolality iodinated contrast material: risk stratification by using estimated glomerular filtration rate. Radiology 268:719–728

    Article  Google Scholar 

  6. Mathur M, Jones JR, Weinreb JC (2020) Gadolinium deposition and nephrogenic systemic fibrosis: a radiologist’s primer. Radiographics 40:153–162

    Article  Google Scholar 

  7. American College of Rardiology Committee on Drugs and Contrast Media. ACR manual on contrast media. Available at: https://www.acr.org/-/media/ACR/Files/Clinical-Resources/Contrast_Media.pdf. Accessed 3 June 2020

  8. Tranche-Iparraguirre S, Marin-Iranzo R, Fernandez-de Sanmamed R, Riesgo-Garcia A, Hevia-Rodriguez E, Garcia-Casas JB (2012) Peripheral arterial disease and kidney failure: a frequent association. Nefrologia 32:313–320

    PubMed  Google Scholar 

  9. Edelman RR, Sheehan JJ, Dunkle E, Schindler N, Carr J, Koktzoglou I (2010) Quiescent-interval single-shot unenhanced magnetic resonance angiography of peripheral vascular disease: technical considerations and clinical feasibility. Magn Reson Med 63:951–958

    Article  Google Scholar 

  10. Varga-Szemes A, Wichmann JL, Schoepf UJ et al (2017) Accuracy of noncontrast quiescent-interval single-shot lower extremity MR angiography versus CT angiography for diagnosis of peripheral artery disease: comparison with digital subtraction angiography. JACC Cardiovasc Imaging 10:1116–1124

    Article  Google Scholar 

  11. Hodnett PA, Ward EV, Davarpanah AH et al (2011) Peripheral arterial disease in a symptomatic diabetic population: prospective comparison of rapid unenhanced MR angiography (MRA) with contrast-enhanced MRA. AJR Am J Roentgenol 197:1466–1473

    Article  Google Scholar 

  12. Amin P, Collins JD, Koktzoglou I et al (2014) Evaluating peripheral arterial disease with unenhanced quiescent-interval single-shot MR angiography at 3 T. AJR Am J Roentgenol 202:886–893

    Article  Google Scholar 

  13. Altaha MA, Jaskolka JD, Tan K et al (2017) Non-contrast-enhanced MR angiography in critical limb ischemia: performance of quiescent-interval single-shot (QISS) and TSE-based subtraction techniques. Eur Radiol 27:1218–1226

    Article  Google Scholar 

  14. Ferreira Botelho MP, Koktzoglou I, Collins JD et al (2017) MR imaging of iliofemoral peripheral vascular calcifications using proton density-weighted, in-phase three-dimensional stack-of-stars gradient echo. Magn Reson Med 77:2146–2152

    Article  CAS  Google Scholar 

  15. Serhal A, Koktzoglou I, Aouad P et al (2018) Cardiovascular magnetic resonance imaging of aorto-iliac and ilio-femoral vascular calcifications using proton density-weighted in-phase stack of stars. J Cardiovasc Magn Reson 20:51

    Article  Google Scholar 

  16. Fleischmann D, Kamaya A (2009) Optimal vascular and parenchymal contrast enhancement: the current state of the art. Radiol Clin North Am 47:13–26

    Article  Google Scholar 

  17. Fraioli F, Catalano C, Napoli A et al (2006) Low-dose multidetector-row CT angiography of the infra-renal aorta and lower extremity vessels: image quality and diagnostic accuracy in comparison with standard DSA. Eur Radiol 16:137–146

    Article  Google Scholar 

  18. Schneider CA, Rasband WS, Eliceiri KW (2012) NIH image to ImageJ: 25 years of image analysis. Nat Methods 9:671–675

    Article  CAS  Google Scholar 

  19. Bischoff B, Kantert C, Meyer T et al (2012) Cardiovascular risk assessment based on the quantification of coronary calcium in contrast-enhanced coronary computed tomography angiography. Eur Heart J Cardiovasc Imaging 13:468–475

    Article  Google Scholar 

  20. Wagner M, Knobloch G, Gielen M et al (2015) Nonenhanced peripheral MR-angiography (MRA) at 3 tesla: evaluation of quiescent-interval single-shot MRA in patients undergoing digital subtraction angiography. Int J Cardiovasc Imaging 31:841–850

    Article  Google Scholar 

  21. Hodnett PA, Koktzoglou I, Davarpanah AH et al (2011) Evaluation of peripheral arterial disease with nonenhanced quiescent-interval single-shot MR angiography. Radiology 260:282–293

    Article  Google Scholar 

  22. Klasen J, Blondin D, Schmitt P et al (2012) Nonenhanced ECG-gated quiescent-interval single-shot MRA (QISS-MRA) of the lower extremities: comparison with contrast-enhanced MRA. Clin Radiol 67:441–446

    Article  CAS  Google Scholar 

  23. Ward EV, Galizia MS, Usman A, Popescu AR, Dunkle E, Edelman RR (2013) Comparison of quiescent inflow single-shot and native space for nonenhanced peripheral MR angiography. J Magn Reson Imaging 38:1531–1538

    Article  Google Scholar 

  24. Sharma S, Boujraf S, Bornstedt A et al (2010) Quantification of calcifications in endarterectomy samples by means of high-resolution ultra-short echo time imaging. Invest Radiol 45:109–113

    Article  Google Scholar 

  25. Du J, Corbeil J, Znamirowski R et al (2011) Direct imaging and quantification of carotid plaque calcification. Magn Reson Med 65:1013–1020

    Article  Google Scholar 

  26. Edelman RR, Flanagan O, Grodzki D, Giri S, Gupta N, Koktzoglou I (2015) Projection MR imaging of peripheral arterial calcifications. Magn Reson Med 73:1939–1945

    Article  Google Scholar 

  27. Serhal A, Koktzoglou I, Edelman RR (2019) Feasibility of image fusion for concurrent MRI evaluation of vessel lumen and vascular calcifications in peripheral arterial disease. AJR Am J Roentgenol 212:914–918

    Article  Google Scholar 

  28. Dietrich O, Raya JG, Reeder SB, Reiser MF, Schoenberg SO (2007) Measurement of signal-to-noise ratios in MR images: influence of multichannel coils, parallel imaging, and reconstruction filters. J Magn Reson Imaging 26:375–385

    Article  Google Scholar 

  29. Norgren L, Hiatt WR, Dormandy JA et al (2007) Inter-society consensus for the management of peripheral arterial disease (TASC II). J Vasc Surg 45(Suppl S):S5–S67

    Article  Google Scholar 

  30. Lin JH, Brunson A, Romano PS, Mell MW, Humphries MD (2019) Endovascular-first treatment is associated with improved amputation-free survival in patients with critical limb ischemia. Circ Cardiovasc Qual Outcomes 12:e005273

    PubMed  PubMed Central  Google Scholar 

Download references

Funding

This study was supported by a research grant from Siemens and by NIH NHLBI R01 HL130093 (RRE).

Author information

Authors and Affiliations

  1. Division of Cardiovascular Imaging, Department of Radiology and Radiological Science, Medical University of South Carolina, Ashley River Tower, MSC 226, 25 Courtenay Dr, Charleston, SC, 29425, USA

    Akos Varga-Szemes, Megha Penmetsa, Tilman Emrich, Pal Suranyi, Stephen R. Fuller & U. Joseph Schoepf

  2. Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg-University, Mainz, Germany

    Tilman Emrich

  3. German Centre for Cardiovascular Research, Partner Site Rhine-Main, Mainz, Germany

    Tilman Emrich

  4. Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA

    Thomas M. Todoran

  5. Department of Radiology, NorthShore University, Evanston, IL, USA

    Robert R. Edelman & Ioannis Koktzoglou

  6. Northwestern University Feinberg School of Medicine, Chicago, IL, USA

    Robert R. Edelman

  7. University of Chicago Pritzker School of Medicine, Chicago, IL, USA

    Ioannis Koktzoglou

Authors
  1. Akos Varga-Szemes
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Megha Penmetsa
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Tilman Emrich
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Thomas M. Todoran
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Pal Suranyi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Stephen R. Fuller
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Robert R. Edelman
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Ioannis Koktzoglou
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. U. Joseph Schoepf
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to U. Joseph Schoepf.

Ethics declarations

Guarantor

The scientific guarantor of this publication is U. Joseph Schoepf.

Conflict of interest

The authors of this manuscript declare relationships with the following companies: U. Joseph Schoepf is a consultant for and/or receives research support from Astellas, Bayer, Elucid Bioimaging, Guerbet, HeartFlow Inc., and Siemens Healthcare. Akos Varga-Szemes receives institutional research and travel support from Siemens Healthcare and is a consultant for Elucid Bioimaging. Robert R. Edelman receives grant support and royalties from Siemens Healthcare. Ioannis Koktzoglou receives research support from Siemens Healthcare.

Statistics and biometry

One of the authors has significant statistical expertise.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.

Methodology

• prospective

• diagnostic or prognostic study

• performed at one institution

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Varga-Szemes, A., Penmetsa, M., Emrich, T. et al. Diagnostic accuracy of non-contrast quiescent-interval slice-selective (QISS) MRA combined with MRI-based vascular calcification visualization for the assessment of arterial stenosis in patients with lower extremity peripheral artery disease. Eur Radiol 31, 2778–2787 (2021). https://doi.org/10.1007/s00330-020-07386-4

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00330-020-07386-4

Keywords

Search

Navigation