director of body mri, pr ofessor of radiology university ...€¦ · • 32 y/o male with...
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Advances in Gated MRA of the Thoracic Aorta Using Blood Pool
Agents
Jeffrey H. Maki, MD, PhD, FSCBTMR Director of Body MRI, Professor of Radiology
University of Washington, Seattle, WA
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Disclosures – Jeffrey H. Maki
• Speaker’s Bureau Lantheus Medical • Research Support Bracco Diagnostics • Consultant Bayer Healthcare
• Will discuss “off label” use of
Gadofosveset (Ablavar) and Gadobenate (MultiHance)
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Question #1 Does your practice perform
Blood Pool Imaging? 1. Yes, frequently 2. Occasionally, for specialized uses 3. No, but it seems intriguing … 4. No, because I don’t understand how
to do it 5. No, because I don’t really see any
benefit
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Gd Blood Pool Agents
• Either bind albumin, or macro-aggregates • Contrast stays intravascular (vs. ECF) • Increased temporal window for imaging
- Higher resolution - ECG gating
• Single BP agent approved in USA (2008) = Gadofosveset Trisodium
- Ablavar - Lantheus - Initially “Vasovist” in EU – Bayer - Developmental name “MS-325” - EPIX
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Gadofosveset • Linear Gd Chelate • Added side chain – 80-85% binding albumin • Increased relaxivity (r1 and r2)
- ~3-5x r1 of conventional Gd
• Increased intravascular residence - Intravascular t1/2 ~ 30 min
Gadolinium chelate
Diphenylcyclohexyl moiety
Phosphate diester bridge
Adapted from Leiner T et al, eds. Clinical Blood Pool MR Imaging.
ABLAVAR® [package insert]. North Billerica, MA: Lantheus Medical Imaging, Inc.; 2009.
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MRA with BPA (Gadofosveset) • First pass –similar to conventional Gd
- Dose 0.03 mmol/kg (vs. standard 0.1 mmol/kg)
• Steady state - Begins ~2-5 minutes - Lasts > 30’ - Allows for greater resolution
• Useful for many MRA territories – e.g. peripheral • Venous imaging
- Allows for ECG triggering • Necessary to negate cardiac motion • T. Aorta (esp root) • Coronary arteries
- Allows for large volume coverage
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Gadofosveset 0.03 mmol/kg
Elderly M w/claudication 3-station Runoff
First Pass
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63-year-old male smoker – Suspected AIOD
Steady State Source Image - 1.0 x 0.9 x 0.9 mm resolution
Plaque easily seen
Axial Reformat
Gadofosveset 0.03 mmol/kg – Steady State (Blood Pool)
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BP Agents T. Aorta • Early uses to aimed at coronary imaging
- “Whole Heart” coronary imaging
Kelle, Thouet, Tangcharoen, Nassenstin, Chiribiri, Paetsxh, Schnackernburg, Rarkhausen, Fleck, Nagel. Med Sci Monit. 2007 Nov;13(11):CR469-474.
Non-contrast Gadofosveset
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Steady State Technique Adapted to Imaging Thoracic Aorta
• Naehle et al.+ 2009, University Bonn • Single dose gadofosveset • First pass and steady state – 25 pts • Congenital and acquired diseases thoracic
vasculature • Steady State – ECG gated, 3D IR, 6-8 min,
1.0 x 1.0 x 2.0 mm true resolution
+ Naehle, C. P., Müller, A., Willinek, W. A., Meyer, C., Hestermann, T., Gieseke, J., Schild, H., et al. (2009). First-pass and steady-state magnetic resonance angiography of the thoracic vasculature using gadofosveset trisodium. JMRI, 30(4), 809–816. doi:10.1002/jmri.21919
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Naehle et al. - Aneurysm
Naehle, et al. JMRI, 30(4), 809–816. doi:10.1002/jmri.21919
First Pass Steady State
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Naehle et al.
• First Pass – higher signal • Steady State – sharper, less
interobserver variability in diameter measurement
Naehle, et al. JMRI, 30(4), 809–816. doi:10.1002/jmri.21919
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UW Practice • Many Cases of Aortic Pathology • Congenital
- Bicuspid AOV - Marfan’s - CHD
• Acquired - Aneurysm - Dissection
• Adapted Bonn technique to clinical practice
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Example
• 32 y/o Male with Marfan’s • s/p Type A Dissection, Bentall and St. Jude • 0.04 mmol/kg gadofosveset
- 15 cc @ 1.0 cc/sec • 5 channel cardiac coil • 1.5T
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First Pass Gadofosveset
1st Pass Vol Rend
1st Pass MIP
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Steady State ECG-gated Gadofosveset Delayed Phase - Like Gated CT
Good (Best?) for accurate measurement aortic size
First Pass Steady State
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Steady State ECG-gated Gadofosveset Delayed Phase - Looks like gated CT
Significant improvement in resolution ~ 1 x 1 x 1 mm
Source Images Obl Sag Axial MPR s
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Example
• 21 y/o Male with chronic respiratory sx • Abnormal CXR • Suspicion of arch anomaly • 0.03 mmol/kg gadofosveset• 5 channel cardiac coil • 1.5T
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Chest X-Ray Right Arch, ? Tracheal Narrowing
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First Pass Ablavar MIP – Double Aortic Arch - Atretic left – Vascular Ring
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Delay SS Ablavar Source Images Delay SS Ablavar Source Images
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Delay SS Ablavar Source Images Delay SS Ablavar Axial Reformats
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Delay SS Ablavar MIPs Double Aortic Arch Atretic left
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Double Aortic Arch - Atretic Left 1st pass vs. gated SS
1st pass SS
1st pass
SS
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Technique Useful
• Following up aortic disease • Serial measurements important
- Often done with Echo or CT • Acoustic window/angle problematic Echo • Radiation dose/motion with CT
• ECG-gating necessary, esp closer to root
- Non-gated CE-MRA blurred
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Work 2010 – Ascending Aorta
Potthast, S., Mitsumori, L., Stanescu, L. A., Richardson, M. L., Branch, K., Dubinsky, T. J., & Maki, J. H. (2010). JMRI, 31(1), 177–184. doi:10.1002/jmri.22016
3D Nav Gated SSFP vs. CE-MRA
Also saw worse interobserver variability CE-MRA *Need ECG gating – esp close to root …
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Example
• 15 y/o Male with ? Marfan s • Possible dilated Ao root by echo • 0.03 mmol/kg gadofosveset • 5 channel cardiac coil• 1.5T
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Steady State ECG-gated Gadofosveset Mild Asc Ao Aneurysm
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Steady State ECG-gated Gadofosveset Mild Asc Ao Aneurysm – STJ Effaced
First Pass Steady State
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Steady State ECG-Gated Gadofosveset Mild Asc Ao Aneurysm – STJ Effaced
First Pass Nav SSFP Gadofosveset SS
Shown nav SSFP better than 1st pass Steady State ? better than nav SSFP … but need to do the study (as per coronary – more SNR; also – time efficient for large volumes)
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Technique Simple • Easy free breathing add-on to CE-MRA • Requires cardiac package/ECG gating • Takes 5-8 minutes • Resolution sufficient for good reformats –
- Axial looks very “CTA”-like - More “approachable” to clinicians used to CT
• While standard Gd ECF agents not “blood pool”, they too can work (if fast)
- We have used gadobenate (MultiHance)
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35 M s/p Ross Age 8, Replacement Asc AO w/reimplantion Coronary Arteries Age 28
30 mm Sinus of Valsalva Aneurysm
SS 5’ after 0.1 mmol/kg MultiHance
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35 M s/p Ross Age 8, Replacement Asc AO w/reimplantion Coronary Arteries Age 28
30 mm Sinus of Valsalva Aneurysm
1st Pass CE-MRA SS 5’ after 0.1 mmol/kg MultiHance
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35 M s/p Ross Age 8, Replacement Asc AO w/reimplantion Coronary Arteries Age 28
30 mm Sinus of Valsalva Aneurysm
1st Pass CE-MRA SS 5’ after 0.1 mmol/kg MultiHance
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35 M s/p Ross Age 8, Replacement Asc AO w/reimplantion Coronary Arteries Age 28
Repeated Ablavar 6 mo later
SS 5’ after 0.1 mmol/kg MultiHance SS 5’ after 0.03 mmol/kg Ablavar
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Question #2 Do you think Blood Pool Imaging
has a future in body MRA? 1. Yes, and we should be using it more 2. Yes, but it is a very “niche” imaging
technique only for experienced centers
3. No, it’s too complicated and/or expensive (time and $)
4. No, doesn’t add anything to what we already have
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Conclusion (1/2) • Accurate and reproducible metrics of
the aorta are extremely important • ECG-gating essential
- Decreased blur - Less interobserver variability
• Blood pool agents an appealing solution
- Simple add on, especially if doing 1st pass MRA anyway
- Free breathing – greater resolution/detail
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Conclusion (2/2)
• Our institution has seen good clinical success/acceptance SS MRA
- Implementing 90+% thoracic aortic MRA’s - > 100 cases to date
• Need studies to compare: - Nav SSFP vs. SS Blood Pool MRA - SS Blood Pool MRA gadofosveset vs. “other ECF”