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Pedal MR Angiography VII.3_Maki 6-06-2005 19:25 Pagina 285 VII.3 Pedal MR Angiography Jeffrey H. Maki Clinical Indications/Background often the below knee popliteal artery (41%), con- sistent with the majority of disease being in the in- Ischemic disease of the foot remains an important frapopliteal vessels. complication of atherosclerotic vascular disease, particularly in the diabetic population, who have a In order to achieve results such as these, accu- 15-46 times higher incidence of lower extremity rate mapping and understanding of the vascular amputation than do nondiabetics [1]. In fact, a anatomy is required to optimally choose the distal large surgical review of patients undergoing ve- anastomotic site, as outcome has been shown to be nous grafting to the pedal arteries for limb salvage directly related to the adequacy of pedal outflow recorded a 95% incidence of diabetes [2]. Further- [10-12]. Thus a complete preoperative evaluation more, 55% of these cases were complicated by in- must sufficiently depict the pedal vasculature to al- fection. Other factors contributing to diabetic ped- low for the management decision of revasculariza- al disease include peripheral neuropathy, structur- tion vs. amputation vs. medical therapy. Until re- al foot deformities, and soft tissue ulceration [1]. cently, conventional x-ray digital subtraction an- The ultimate therapeutic goal under these circum- giography (DSA) was considered the gold standard stances, as with all ischemic disease, is the restora- for evaluating peripheral vascular anatomy [10, tion of pulsatile blood flow to the affected region. 13]. Recent experience with peripheral magnetic Thus evaluation of the ischemic foot, typically dia- resonance angiography (MRA), however, suggests betic and often infected, is the most common indi- MRA is superior to DSA in terms of visualizing in- cation for pedal angiography. frapopliteal runoff vessels, and thus the term an- giographically “occult” vessel emerged [9, 14-18 ]. Recent surgical thinking and techniques have Regardless of modality, pedal arterial imaging moved away from primary amputation toward must adequately depict the arterial anatomy (see revascularization for limb salvage in pedal is- paragraph “Normal Anatomy” below). Luminal en- chemic disease [2-8].This is in part because the hancement must be sufficient to define vessels to pedal arteries (particularly the dorsalis pedis) of- at least the distal metatarsal level, and resolution ten remain patent despite severe multilevel proxi- must be adequate to assess the patency of main mal disease, which in diabetics is most often in the pedal branch vessels as well as define any stenoses infra-popliteal arteries [2, 9]. A recent study fol- distal to a planned site of graft anastomosis [10]. lowing two subgroups with limb-threatening ped- In addition, the primary and secondary pedal al ischemia (108 patients), demonstrated that the arches must be evaluated for patency, as limb sal- subgroup treated with bypass grafting had a much vage has been shown to be related to patency of more favorable limb preservation rate than those the pedal arch [10, 11, 19]. treated non-surgically (limb salvage rates at 1 and 24 months of 95/85% vs. 35/17% respectively) [7]. A separate ten year review of 1032 patients (92% Normal Anatomy with diabetes) undergoing dorsalis pedis grafting for limb-threatening ischemia demonstrated five Pedal arterial anatomy can be divided into the an- year primary patency, secondary patency, and limb terior circulation, the posterior circulation, and the salvage rates of 57%, 63%, 78% respectively [3] . In pedal arches, which connect the two circulations this study, the inflow portion of the graft was most (Figs. 1-3). The anterior circulation consists of the VII.3_Maki 6-06-2005 19:25 Pagina 286 286 Magnetic Resonance Angiography a b Fig. 1. Pedal arteries. Frontal (a) and plantar (b) views a b A Anterior tibial artery 1 Posterior tibial artery B Dorsalis pedis artery 2 Medial plantar artery C Lateral tarsal artery 3 Lateral plantar artery D Perforating arteries 4 Plantar arch E Dorsal metatarsal arteries 5 Superficial branch 6 Perforating arteries 7 Plantar metatarsal arteries dorsalis pedis artery, the medial and lateral tarsal Technique arteries, the arcuate artery, and the deep plantar (or perforating) artery. These vessels are all quite Pedal MRA is most commonly performed as 2D small, with the dorsalis pedis artery being 2.0 – 3.0 TOF or 3D CE-MRA. In general, 3D CE-MRA is mm in diameter [20]. The posterior circulation be- less prone to artifacts and of better diagnostic gins as the distal posterior tibial (or common plan- quality [21, 22], but we believe both should be per- tar) artery, bifurcating into the medial and lateral formed, as shortcomings with either sequence may plantar arteries. The lateral plantar artery contin- be overcome by evaluating the two exams simulta- ues as the plantar arch, which anastomoses to the neously (Fig. 4) [23]. Other authors advocate 2D deep plantar artery, thereby forming the primary CE-MRA as an alternative to 3D-CE MRA. (24, 25) pedal arch. The first dorsal metatarsal artery is the Pedal MRA can be performed as a targeted pedal largest artery off of the primary arch, being 1.0 to only exam, as part of a multi-station complete pe- 1.5 mm in diameter [20]. Secondary arches may ripheral MRA study, or as part of an entire below form via knee lower extremity MRA [9, 21, 23, 26]. Regard- (a) the dorsalis pedis, lateral tarsal, lateral plan- less of the context, several basic principles apply, tar, and common plantar arteries, and these will be discussed in detail. (b) the dorsalis pedis, the medial tarsal, the me- dial plantar, and common plantar arteries, or (c) dorsalis pedis, arcuate artery, lateral plan- Coils tar, and common plantar arteries (Figs. 2, 3). In imaging, non-filling of one of these named High quality pedal MRA, like MR of any small re- segments cannot be considered definitive occlu- gion, requires an appropriately sized birdcage or sion unless clearly opacified unnamed pedal ves- surface phased array coil. For cases of targeted sels and collaterals are seen along its course [10]. pedal only MRA, most investigators use a birdcage VII.3_Maki 6-06-2005 19:25 Pagina 287 VII.3 • Pedal MRA 287 Fig. 3. Lateral DSA. AT = anterior tibial artery, PT = posterior tib- ial artery, Per = peroneal artery, MT = medial tarsal artery, LT = lat- eral tarsal artery, AA = arcuate artery, DP = dorsalis pedis artery, Perf = perforating artery, PA = plantar arch, LP = lateral plantar ar- tery, MP = Medial plantar artery, 1st DM = first dorsal metatarsal ar- tery. The PT is occluded proximally and reconstitutes just above the ankle via collaterals from the Per (c). There is significant disease of the PT just proximal the bifurcation into MT/LT (black arrow) and the distal PT (white arrow). Note the significantly better depiction of tiny vessels compared to MRA (Fig 2) Fig. 2. Pedal MRA demonstrating anatomy of the pedal vascula- ture (lateral view MIP). AT = anterior tibial artery, PT = posterior tibial artery, Per = peroneal artery, MT = medial tarsal artery, LT = lateral tarsal artery, AA = arcuate artery, DP = dorsalis pedis artery, Perf = perforating artery, PA = plantar arch, LP = lateral plantar ar- tery, MP = Medial plantar artery, 1st DM = first dorsal metatarsal ar- tery. Note complete primary arch formed by AT, DP, Perf, PA, LP, PT. Portions of the secondary arches can be visualized. Disease is seen in the distal AT (arrows). This study was performed using the gadolinium blood pool agent MS-325 (EPIX Medical, Cambridge, MA) in the arterial phase quadrature head or knee coil, although new dedi- niques can be used to accelerate data acquisition, cated phased array ankle coils are becoming avail- accelerate volume coverage, or improve resolution. able [9, 14, 15]. In cases where the pedal arteries are included as a part of the entire lower leg (single or multi-station), a larger field of view phased ar- Patient Preparation ray coil is typically used [27, 29]. These can be in- dependent one station coils (e.g. torso array), or As with all CE-MRA techniques, an intravenous larger arrays designed to cover the entire body line (22 g. or better) should be placed in the arm from the abdominal aorta to the feet (e.g. periph- before the patient enters the magnet. The shoes eral vascular). Such coils have the advantage of be- should be removed, and care should be taken to ing capable of imaging both feet simultaneously. ensure any metallic objects such as clips holding Another important advantage to the phased array stretchable bandage material have been removed approach is that parallel imaging techniques such from the foot.When the foot is placed in the coil, a as SENSE become possible [26, 30, 31]. These tech- combination of padding and/or straps should be VII.3_Maki 6-06-2005 19:25 Pagina 288 288 Magnetic Resonance Angiography used to immobilize the foot as much as practical. Imaging Protocol Multi-element phased array coils, if used, can have decreased signal to noise secondary to cross talk if Sample protocols for both 2D TOF and 3D CE- the coil elements are too close to one another, and MRA are shown below (Tables 1, 2). These assume some padding to ensure the coils remain symmet- unilateral pedal only imaging, and can be modified rically spaced from each other can be helpful. The accordingly if planned as part of a peripheral study. foot should be in a relatively neutral position,as Some general considerations follow. First, in order even moderate plantar flexion is known to cause to accurately characterize a stenosis, true spatial an artifactual stenosis of the proximal dorsalis resolution (in all three planes) must be such that pedis artery due to compression by the inferior ex- the vessel is spanned by three pixels – i.e.
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