Pages From 2003, Vol.41, Issues 1, Body MR Imaging

Radiol Clin N Am 41 (2003) 115 144
MR angiography of the abdominal aorta

and peripheral vessels
Vincent B. Ho, MDa,*, William R. Corse, DOb
a
Department of Radiology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda,
MD 20814, USA
b
MR Imaging, Doylestown Hospital, 595 West State Street, Doylestown, PA 18901, USA
MR angiography (MRA), in particular gadolinium

(Gd)-enhanced three-dimensional MRA, is well
suited for the evaluation of patients with suspected
or known disease of the abdominal aorta and peripheral vessels [1 3]. In most of these patients, the
underlying vascular disease is degenerative and associated with atherosclerosis. Atherosclerosis and its
related sequelae are leading causes for morbidity and
mortality in the Western world. Renal insufficiency is
prevalent in this population because of underlying
diabetes mellitus or renal artery disease. The ability
of MRA to provide reliable arterial depiction without
the need for the use of nephrotoxic contrast agents
(eg, iodinated contrast media) is one of the more
compelling arguments for the use of MRA in this
patient population.
Time-of-flight and phase-contrast MRA

The potential of MR imaging to illustrate arterial
structures noninvasively using time-of-flight (TOF)
and phase-contrast (PC) MRA has been known for
almost two decades [4 6]. These techniques rely on
The opinions or assertions contained herein are the private

views of the authors and not to be construed as official or
reflecting the views of the Uniformed Services University of
the Health Sciences or the Department of Defense.
* Corresponding author.
E-mail address: vho@usuhs.mil or vho@nih.gov
(V.B. Ho).
the properties of moving protons (flowing blood) and

can be performed as either a two- or a three-dimensional acquisition. TOF MRA relies on flow-related
enhancement or in-flow effect caused by the entry
of unsaturated protons into the imaging slice (twodimensional) or volume (three-dimensional). Arterialto-background image contrast is improved by the
application of repetitive radiofrequency pulses to
suppress the signal from stationary background tissue. Arterial in-flow (and arterial signal) is highest if
blood flow is brisk; the imaging slice (or volume in
the case of three-dimensional TOF) is thin; and
imaging is performed perpendicular to the direction
of flow. Vertically oriented vessels, such as the aorta
and peripheral arteries, are best imaged using axial
TOF scanning. Unfortunately, the acquisition of
images perpendicular to the length of the vessel is
inefficient and can result in long acquisition times.
Axial two-dimensional TOF MRA of the peripheral
vessels (from the aortic bifurcation to the ankle) can
often require 2 or more hours to accomplish. Long
imaging times increase the likelihood of motion
artifacts not only from physiologic motion (eg, respiration and peristalsis) but also from bulk patient
movement. This is further complicated by the fact
that viewing of the vessels is best performed in their
long axis. The use of thicker slices or partitions to
shorten acquisition time has the untoward effect of
not only increased saturation concerns but also
decreasing the spatial resolution of the vessels on
the subsequent longitudinal image reformation used
for image interpretation.
The other traditional MRA technique is PC, which
relies on the phase shifts that protons experience
0338-3890/03/$ see front matter D 2003, Elsevier Science (USA). All rights reserved.
PII: S 0 3 3 8 - 3 8 9 0 ( 0 2 ) 0 0 0 6 2 - 3
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V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144
when they move along a gradient field. In practice,

PC MRA generally requires longer scan times and is
technically more challenging to perform than TOF
MRA and not widely used. For targeted imaging of
smaller vascular regions, however, such as the renal
arteries, PC MRA has been found to be useful,
especially as an adjunct to TOF MRA [7 9]. For a
PC MRA, the operator must set an appropriate flow
direction and velocity encoding, which in cases with
complex flow or geometries may be difficult to
determine a priori.
Because TOF and PC imaging rely on flow, both
techniques are prone to artifacts related to disruptions
or variations in blood flow (eg, pulsatile flow and
turbulent flow) [10,11]. Turbulent flow is particularly
problematic because it results in intravoxel phase
dispersion and ultimately in vascular signal loss. This
is common about stenoses and regions with complex
geometries, which unfortunately are typically the
regions of clinical interest. Intravoxel dephasing is a
known limitation of TOF and PC MRA, which results
in the overestimation of the severity of a stenosis or
even in the erroneous appearance of a stenosis or
occlusion. These pitfalls and the other previously
mentioned issues related to TOF and PC imaging
have contributed to the general lack of enthusiasm for

their routine clinical use for imaging of the aorta and
peripheral vessels.
Gd-enhanced three-dimensional MRA

In the early 1990s, a new MRA technique
for aortography called Gd-enhanced three-dimensional MRA was introduced by Prince et al [12].
Unlike TOF and PC MRA, this method does not
rely on blood flow but rather on the T1 shortening
effects of circulating Gd-chelate contrast media. The
technique is quick, fairly easy to perform, and provides
high-resolution three-dimensional arterial image sets.
Artifacts related to spin saturation, slow flow, or
turbulent flow encountered with TOF are minimal
for Gd-enhanced three-dimensional MRA. As a result,
Gd-enhanced three-dimensional MRA can be tailored
for most efficient high spatial resolution imaging
(ie, parallel to the length of the vessel).
On Gd-enhanced three-dimensional MRA, arterial
signal relies on the concentration of Gd within
the lumen of the vessel during image acquisition.
The resultant images are essentially lumingrams
Fig. 1. A 77-year-old man with hypertension. On standard coronal maximum intensity projection (MIP) (A) from a Gd-enhanced
three-dimensional MRA, the proximal renal arteries are noted to be normal and patent. On oblique coronal MIP (B) and axial
subvolume MIP (C), however, the occluded left upper pole segmental renal artery (large arrow) and the moderate stenosis (small
arrow) of the left lower pole segmental renal artery are better visualized.
117
Fig. 2. A 49-year-old man with rectal cancer. Gd-enhanced three-dimensional MRA of the aortoiliac vessels was performed as a
preprocedural road map for intra-arterial chemotherapy planning. The arterial anatomy is well seen on volume-rendered projection of the three-dimensional data set. (A) Coronal maximum intensity projection (MIP). (B) Sagittal MIP.
118
Fig. 3. An 82-year-old woman suspected of having

mesenteric ischemia. Coronal volume-rendered projection
of the Gd-enhanced three-dimensional MRA demonstrates
normal orientation of the celiac artery and superior mesenteric
artery. Multiplanar reformation (not shown) noted both
vessels to have a normal caliber.
similar to that of conventional x-ray angiography.

Gd-enhanced three-dimensional MRA provides
data that can be formatted in angiographic projections
identical to those of x-ray angiography (views familiar to referring surgeons) without the risks related
to catheterization, nephrotoxicity, and radiation exposure inherent to x-ray angiography. Gd-enhanced
three-dimensional MRA has the additional benefit
of providing volumetric (three-dimensional) angiographic data sets, which can be used for improved
projectional viewing. Arteries are often tortuous
or obscured by overlapping structures (eg, large
aneurysm) on conventional x-ray angiography. Gdenhanced three-dimensional MRA can provide not
only the standard angiographic projections but also
the opportunity to view arteries in nonstandard obliquities using maximum intensity projection (MIP).
Overlying structures can be removed easily using
subvolume MIP (Fig. 1) or multiplanar reformation
(MPR). The three-dimensional data can also be
processed for advanced viewing using volume rendering, shaded surface display, and virtual intraarterial endoscopy [13,14]. Direct volume rendering
(Figs. 2 4) often can provide a different perspective
and may be helpful not only for image interpretation
but also for preoperative surgical discussions and
conferences. Standard MIP and MPR, however,
are all that are typically needed for routine interpretation [13].
Gadolinium-enhanced three-dimensional MRA
has consistently been shown to be accurate and
preferable to traditional noncontrast MRA techniques
for evaluation of not only the aorta but also the
lower extremity arteries [1 3]. In many institutions,
Gd-enhanced three-dimensional MRA is steadily
emerging as the preferred method for evaluation
of the abdominal aorta, and the peripheral run-off
vessels. The growing popularity of Gd-enhanced
three-dimensional MRA has been facilitated by MR
scanner and equipment manufacturers who have
designed new pulse sequences, interactive timing
algorithms, improved user-interfaces, and coil products specifically for the performance of Gd-enhanced
three-dimensional MRA. In addition, a large variety
of vendor and third-party products are now available
for soft-copy interpretation and viewing of the threedimensional data sets. In the ensuing sections, the
theory and technical considerations associated with
Gd-enhanced three-dimensional MRA are discussed
followed by a brief clinical discussion of interpretative issues for several common clinical indications
for MRA of the abdominal aorta, its branches, and
peripheral vessels.
Principle of Gd-enhanced three-dimensional MRA

Arterial depiction is optimized by proper timing of
data acquisition, especially the low spatial frequency
Fig. 4. A 69-year-old woman with a celiac artery aneurysm.

The volume-rendered projection of a Gd-enhanced threedimensional MRA clearly illustrates an aneurysm of the
celiac artery (arrow).
k-space data (center of k-space) for the period of peak

arterial enhancement (ie, peak concentration of Gd)
[15 17]. Late data acquisition can result in substantial venous contamination of the image sets and can
hinder image interpretation. Premature image acquisition can result in insufficient arterial Gd and poor
vascular depiction. The acquisition of central k-space
data during the period of preferential arterial enhancement (arterial phase) is generally preferable. Gdenhanced three-dimensional MRA was originally
described using a slow venous infusion 40 to 60 mL
Gd-chelate contrast media during a long (3 to
4 minutes) three-dimensional spoiled gradient echo
acquisition, one typically used for three-dimensional TOF MRA, leading to its early description as
Gd-enhanced three-dimensional TOF MRA. The
slow contrast infusion (0.3 mL/second) prolonged
the arterial phase of enhancement and delayed significant venous enhancement, extending the time
window for preferential arterial enhancement (Fig. 5).
Improvements in gradient strength and pulse
sequence design have yielded faster data acquisition
speeds (eg, 20 to 30 seconds per three-dimensional
acquisition, and recently with sensitivity encoding
119
[18] 10 to 20 seconds per three-dimensional acquisition). This has enabled the performance of breathhold
image acquisition, which minimizes respiratory
motion artifacts and significantly improves arterial
visualization of abdominal aortic branch vessels
[19 22]. Faster imaging, however, has necessitated
more accurate timing of data acquisition.
Timing
There are several methods for achieving proper
timing of a Gd-enhanced three-dimensional MRA
[15,19,20,23 26]. The simplest is using a fixed
timing delay (eg, 15 seconds). This can often be
unreliable, however, because circulatory times are
highly variable, especially if the patient has a poor
ejection fraction or large capacious aortic aneurysm.
The arrival of a contrast bolus in the abdominal aorta
can take from 10 to 60 seconds [19]. The preferred
methods are the use of a timing bolus injection
[19,20], a triggering algorithm [23,24,26], or a fast
multiphase technique [25]. The timing bolus strategy
entails the administration of a small 1- to 2-mL test
bolus at the same rate as the actual bolus (eg, 2 mL/
Fig. 5. Diagram of vascular signal intensity as it relates to bolus injection rate. Fast bolus injection results in higher arterial
contrast media concentrations and higher signal intensity. With faster injection rates, however, the duration of preferential arterial
enhancement is diminished because of earlier and more significant venous enhancement than seen with slower injection rates.
Slow injection rates prolong the arterial phase; however, the maximum arterial concentration of contrast media is lower. Very
slow injection rates may result in insufficient signal for adequate arterial visualization. (From Ho VB, Choyke PL, Foo TKF, et al.
Automated bolus chase peripheral MR angiography: initial practical experiences and future directions of this work-in-progress.
J Magn Reson Imaging 1999;10:376 88; with permission.)
120
second for a Gd-enhanced three-dimensional MRA of

the aorta) and imaging the target vessel at a high
enough temporal rate (eg, one to two frames per
second). For this technique it is critical that sufficient
flush (eg, 30 mL) is used to ensure that the bolus is
within the central vasculature and that the contrast
injections of the test bolus and actual bolus are
similar. Use of an MR imaging-compatible injector
(eg, Spectris, Medrad, Indianola, PA; and Optistar,
Mallinckrodt, St. Louis, MO) minimizes variations in
the delivery of contrast boluses. If monitoring is
performed in a plane perpendicular to the vessel
(eg, axial timing scan for the abdominal aorta),
superior and inferior saturation bands should be used
to minimize the in-flow signal and ensure vascular
signal is attributable only to the contrast bolus arrival.
The merit of this method is that it can be universally
performed on all current scanner platforms.
There also are several vendor-specific real-time

triggering options for Gd-enhanced three-dimensional
MRA. In one technique called automated bolus
detection algorithm (SmartPrep, GE Medical Systems, Waukesha, WI [23]), a monitoring volume is
placed in addition to the three-dimensional MRA
volume. The algorithm is able to detect the bolus
arrival into the monitoring volume and automatically
initiates the MRA data acquisition once the operatordefined thresholds are exceeded. There is a change in
scanner noise between the monitoring phase and the
MRA data acquisition that provides an audible cue
for the coordination of the patients breathholding.
Another real-time triggering algorithm uses MR
fluoroscopy (BolusTrak, Philips Medical Systems,
Best, The Netherlands; Care Bolus, Siemens Medical
Systems, Iselin, NJ). This technique provides a MR
fluoroscopic image of the target vasculature and
Fig. 6. Proper alignment of preferential arterial-phase enhancement for a variety of k-space schemes used for Gd-enhanced threedimensional MRA. The critical issue for all the schemes is for the central k-space data (ie, low spatial frequency data) to be
acquired during the plateau phase of arterial enhancement. In the conventional sequential k-space scheme, the central k-space
data are acquired during the middle of the data acquisition period. In both the conventional centric and elliptical centric
acquisition schemes, the central k-space data are obtained at the beginning of imaging. Note that with conventional centric
acquisitions, k-space is only centric in ky and that the high spatial frequency encodings in kz are also acquired during each linear
pass and the central k-space encodings in ky and kz are gathered more efficiently (ie, acquired more quickly) in the elliptical
centric acquisition scheme. Partial Fourier imaging with reverse sequential acquisition ordering can also provide a compact
acquisition of low spatial frequency data during the beginning of image acquisition. Note that low spatial frequency data are best
obtained during the plateau period of arterial enhancement. Acquisition of central k-space data prematurely during the rapid rise
in arterial signal (open arrow) can result in significant ringing artifacts (see Fig. 7). (Adapted from Ho VB, Foo TKF, Czum JM,
et al. Contrast-enhanced magnetic resonance angiography: technical considerations for optimized clinical implementation. Top
Magn Reson Imaging 2001;12:283 99; with permission.)
enables the operator to trigger the MRA data acquisition manually on contrast bolus arrival [26].
The final timing method is simply to perform
multiple fast MRA acquisitions in succession [25].
This tact, also known as multiphase or time-resolved
imaging, assumes that at least one of the MRA
acquisitions is performed properly during the arterial
phase of the bolus. The typical compromise for high
temporal resolution (5 to 8 seconds per three-dimensional acquisition) is lower spatial resolution of any
individual acquisition. This method may have little
use in patients with a poor breathholding capacity
because the limitations in breathholding may preclude the acquisition of sufficient data sets during a
single breathhold to ensure arterial-phase imaging.
Furthermore, respiratory motion during these acquisitions significantly degrades what are already lower
spatial resolution data sets.
Pulse sequence
Gadolinium-enhanced MRA is traditionally performed with a T1-weighted fast three-dimensional
spoiled gradient echo pulse sequence using the shortest possible repetition time (TR) and echo time (TE)
to ensure the fastest possible imaging speed. The use
of a three-dimensional acquisition provides high
121
spatial resolution and improves background suppression. Radiofrequency spoiling and the use of a higher
flip angle improve the T1 weighting of the acquisition
and the arterial signal following contrast administration. The imaging parameters should be tailored to
afford the highest possible spatial resolution for the
allotted time period, which for a breathhold acquisition is generally 20 to 30 seconds. Prescription of a
volume with a matrix of 256 224 to 256, partition
thickness of 1.5 to 2.5 mm, and 40 to 60 partitions is
usually sufficient for imaging the abdominal aorta
during a 20- to 30-second breathhold Gd-enhanced
three-dimensional MRA of the abdominal aorta.
Knowledge of the k-space trajectory of the threedimensional pulse sequence is also critical for proper
timing [15]. Historically, Gd-enhanced three-dimensional MRA had only been implemented using a
traditional sequential k-space scheme in which the
k-space is filled linearly in a sequential fashion from
top to bottom with the low spatial frequency data
(center of k-space) being acquired during the middle
of the imaging period. Because the central k-space
data are responsible for most image contrast, its
acquisition should be timed for peak arterial enhancement, and preferably before significant venous
enhancement occurs (Fig. 6). With the development
of real-time triggering methods, however, a variety of
Fig. 7. Ringing artifact on breathhold renal Gd-enhanced three-dimensional MRA in a 36-year-old man with left renal artery
stenosis. This artifact is recognized by the presence of bright and dark lines ([A] coronal maximum intensity projection, [B]
coronal source image) that parallel the edge of the enhancing abdominal aorta (small arrows) and results from the premature
acquisition of low spatial frequency data during leading edge of the contrast bolus when arterial signal is rapidly rising. This
artifact is more common with centric acquisition ordering, which acquires central k-space data early. Ringing artifact can be
avoided by timing for the low spatial frequency to be obtained during the plateau phase of the arterial enhancement (see Fig. 6).
Note that despite the artifacts, the patients left renal artery stenosis (large arrow) was well delineated. (Adapted from Ho VB,
Foo TKF, Czum JM, et al. Contrast-enhanced magnetic resonance angiography: technical considerations for optimized clinical
implementation. Top Magn Reson Imaging 2001;12:283 99; with permission.)
122
alternate k-space schemes were designed. In these

alternate k-space schemes, the central k-space data
are acquired during the beginning of the imaging
period, which improves the ability to synchronize the
bolus arrival with the critical central k-space data
acquisition. This allows monitoring of contrast arrival
within the target vessel itself versus proximal or
upstream. Two such alternate k-space schemes are
centric-phase ordering [23] and elliptical centricphase ordering (see Fig. 6) [26]. Partial Fourier
imaging (eg, 0.5 NEX) is another alternate method
for selective k-space sampling. As with traditional

sequential phase-ordered acquisitions, partial Fourier
imaging uses a linear k-space sampling scheme but
only a little over a half of k-space is acquired. As
such, the center of k-space can be prescribed to be
acquired either at the end (conventional sequential) or
at the beginning (reverse sequential) of the acquisition. The disadvantage of partial Fourier imaging is a
decrease in signal-to-noise, but with Gd-enhanced
three-dimensional MRA there is typically sufficient
arterial signal if timing is proper. With these alternate
Fig. 8. A 72-year-old man with a 9-cm abdominal aortic aneurysm. The extent of this large aortic aneurysm is displayed on the
arterial-phase Gd-enhanced three-dimensional MRA ([A] coronal maximum intensity projection [MIP], [B] sagittal MIP) and
delayed-phase Gd-enhanced three-dimensional MRA ([C] coronal MIP). Note the improvement in visualization of the infrarenal
aorta on the later delayed-phase acquisition (C) compared with the arterial-phase images (A,B). This is secondary to the slow
aortic flow within the large abdominal aortic aneurysm. Performing two acquisitions (arterial phase and delayed phase) after the
administration of contrast agent is prudent because it is hard to know a priori whether the patient has slow blood flow.
Furthermore, the delayed-phase images can often provide diagnostic quality angiographic images should there be inadequate
patient breathholding or motion during the arterial-phase acquisition. An axial image (D) from a late delayed-phase axial twodimensional spoiled gradient echo acquisition (ie, traditional axial two-dimensional time-of-flight MRA) taken through the
abdominal aorta delineates the circumferential mural thrombus (T) within the aneurysm and provides a better assessment of
actual aortic wall-to-wall diameter (arrows). (Adapted from Ho VB, Prince MR, Dong Q. Magnetic resonance imaging of the
aorta and branch vessels. Coron Artery Dis 1999;10:141 9; with permission.)
k-space sampling schemes, it is particularly important

not to acquire central k-space views during the rapid
rise in arterial Gd (see Fig. 6) because this can result
in a ringing artifact [16] seen as alternating black and
white lines about the edges of arteries (Fig. 7).
123
Bolus delivery
Faster pulse sequences have enabled the achievement of high-quality Gd-enhanced three-dimensional MRA more efficiently using smaller doses
Fig. 9. A 66-year-old man with a small infrarenal abdominal aortic aneurysm (AAA). On the coronal maximum intensity
projection (MIP) (A), a small AAA can be seen (arrow) well below the renal arteries, which are noted to be solitary for each
kidney and to have a normal caliber. On sagittal subvolume MIP (B), the ventral origins of the celiac artery (thick arrow) and the
superior mesenteric artery (thin arrow) are noted to also have a normal caliber. The contour and shape of the lumen of the small
infrarenal AAA (arrow) is particularly well seen on a volume-rendered projection (C).
124
of Gd-chelate contrast media [24,27,28]. With their

shorter bolus length requirements, faster imaging
provides the opportunity to deliver the contrast
media at a higher injection rate, which can provide
sufficiently high arterial Gd concentrations using
much lower doses (see Fig. 5). In general, contrast
injections are best delivered by a right antecubital
vein using a 22-guage or larger angiocatheter. The
reliability of contrast administration can be
improved by the use of an MR-compatible injector
and is particularly important for those who choose a
test bolus for timing. In general, contrast media
injections should always be accompanied by a
sufficiently large saline flush to ensure that the
contrast bolus is pushed out of the tubing set and

peripheral venous system and well into the central
circulation. Recently, Boos et al [29] demonstrated a
clear advantage for the use of a 30-mL or larger
saline flush for Gd-enhanced three-dimensional
MRA in that it significantly prolonged the duration
of arterial enhancement.
MRA of the abdominal aorta

An MRA of the abdominal aorta is primarily
performed for the assessment of aortic aneurysm;
aortic dissection; aortic occlusion; or a suspected
Fig. 10. A 75-year-old woman with hypertension and an infrarenal AAA. On coronal maximum intensity projection (MIP) (A) a
long, fusiform infrarenal AAA that extends to the aortic bifurcation. High-grade stenoses are also noted at the origins of both
common iliac arteries. On an oblique coronal subvolume MIP (B), a high-grade stenosis of the left renal artery is noted (arrow).
A high-grade stenosis (arrow) was also noted in the right renal artery at its origin; however, this was best seen on an oblique axial
subvolume MIP (C) from below.
branch vessel stenosis (especially renal artery stenosis). As discussed in the ensuing sections, breathhold Gd-enhanced three-dimensional MRA can
adequately answer the clinical questions related to
these aortic diseases. Gd-enhanced MRA of the
abdominal aorta is best performed in the coronal or
oblique coronal three-dimensional prescription. On
occasion, a sagittal acquisition may be preferable for
imaging arterial branches that originate ventrally,
such as the superior and inferior mesenteric arteries,
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especially if the patients breathholding ability is

limited and the volume needs to be minimized
because of imaging time considerations. The superior
mesenteric artery, however, can often be well visualized on a sagittal reconstruction of a coronal threedimensional MRA data set if the vessel is included
within the field of view. The examination, however,
should always include an axial T1-weighted fast spin
echo and an axial T2-weighted fast spin echo, preferably performed before the MRA. These initial
Fig. 11. A 78-year-old man with chronic type B aortic dissection. On oblique sagittal maximum intensity projection (A), the
patient is noted to have a very tortuous thoracic aorta with only a hint of the dissection, which begins in the distal arch beyond the
subclavian artery (not shown). On oblique sagittal multiplanar reformation (MPR) (B), however, spiral extension of the intimal
tear into the abdominal aorta is clearly seen. Oblique axial MPRs at the levels of the celiac artery (C), superior mesenteric artery
(D), and renal arteries (E) demonstrate that all four arteries originate from the true lumen (T ) and not the false channel (F ).
126
sequences enable the evaluation of the aortic diameter

and wall and screening for any unexpected visceral
pathology (eg, pelvic kidney).
In general, before the breathhold Gd-enhanced
three-dimensional MRA, an unenhanced breathhold
three-dimensional MRA using the same imaging
parameters should be performed as a trial run. This
not only ensures that the three-dimensional volume is
appropriately placed and artifacts, such as phase
wrap, do not overlap critical regions but also provides
a preparatory experience for the patient (and the
operator) in which he or she can familiarize themselves with the breathholding requirements.
should always include at least two postcontrast
acquisitions (arterial phase and delayed phase). The
additional time is trivial (additional breathhold) and
the second acquisition (delayed-phase MRA) often
can provide additional information. If blood flow is
slow as in a large aneurysm (Fig. 8), the initial arterialphase MRA may be completed before the attainment
of sufficient Gd concentrations have been achieved

within the distal aorta. Similar concerns arise in an
aortic dissection where flow within the false channel
is often slow. Imaging multiple phases has additional
benefits for renal artery evaluations because it also
enables the detection of delays or changes in parenchymal enhancement [30]. An additional benefit for
delayed-phase imaging is not only to provide a
secondary set of images but an improved depiction
or mural thrombus. The routine performance of an
axial two-dimensional fast spoiled gradient echo pulse
sequence (ie, a conventional axial two-dimensional
TOF MRA) after the coronal breathhold acquisitions
can be a helpful option to consider for the evaluation
of thrombus (see Fig. 8).
A contrast dose of 20 to 30 mL of Gd-chelate
injected at 2 mL/second [21] usually provides sufficient illustration of the abdominal aorta on Gdenhanced three-dimensional MRA. Although a single
dose (20 mL [27]) of a Gd-chelate contrast agent has
been shown to be adequate for renal artery imaging, a
Fig. 12. A 60-year-old woman with chronic type B aortic dissection but worsening vague abdominal pain. Sagittal maximum
intensity projection (MIP) (A) from a sagittal Gd-enhanced three-dimensional MRA demonstrates a narrowing of the celiac
artery (arrow) at its origin. On an oblique axial subvolume MIP (B), the extension of the dissection into the proximal celiac
artery is better visualized. Note that the true lumen is bright but the false channel was thrombosed and only apparent by its mass
effect on the true lumen (arrows) on Gd-enhanced three-dimensional MRA.
larger dose of 30 mL (or 0.2 mmol/kg) is recommended in patients with a large abdominal aortic
aneurysm (AAA), an aortic dissection, or aortic
occlusion because this ensures a sufficiently high
arterial Gd concentration for adequate visualization
of the arterial structures.
Clinical considerations
Abdominal aortic aneurysm
Aneurysms are defined as enlargement of the
arterial diameter by 50% or more from its normal
caliber, which for the abdominal aorta is generally
greater than or equal to 3 cm [31]. AAAs are common
especially in men above the age of 55 and in women
above the age of 70 [32]. The urgency of this
diagnosis relates to its risk of rupture, which is fatal
in most cases (81% to 94% [33]). AAAs are frequently asymptomatic, however, until they rupture.
Large AAAs (greater than 5 cm) have a 25% to
41% likelihood of rupture within 5 years [34,35] and
generally are repaired surgically. The risk of rupture
of small AAAs (aortic diameter less than 4 cm), on
the other hand, is low (0% to 2% [34,35]). Because
the 30-day operative mortality risk for elective AAA
repair is 5% to 6% [36], AAAs with diameters less
than 4 cm are typically followed with periodic
surveillance to check for interval expansion, which
is typically 0.2 to 0.4 cm per year [34,35]. Of course,
rapid expansion of an AAA (eg, greater than 1 cm per
year), widening of the pulse pressure, or the mani-
127
festation of symptoms (eg, abdominal tenderness or

pain) favors early surgical intervention. Ideally, surgical repair is elective because emergent repair carries
roughly a 10-fold increase in operative morbidity
(30-day operative mortality of 40% to 50% [36]).
The elective repair of AAA with diameters between
4 and 5 cm, however, continues to be debated because rupture rates are 3% to 12% after 5 years [34].
Improvements in aortic stent grafts has enabled
successful endovascular repair of some aneurysms,
especially small infrarenal AAA. Although preprocedural assessments can be obtained using MRA,
magnetic susceptibility artifacts can be significant
for certain stent materials and CT generally has been
the modality of choice for imaging prestenting and
poststenting patients with AAA. There are a growing
number of stent grafts, however, which are made of
materials, such as nitinol or polytetrafluoroethylene,
that seem to have minimal artifacts on Gd-enhanced
three-dimensional MRA [37,38].
Degenerative aneurysms of the aorta are commonly associated with atherosclerosis but recent
observations suggest a multifactorial causation and
a categorization of most AAAs as nonspecific
[31,34]. AAA is typically fusiform but may on
occasion be saccular. A saccular aneurysm should
lead one also to entertain an infectious etiology (ie,
mycotic aneurysm) [39]. Aneurysms are typically
infrarenal (84%) but can also involve the entire
abdominal aorta (4%) or be limited to the pararenal
region (12%) [40]. Aneurysms of the proximal
Fig. 13. A 56-year-old man with Leriches syndrome who presented with hypertension and buttock claudication. Preoperative
Gd-enhanced three-dimensional MRA ([A] coronal maximum intensity projection [MIP]) demonstrates the characteristic
occlusion of the distal abdominal aorta below the renal arteries. A high-grade stenosis was also noted in the proximal left renal
artery (arrow). The postoperative Gd-enhanced three-dimensional MRA ([B] coronal MIP) demonstrates the aortobifemoral graft
that included revascularization of the left renal artery at the proximal anastomosis. (Courtesy of Qian Dong, MD, and Martin
Prince, MD, PhD, Ann Arbor, MI.)
128
abdominal aorta carry a higher operative morbidity

and are particularly challenging because aortic reconstruction requires proper incorporation of branch
vessel ostia (ie, renal arteries, celiac arteries, or
superior mesenteric artery).
Conventional T1-weighted spin echo images have
been found to be excellent for the delineation of
aortic dimensions [41,42]. Preoperative planning,
however, also requires not only the assessment of
aneurysm size (width, depth, and length) but also its
proximal and distal extent and its relationship to the
visceral branch vessels. In addition, evidence for
rupture, complications of the aortic wall, supernumerary renal arteries, obstructive disease of renal, celiac,
or mesenteric vessels, or an anomaly, such as a
horseshoe kidney, can significantly alter the surgical
plan [43]. Gd-enhanced three-dimensional MRA
(Figs. 9, 10) can illustrate these features accurately
and reliably and has been shown to be sufficient for
preoperative planning for AAA interventions
[22,44 47]. For example, Gd-enhanced three-dimensional MRA has been shown to predict correctly the
proximal anastomotic site for AAA repair in 95% of
patients, which was comparable with that of conven-
Fig. 14. A 50-year-old woman with hypertension. On Gd-enhanced three-dimensional MRA ([A] oblique coronal subvolume
maximum intensity projection (MIP), [B] axial subvolume MIP, [C] coronal volume-rendered projection, [D] coronal transparent
volume-rendered projection), the string of beads appearance (arrows) characteristic for fibromuscular dysplasia is noted in the
right renal artery, which looks comparable with that of conventional x-ray angiography (E). Note that the beaded appearance was
well seen in the right renal artery on Gd-enhanced three-dimensional MRA, especially on the volume-rendered projections (C,D).
(F) Mild fibromuscular dysplasia was also noted on conventional x-ray angiography in the proximal left renal artery (arrow).
This was suggested on Gd-enhanced three-dimensional MRA (G) but less clearly seen, most probably secondary to the inherent
lower spatial resolution of MRA.
tional x-ray angiography (97%) [46]. MIP and MPR

are particularly helpful for the identification of stenotic branch vessels, which are preferably revascularized at the time of the AAA repair. Gd-enhanced
three-dimensional MRA has been shown to be accurate for the detection of significant occlusive celiac,
renal, mesenteric, or iliac arterial disease (94% sensitivity and 98% specificity [47]).
Aortic dissection
Dissections much more frequently arise in the
thoracic aorta but can often extend inferiorly into the
abdominal aorta to involve the renal, celiac, mesenteric, and iliac arteries [48]. The principle concern
with dissections is the involvement of visceral
branch vessels, which can result in their obstruction.
On Gd-enhanced three-dimensional MRA, the true
and false channels and entry and exit intimal tears
can be well illustrated (Figs. 11, 12) [49 51]. MPR
129
of the three-dimensional data sets enables the selective viewing of individual aortic branch vessels and
the identification of their blood supply (ie, from true
versus false channel). The extension of an intimal
tear into the abdominal aorta typically spirals posterior laterally about the arch with the false channel
coursing to the left of the aorta potentially to involve
the left renal artery and possibly the celiac and
superior mesenteric arteries. Delayed-phase imaging
is recommended (ie, at least two postcontrast MRA
acquisitions) because flow within the false channel
may be slow and not adequately fill with contrast
media during the initial acquisition.
Aortic occlusion (Leriches syndrome)
Occlusion of the abdominal aorta is uncommon
but worth mentioning because MRA can be very
useful in this condition [43,52]. Abdominal aortic
occlusion may occur as a result of a variety of
Fig. 14 (continued )
130
causes, in the acute setting most commonly as a

result of embolism. Chronic occlusion most commonly results from thrombosis superimposed on
severe atherosclerotic involvement of the distal
abdominal aorta and common iliac arteries. Chronic
occlusion can produce Leriches syndrome (named
after Leriche who was the first to describe aortic
occlusion in 1940 [52]). Leriches syndrome refers to
the clinical syndrome that results from occlusion of
the infrarenal aorta. Patients typically have buttock
and thigh claudication, erectile impotence, atrophy of
the thigh musculature, and diminished femoral
pulses. Invariably patients with chronic occlusion
develop a rich collateral circulation. Arterial access
is limited in these individuals and Gd-enhanced
three-dimensional MRA (Fig. 13) can often be sufficient for the primary assessment of the occlusion or
the assessment of graft repairs.
Branch vessels
Renal artery stenosis. Although all major abdominal aortic branches can be well evaluated with
MRA, the renal arteries merit special discussion
because renal artery stenosis is particularly common
among patients with conditions affecting the aorta
and peripheral vessels. Up to 22% of patients with
infrarenal AAA (see Fig. 10) [53] and 45% of patient
with peripheral vascular disease [54] also have renal
artery stenosis. Renal artery stenosis frequently manifests clinically as systemic hypertension (70% [55]),
which can often be reversed with renal revisualization by balloon angioplasty, stenting, or vascular
surgery. Patients with renal artery stenosis can often
progress to end-stage renal disease if left untreated.
Atherosclerotic renal artery stenosis has a 35%
cumulative incidence of disease progression at
3 years and 51% at 5 years [56]. Renal artery
stenosis and disease progression are particularly
prevalent in diabetic patients, which comprise
roughly 50% of patients with renal artery stenosis
[55,56].
The preoperative identification of renal artery
stenosis is important and may augment or change
the surgical plan. Concomitant renal revascularization
during surgery for an AAA or aortoiliac occlusive
disease has been shown to result in significant
improvement or reversal of hypertension in most
patients [57,58].
The critical technical issue for achieving diagnostic renal MRA is spatial resolution, which ideally
is less than 1.5 mm in any single dimension [59].
The diagnosis that is especially challenging by Gdenhanced three-dimensional MRA is that of fibro-
muscular dysplasia because the changes may be

subtle (Fig. 14). Like atherosclerotic renal artery
stenosis, fibromuscular dysplasia can result in reversible systemic hypertension. Patients with fibromuscular dysplasia, however, are typically young
women; whereas, atherosclerosis tends to occur in
older men [60]. Fibromuscular dysplasia typically
has a string of beads appearance, which may be
subtle on Gd-enhanced three-dimensional MRA
(see Fig. 14).
has been shown to be very accurate (sensitivity 91%
to 100%, specificity 89% to 100% [30,61 66])
for the detection of greater than 50% diameter
stenoses of the main renal artery. The supplementation of Gd-enhanced three-dimensional MRA with a
postcontrast PC three-dimensional MRA can provide ancillary and often complementary information, which improves the specificity of MRA for
the detection of renal artery stenosis [64,67,68]. On
PC MRA, spin dephasing invariably is present in
hemodynamically significant renal artery stenosis.
PC MRA relies on blood flow and the phase shifts
that it experiences while moving across a gradient
field. Because of the significant time requirements,
this technique was never popular for routine clinical applications. Like the previously discussed
flow-based technique of TOF, PC MRA is also
prone to flow-related artifacts, such as intravoxel
dephasing about regions of arterial narrowing. After
contrast administration, however, arterial signal on
PC MRA is especially high [69]. Because the
technique is still sensitive to turbulent flow, intravoxel dephasing is still present on postcontrast
imaging and can be used to confirm the presence
of a hemodynamically significant stenosis (Fig. 15).
The performance of a Gd-enhanced three-dimensional MRA first provides a road map for the
appropriate prescription of the phase-contrast
MRA over a more limited anatomic region and a
more time-efficient PC acquisition.
Renal transplant evaluation. Without the concerns
of nephrotoxicity associated with CT and conventional x-ray angiography, Gd-enhanced three-dimensional MRA can be a good method for the
postoperative assessment of renal transplant recipients (Fig. 16) [70,71]. Dual-phase Gd-enhanced
three-dimensional MRA easily can assess the
patency of the vascular anastomoses of the transplanted kidney.
can also be used to screen potential renal donors
and has been found to be comparable with CT
131
Fig. 15. A 71-year-old man with a history of hypertension and diabetes mellitus. Gd-enhanced three-dimensional MRA ([A]
coronal maximum intensity projection) shows severe renal artery stenosis bilaterally (arrows). On phase-contrast threedimensional MRA (B), signal loss distal to the renal artery stenoses (arrows) is seen. This suggests that both arterial narrowings
are hemodynamically significant. Bilateral high-grade stenoses (75% on right and 80% on left) are noted on conventional x-ray
angiography (C). (Adapted from Hood MN, Ho VB, Corse WR. Three-dimensional phase contrast MR angiography: a useful
clinical adjunct to gadolinium-enhanced three-dimensional renal MRA? Mil Med 2002;167:343 9; with permission.)
angiography [72,73]. The critical issue for the preoperative evaluation of potential donors is to determine the most suitable kidney for expedient and safe
removal [74,75]. Imaging is performed to identify the
number of renal arteries, the presence of early branching arteries, unsuspected renovascular disease, or any
parenchymal disease (eg, renal cell carcinoma) that
may influence the choice of kidney. On dual-phase

Gd-enhanced three-dimensional MRA, renovascular
anatomy and anomalies (eg, renal ectopia and retroaortic or circumaortic renal vein) readily can be
identified. Supernumerary renal arteries (Fig. 17)
are particularly common (27% of kidneys [75]) and
although not a contraindication for renal donation
132
Fig. 16. A 48-year-old man with autosomal-dominant polycystic kidney disease. On Gd-enhanced three-dimensional MRA ([A]
coronal maximum intensity projection [MIP], [B] oblique coronal subvolume MIP, [C] coronal multiplanar reformation [MPR])
a normal and patent arterial anastomosis (arrow) of the transplant kidney (t) with the external right iliac artery (a) is noted. On
MPR (C), overlapping signal from the right external iliac artery could be removed, enabling improved visualization of the
anastomosis (arrow).
may affect the choice of kidneys for transplant or the

surgical approach.
MRA of the peripheral vessels

The primary indication of peripheral angiography
is for the evaluation of patients with suspected or
known peripheral arterial occlusive disease (PVOD).
Once again, patients typically have atherosclerosis.
Atherosclerotic PVOD is common and its prevalence

increases with age, affecting 20% of the population
over the age of 75 years, and is twice as common in
men [76,77]. Patients typically present with intermittent claudication in calf, thigh, or buttocks, which is
exacerbated with exercise or ambulation. Claudication is indicative of a diminished arterial flow reserve
and an inability to augment blood flow for the
increased metabolic demands of exercise. Symptoms
are typically self-limiting but can significantly impact
an individuals quality of life. It is this latter effect on
133
Fig. 17. Arterial-phase renal Gd-enhanced three-dimensional MRA using an automated bolus detection scheme that was
prescribed to monitor signal in a 3 3 3 cm volume within the mid-abdominal aorta at the level of the renal artery origins.
The breathheld renal Gd-enhanced three-dimensional MRA ([A] coronal maximum intensity projection [MIP], [B] oblique
subvolume MIP) in this 46-year-old male renal donor demonstrates supernumerary renal arteries (two right and three left renal
arteries). (Adapted from Ho VB, Foo TKF, Czum JM, et al. Contrast-enhanced magnetic resonance angiography: technical
considerations for optimized clinical implementation. Top Magn Reson Imaging 2001;12:283 99; with permission.)
quality of life that may bear significantly on the

decision to treat patients with intermittent claudication more aggressively [78 80].
In more severe cases of PVOD, ischemia may be
limb threatening and therapeutic intervention (eg,
balloon angioplasty, stenting, bypass graft placement,
or amputation) is typically required. These patients
typically complain of claudication at rest or develop
nonhealing ulcers or even gangrene in the affected
leg. The therapeutic option depends on the location of
the disease, degree of stenosis, and length of the
lesion. Focal stenosis or occlusion (length less than
5 cm) of iliac artery, for example, responds well to
balloon angioplasty or stenting [81 84]. Long iliac
artery stenoses or occlusions, however, have lower
long-term patency success rates and often require a
surgical bypass procedure. The decision to perform a
bypass procedure is always considered carefully
because failure of the bypass graft may result in a
higher level of amputation than initially required
[85,86].
Multistation Gd-enhanced three-dimensional MRA
(bolus-chase MRA)
Arteriography of patients with PVOD has been
particularly challenging because the length of the
vascular anatomy that must be illustrated (from at
least the aortic bifurcation to the level of the ankle or
distal trifurcation vessels) is extensive (eg, greater

than 1 m). This is required because lesions are
typically multiple and tandem lesions are common
(70%) [79]. Surgical planning requires comprehensive evaluation of the entire arterial territory. Repair
of a popliteal artery stenosis, for example, may have
little effect if the patient has an ipsilateral iliac
occlusion and generally in-flow disease (aortoiliac)
is treated first. Arteriography is also necessary to
illustrate potential donor and recipient sites for potential bypass.
Using individual fields of view of roughly 40 to
50 cm, peripheral MRA typically requires the
imaging of three or more overlapping locations or
stations. Using two-dimensional TOF technique, peripheral MRA has been successful at detecting arterial
stenoses greater than 50% (eg, sensitivity 85% to
92%, specificity 81% to 88% [87,88]). Aside from its
obvious clinical benefits versus x-ray angiography,
two-dimensional TOF MRA has also been shown
to demonstrate suitable infrapopliteal bypass recipients not visible on conventional x-ray angiography
(so-called occult run-off vessels), which are critical
for bypass graft planning [87,89,90]. The lengthy
time requirements (often greater than 2 hours) and
numerous pitfalls, however, have limited the acceptance of two-dimensional TOF imaging for routine
clinical peripheral MRA. Gd-enhanced three-dimensional MRA is much faster than two-dimensional
134
TOF MRA and has been found to afford improved

diagnostic performance for imaging the peripheral
vessels [1,2].
The most recent development of Gd-enhanced
three-dimensional MRA has been the development
of a technique called bolus-chase MRA [91 102].
Bolus chasing has been used for many years in
conventional x-ray angiography. The basic concept is to synchronize imaging with the arterial transit
of a single contrast bolus. In MR imaging, this
can be achieved by aligning table translation
with the arterial phase of an intravenously administered Gd-chelate contrast bolus (Fig. 18). Typically, a
40-mL or 0.2-mmol/kg dose of Gd-chelate contrast
media is administered at a slow rate (0.3 to 0.8 mL/
second) [93,94,97]. The rate of contrast infusion
should be adjusted so that the length of the contrast
bolus duration matches roughly the time required to
acquire the critical k-space data for the three overlapping stations (Fig. 19). For example, if imaging
requires 100 seconds (30 seconds per station with
5 seconds between stations), a 40-mL dose injected at
0.4 mL/second results in a 100-second bolus duration. Recently, a biphasic injection rate (Fig. 20) has
also been shown to be effective [101].
To ensure that the bolus duration and injection
rates are standardized, another tact is to dilute a
0.2-mmol/kg dose to a fixed volume (eg, 45 mL)
and inject it at a fixed rate (eg, 1 mL/second) [94].
The use of a 0.2-mmol/kg dose ensures the ability
to perform another Gd-enhanced three-dimensional
MRA using 0.1 mmol/kg should a segment require
additional investigation. The actual technique varies
with the imaging capabilities of the scanner that is
being used [95]. Some scanners, for example, are

capable of partial Fourier imaging (ie, 0.5 excitation or NEX) which allows for the foreshortening
of the bolus duration requirements (see Fig. 19).
Table translation can be performed manually by
simply unhooking the scanner table and sliding the
patient out of the bore [91 93,97]; by using a
specially designed coil on platform apparatus (eg,
SKIP, Magnetic Momments, Bloomfield, MI [101];
or AngioSURF, MR Innovation, Essen, Germany
[99]); or using software that integrates imaging with
automated table motion (eg, MoBI-Track, Philips
Medical Systems, Best, The Netherlands [96]; and
SmartStep, General Electric Medical Systems, Waukesha, WI [100]). The selection of table translation
method primarily depends on the individual MR
scanner because options vary between vendors. Each
vendor has similar variation in timing method options
(MR fluoroscopic trigger, automated bolus detection,
and so forth) and pulse sequence choice (partial
Fourier versus full Fourier, sequential versus centric
phase ordering, and so forth). Operators are advised
to familiarize themselves with the specific options
available with their scanner.
Although specific table motion technique and
timing methods may differ, the basic bolus-chase
MRA procedure remains fairly similar. All techniques
require a multistation localizer and matching precontrast coronal (or oblique coronal) three-dimensional
acquisitions at each location, typically using the same
table motion procedure as for the subsequent boluschase MRA. As with single-station Gd-enhanced
three-dimensional MRA, the precontrast multistation
three-dimensional MRA serves to ensure appropriate
Fig. 18. Schematic of multistation peripheral bolus chase three-dimensional MRA. Imaging of the peripheral vasculature requires
the imaging of three contiguous anatomic regions: the aortoiliac segment (station 1); the femoropopliteal segment (station 2); and
the tibioperoneal or trifurcation segment (station 3). (From Ho VB, Choyke PL, Foo TKF, et al. Automated bolus chase
peripheral MR angiography: initial practical experiences and future directions of this work-in-progress. J Magn Reson Imaging
1999;10:376 88; with permission.)
135
Fig. 19. Schematic of arterial-phase imaging of the contrast bolus at stations 1 through 3. The relative timing of the data
acquisition of the half-Fourier three-dimensional gradient echo sequences is diagrammed as A (station 1), B (station 2), and C
(station 3) with the center lines of k-space for each marked by diagonal lines. Note that the use of sequential view ordering for
station 1 and reverse sequential view ordering for station 3 results in a shortened duration required for central k-space coverage
during the arterial phase (ie, shortened critical arterial imaging period). (From Ho VB, Choyke PL, Foo TKF, et al. Automated
bolus chase peripheral MR angiography: initial practical experiences and future directions of this work-in-progress. J Magn
Reson Imaging 1999;10:376 88; with permission.)
anatomic coverage and familiarize the patient with

the procedure. For bolus-chase MRA, however, the
precontrast images have an additional benefit in that
they provide a mask for image subtraction, which can
significantly improve arterial visualization in the
peripheral vasculature, especially in the calf
[94,103,104]. It is advisable to take efforts to minimize bulk patient movement between the precontrast
and postcontrast imaging by minimizing not only the
time between acquisitions but also securing the
patients lower extremities whenever possible.
Bolus-chase MRA has been shown to depict
reliably and accurately peripheral arterial stenoses
greater than 50% (eg, sensitivity 81% to 95%; specificity 91% to 98% [93,97,98]). This technique can be
helpful not only for the initial screening of patients
with suspected PVOD (Figs. 20 22) but also for the
postoperative surveillance of graft patency (Fig. 23)
[91]. A known pitfall for the use of Gd-enhanced
three-dimensional MRA for postoperative evaluations
is its diminished ability to access stent graft patency
in patients who have undergone endovascular repair

with a stent that contains stainless steel (eg, Palmaz
stent) or cobalt-based alloy (eg, Wallstent). The
magnetic susceptibility from these stents results
in significant signal loss and precludes proper visualization of the stent lumen even on Gd-enhanced
three-dimensional MRA [37]. Stents that are made
of nitinol wire (eg, Cragg stent, Cragg Endo ProSystem 1, and Passager stent) and polytetrafluoroethylene (eg, Hemobahn stent), however, have been
shown to have minimal artifacts on Gd-enhanced
three-dimensional MRA [37,38]. In patients who
have undergone endovascular therapy using nitinolor polytetrafluoroethylene-based stent grafts, Gd-enhanced three-dimensional MRA can be a suitable
modality for the assessment of graft patency.
Current bolus-chase MRA methods are reliable
for imaging the peripheral vessels through the level
of the trifurcation. Visualization of the distal run-off
vessels, however, is often variable [15,94,102]. This
results from a combination of issues. Timing with
136
current techniques is only provided for the initial

station and timing for arterial-phase imaging of the
terminal station (third or fourth station) is understandably variable. In addition, imaging of the terminal station begins only after completion of imaging
for the proximal stations. These concerns are amplified in patients with PVOD because they often
have slow flow or significant intervening aneurismal
or occlusive disease in which the transit time for
contrast media can be highly variable and often

asymmetric. In patients with limb-threatening ischemia, the identification of recipient run-off vessels is
critical for successful bypass grafting. Visualization
of distal run-off vessels can be ensured by the
preliminary performance of a traditional two-dimensional TOF below the knee (especially foot). Most
patients with PVOD present with milder disease and
intermittent claudication, however, and therapy is
typically conservative (eg, smoking cessation and
regular exercise) and noninvasive [77]. In these
individuals, a three-station bolus-chase MRA typically can provide sufficient diagnostic information
for patient management.
Future directions
In addition to the use of higher field strength MR
scanners (eg, 3 T) and high performance gradients,
there are a variety of new techniques that may
significantly improve the speed of MRA data acquisition. New parallel imaging techniques, such as simultaneous acquisition of spatial harmonics [105] and
sensitivity encoding [18], use the spatial-encoding
properties of multiple phased-array coil elements to
reduce the number of requisite spatial-encoding
views. These can result in a significant reduction
(twofold or threefold) in scan time but at the cost of
signal-to-noise (approximately equal to the square
root of the scan time reduction factor). This is
especially promising for MRA of the abdominal aorta
Fig. 20. A 60-year-old man with atherosclerosis. Coronal

maximum intensity projection from a three-station Gd-enhanced bolus chase three-dimensional MRA using a biphasic
injection provided sufficient Gd for good visualization of the
abdominal aorta and iliac arteries (station 1); the femoropopliteal arteries (station 2); and the trifurcation vessels (station
3). The contrast was injected intravenously at 0.6 mL/second
for initial 20 mL and at 0.4 mL/second for the remaining
20 mL. This was followed by a saline flush at 0.4 mL/second. This provided a sufficiently long bolus to match the
100 seconds required for data acquisition (30 seconds for
each of three stations plus 5 seconds for each of the two table
movements between stations). Although, a single slow injection rate of 0.5 mL/second provides near equivalent bolus
duration, the slightly faster initial rate of injection provides a
higher concentration of Gd for improved visualization of the
abdominal aorta. The decrease in the injection rate for the
later half of the bolus ensures sufficient arterial Gd concentrations during the imaging of the distal trifurcation vessels. On this examination, fusiform dilatation of the distal
abdominal aorta and common iliac arteries and a moderate
stenosis in the distal right external iliac artery were noted.
Fig. 21. A 65-year-old man with right lower extremity

claudication. Coronal maximum intensity projection from a
three-station Gd-enhanced bolus chase three-dimensional
MRA demonstrates bilateral narrowing of the common iliac
arteries, which is much worse and high-grade in the right
common iliac artery (arrow). The remaining arterial segments were patent.
137
Fig. 22. A 53-year-old man with bilateral occlusion of the

proximal superficial femoral arteries. Coronal maximum
intensity projection from a three-station, Gd-enhanced bolus
chase three-dimensional MRA demonstrates not only the
occlusions but also the reconstitution of superficial femoral
artery at the mid-thigh level (arrows). Note the numerous
collateral vessels in the thigh about the regions of occlusion.
138
Fig. 23. Adult patient with atherosclerosis and a history of

abdominal aortic aneurysm (AAA) repair. The Gd-enhanced
bolus chase three-dimensional MRA demonstrates a residual
AAA in the proximal abdominal aorta but the aortobifemoral graft in the distal abdominal aorta is intact. Mild
irregularity is noted in the distal superficial femoral arteries
bilaterally consistent with mild to moderate disease.
where imaging speed can be used to acquire a larger

number of partitions for improved anatomic coverage
or more importantly higher spatial resolution. Alternatively, the speed can be used to achieve improved
temporal resolution and an increase in the number of
phases during a breathhold.
There also has been the introduction of hybrid
bolus-chase schemes. Maki et al [106] have demonstrated the feasibility of an interleaved image acquisition in which a two-dimensional MRA is performed at
the thigh station (station 2) between two three-dimensional MRAs (abdomen-pelvis, station 1; and calf,
station 3). This expedites imaging of the calf and can
minimize the concerns related to venous contamination. Another approach was described by Foo et al
[107] in which the three-dimensional acquisitions
were segmented such that only the central portions
of k-space (low spatial frequency data) are acquired
during an initial pass during the arterial phase of the
contrast bolus and remaining k-space data are
acquired later during a second pass during the delayed
phase. This technique called segmented volume
acquisition (shoot and scoot) enables more efficient
data acquisition because the time-critical portions of
k-space (ie, the center of k-space) are preferentially
acquired during the arterial phase of the bolus and
provides high spatial resolution data sets (Fig. 24).
Another innovation is time-resolved two-dimensional [102] and three-dimensional (eg, TRICKS
[108]) digital subtraction angiography. These techniques are somewhat similar to the multiphase threedimensional MRA scheme previously discussed
under timing methods but require specialized off-line
computer equipment or software, which are not yet
commercially available. Like multiphase threedimensional MRA, MR digital subtraction angiography may have limited use for imaging regions where
breathhold acquisitions are desired (ie, aortoiliac
region) but for imaging of the thigh, calf, and feet,
these techniques may be very helpful.
There have also been technical improvements
that relate to the pulse sequence. Until recently,
Gd-enhanced MRA has typically been performed
using a T1-weighted spoiled fast gradient echo pulse
sequence. Foo et al [109] recently reported success
using a steady-state free precession (TrueFISP, Siemens Medical System; FIESTA, General Electric
Medical Systems; balanced FFE, Philips Medical
Systems) for Gd-enhanced MRA. On steady-state
free precession, vascular signal is a function of the
ratio of tissue T2 to T1 relaxation times. This effect
can provide additional vascular signal contributions
that may improve luminal visualization despite low
Gd concentrations (Fig. 25).
The final developments have been in the contrast

agents [110]. There are a variety of new contrast agents
that have unique binding to large molecules like
albumin (eg, MS-325, Epix Medical, Cambridge,
MA) or inherently large structure (eg, NC100150,
Amersham Health, Buckinghamshire, United Kingdom) and are retained within the blood pool for
a prolonged period of time, whereas conventional
extracellular Gd-chelate contrast agents leak out
of the vessels within 2 to 3 minutes of venous
139
injection. Blood pool agents like conventional extracellular Gd-chelates rely on their T1-shortening effects
for improved signal on contrast-enhanced MRA. The
prolonged window of arterial signal improvement
affords a large temporal window for high spatial
resolution scanning. The main limitation of this technique is the significant venous enhancement that is
typically present after the initial 1 to 2 minutes. Given
the systemic nature of atherosclerosis, however, the
use of blood pool agents may be beneficial for wholebody screening. A hybrid contrast agent called
gadobenate dimeglumine (MultiHance, Bracco Diagnostics, Milan, Italy) has been approved for use in
Europe and has some protein binding, which has been
shown to improve arterial signal-to-noise significantly
when compared with traditional Gd-chelate contrast at
a comparable Gd dose of 0.1 mmol/kg [111]. Recently,
Ruehm et al [99] demonstrated the feasibility of
performing a five-station bolus-chase MRA using a
0.3-mmol/kg dose of gadobenate dimeglumine.
Any of the aforementioned improvements may
significantly expand the current role and diagnostic
accuracy of aortic and peripheral MRA. Specifically,
they may improve the reliability of infrapopliteal
imaging and even renal imaging during a boluschase MRA. A high percentage of patients with
peripheral vascular disease have renal artery stenosis, yet most of the current bolus-chase techniques
fail to produce diagnostic-quality images of the renal
arteries reliably. Although this may be secondary to
the height of the patient (insufficient superior anatomic coverage of overlapping stations), more commonly time considerations often result in the use of
Fig. 24. Segmented volume bolus chase acquisition (shoot

and scoot). In this acquisition scheme, the low spatial frequency data for each of the three stations are acquired during
the arterial phase of the bolus. Imaging was initiated by an
automated bolus detection algorithm that monitored the
contrast bolus arrival in the mid-abdominal aorta, which
represented the center of the proximal station. After
acquiring the critical central k-space data, the algorithm
returns the table to the proximal stations so that remaining
high-spatial frequency data can be acquired to complete
data acquisition for each station. By segmenting k-space
data acquisition into two separate passes, this technique
shortens the time requirements for the duration of the arterial
enhancement and minimizes the time delay before
imaging of the terminal station. This in turn enables the
use of faster injection rates for improved arterial visualization of the infrapopliteal arteries. (Adapted from Ho VB,
Foo TKF, Czum JM, et al. Contrast-enhanced magnetic
resonance angiography: technical considerations for optimized clinical implementation. Top Magn Reson Imaging
140
and Maureen N. Hood, BSN, RN, RT(MR), of the

Uniformed Services University of the Health Sciences for their invaluable assistance in the preparation
of this manuscript.
References
Fig. 25. Delayed-phase three-dimensional steady-state free

precession MRA. In this 64-year-old man, venous invasion
from a large left inferior pole renal cell carcinoma (white
arrows) is well seen on a three-dimensional steady-state free
precession MRA performed approximately 7 to 8 minutes
following a single dose of Gd-chelate contrast media. This
oblique coronal subvolume maximum intensity projection
clearly depicts the tumor extension from the left renal vein
and into the inferior vena cava (black arrows). (From Ho
VB, Foo TKF, Czum JM, et al. Contrast-enhanced magnetic
resonance angiography: technical considerations for optimized clinical implementation. Top Magn Reson Imaging
thicker partitions (eg, 2.5 to 3 mm thick partitions)

in the aortoiliac station such that renal artery assessment is suboptimal.
Summary
Contrast-enhanced MRA can be an accurate and
reliable method for the arterial evaluation of the
abdominal aorta and peripheral vessels. This technique can be adapted for a variety of anatomic
regions. The basic issues relate to proper synchronization of imaging with peak arterial enhancement
and to optimization of voxel dimensions for adequate
depiction of the arterial structures.
Acknowledgments
The authors thank Michael Schweikert, RT(R),
(MR), lead MR technologist at Doylestown Hospital,
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Radiol Clin N Am 41 (2003) 115 144

MR angiography of the abdominal aorta

MR angiography (MRA), in particular gadolinium

Time-of-flight and phase-contrast MRA

The opinions or assertions contained herein are the private

the properties of moving protons (flowing blood) and

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

when they move along a gradient field. In practice,

have contributed to the general lack of enthusiasm for

Gd-enhanced three-dimensional MRA

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

Fig. 3. An 82-year-old woman suspected of having

similar to that of conventional x-ray angiography.

Principle of Gd-enhanced three-dimensional MRA

Fig. 4. A 69-year-old woman with a celiac artery aneurysm.

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

k-space data (center of k-space) for the period of peak

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

second for a Gd-enhanced three-dimensional MRA of

There also are several vendor-specific real-time

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

alternate k-space schemes were designed. In these

for selective k-space sampling. As with traditional

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

k-space sampling schemes, it is particularly important

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

of Gd-chelate contrast media [24,27,28]. With their

contrast bolus is pushed out of the tubing set and

MRA of the abdominal aorta

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

especially if the patients breathholding ability is

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

sequences enable the evaluation of the aortic diameter

of sufficient Gd concentrations have been achieved

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

festation of symptoms (eg, abdominal tenderness or

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

abdominal aorta carry a higher operative morbidity

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

tional x-ray angiography (97%) [46]. MIP and MPR

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

causes, in the acute setting most commonly as a

muscular dysplasia because the changes may be

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

may influence the choice of kidney. On dual-phase

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

may affect the choice of kidneys for transplant or the

MRA of the peripheral vessels

Atherosclerotic PVOD is common and its prevalence

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

quality of life that may bear significantly on the

distal trifurcation vessels) is extensive (eg, greater

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

TOF MRA and has been found to afford improved

being used [95]. Some scanners, for example, are

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

anatomic coverage and familiarize the patient with

in patients who have undergone endovascular repair

V.B. Ho, W.R. Corse / Radiol Clin N Am 41 (2003) 115144

current techniques is only provided for the initial

contrast media can be highly variable and often

Fig. 20. A 60-year-old man with atherosclerosis. Coronal