RENAL ARTERY PROTOCOL

(for GS LX 1.5 Tesla Scanner at 8.45

Software)
Overview
This renal MRA
protocol has been
refined over 1000’s
of cases to make it
relatively easy and
fast to acquire the data and yet still provide a comprehensive evaluation of the patients
suspected of reno-vasculare hypertension. Start with a sagittal locator; spin echo provides
high quality blackblood images. SSFSE is slightly faster yet still has acceptable quality.
The axial T2 is important to evaluate any mass that might be present. In addition the axial
T2 takes about 5 minutes, which provides sufficient time to set-up the 3D Gd MRA. The
most important sequence is 3D Gd MRA acquired during the arterial phase of the
injection of Gd. Finally 3D PC and cine PC help to evaluate the homodynamic
significance of any stenosis identified.
The entire study can be obtained within 45 minutes. However, when first beginning of
this exam, we recommended booking patient into 1 hour time slots.

Spin Echo SSFSE Axial 3D Delayed Optional

3D PC
Loc Loc T2 Gd:MRA (IVP) Cine PC

IMAGING PARAMETERS
Plane Sagittal Sagittal Axial Coronal Axial Coronal Axial
Mode 2D 2D 2D 3D 3D 3D Cine
Spin Vasc TOF Vasc TOF
Pulse Seq Spin Echo Spin Echo Vasc PC Vasc PC
Echo SPGR SPGR
Fast, MPh,
Imaging
RC, NPW Fast, SS Fast, FC Zip2, FC Fast, Zip2 --
Options
Smartprep

SCAN TIMING
1,
# of Echoes 1 1 1 1 1 1
ETL=8
TE Min Full 180 102 Minimum -- Minimum --
TR 325 -- 2920 -- 18 6 18
Flip Angle -- -- -- 45 25 45 30
Bandwidth -- 31.25 -- 31.25 -- 31.25 --

ADDITIONAL PARAMETERS (see attached instructions)

SAT None None S,I, FAT None None None None

ACQUISITION TIMING
256 (256-
Freq 256 256 256 256 256 256
512)
160 (128-
Phase 192 256 256 192 160 160
256)
NEX 2 -- 3 1 (0.5 - 1) 1 1 1
Phase FOV 1 1 1 1 1 1 1
Locs Before
-- 0 0 1 -- -- --
Pause
Freq DIR S/I S/I R/L S/I R/L S/I R/L
Auto Center
Peak Water Water Water Water Water Water
Freq
Auto Shim On On Off On Off On On
30 (20-50) 30 (20- 30 (20-50) 30 (20-
Contrast -- -- --
ml 50) ml ml 50) ml

SCANNING RANGE
32 (26- 28 (26-
FOV 40 (32-48) 40 (32-48) 34 (30-44) 32 (28-40)32
44) 40)
Slice 8.0 (8-
8.0 9.0 2.6 (2-4) 2.5 (2-3) 3.0 (2-5) 3.0
Thickness 12)
Spacing Interleave 0 2 (2-3) -- 0 0 0
L100- See See See
Start - End L90 - R90 See Graphic
R100 Graphic Graphic Graphic
28 (28 -
# Slices 24 24 18 34 (28-44) 30 (20-40)2
60)
Scan Time 0:30 (0:15-
4:39 0:56 4:46 7:23 35 4:38
(min:sec) 0:58)
Common Indications:
  Hypertension (especially if difficult to control on multiple meds)
 Elevated serum creatinine
 Pre-op mapping of renal artery anatomy
 Post-op check

Scheduling Guidelines:
MRI & MRA of Abdomen with Gadolinium
45 minute slot any time nurse is available for injecting Gadolinium

First Ask
1) Hypertesion?  How many medications?
2) Renal infufficiency? What is the serum creatinine_________?
3) Prior abdominal surgery?

Patient Preparation:
 Start intravenous line (20 or 22 gauge iv) and attach SmartSet (TopSpins. Tel:
734-623-6400) before placing patient into the magnet. This avoids the problem of
patient movement during iv placement causing the locator to be inaccurate.
 Oxygen, 2-4 liters/min by nasal canula is essential if patient is short of breath.
 Valium (5-10mg po) or Xanax (1-2 mg po) if patient is claustrophobic may be
given.

Coil: With large patient (>200 lb), body coil is acceptable and easiest to use. It provides a
large field-of-view (FOV) with homogeneous signal. Higher SNR is possible with the
torso array coil although the signal reception is not as homogeneous because of hot spots
near the coil. The torso coil is not useful in obese patients. When using the torso array,
rotate 90 degrees for greater S/I coverage and less R/L wrap-around artifact. I have found
that the higher SNR of the surface coils allows the standard gadolinium dose to be
reduced from 40 to 30 ml in small and average size patients.

Patient Positioning: Supine, feet first.

Landmark: on lower anterior rib margin or just above iliac crest.

 

Series 1: Sagittal Locator

Spin Echo Locator SSFSE Locator

 For renal artery imaging sagittal plane is the best orientation for the locator. You
may consider landmarking high and using a large FOV (48cm) to also cover the
thoracic aorta in case the patient is suspected of coarctation, thoracic aneurysm or
dissection.
 When using the spin echo sequence with interleaved acquisition (as
recommended) half of the images are reconstructed half way through the scan.
These images can be used to set-up series 2 while you are waiting for series 1 to
finish.
 Breath-hold fast multiplanar spoiled gradient echo (FMPSPGR) is the fastest
sequence but is not recommended because it does not show the abdominal aorta
well especially if there is any trouble with breath holding.
 Single shot fast spin echo (SSFSE) is also a good sequence but it will not show
the thoracic component of the aorta and it is not available on all scanners. It can
be performed without breath-holding although breath-holding is preferred. Use 8
skip 0, TE=180 and do not use fatsat.

Series 2: Axial T2 Fat Sat

This sequence helps to evaluate renal masses to determine if they are simple benign cysts
or more suspicious for malignancy. It also keeps the scanner busy while you are setting
up the 3D Gd MRA (series 3). If the patient has a regular respiratory rhythm, better
image quality is possible with respiratory triggering. For respiratory triggering use:

 RR intervals = 2-3;
 trigger point = 20%;
 trigger window =20%;
 inter-sequence delay = minimum;

Scanning Range for Axial T2 T2 weighted image shows benign cysts

Series 3: Coronal 3D Gd:MRA

This is the main sequence for showing the aorto-iliac and renal artery anatomy. It is
essential to have perfect gadolinium infusion timing so that central k-space data will be
acquired during the arterial phase of the bolus. Use MR SmartPrep to ensure
synchronization of central k-space with the contrast bolus peak.

 ADDITIONAL PARAMETERS

o Vascular Screen:
 Projection Images: 0
 Collapse: on
o User CVs Screen:
 Max Monitor Period&: 35 (30-60)
 Image Acq. Delay: 6 (5-10)
 SPECIAL: off

 Eliptical Centric: on
 Use longer Max Monitor Period and Image Acq. Delay in patients who
have slow flow including patients older than 70, patients with congestive
heart failure or patients with abdominal aortic aneurysm.

o Multi Phase Screen:

 Phases per Location: 2
 Delay After Acq.: Minimum (?)

Positioning for Coronal Volume and Tracker Coronal 3D Gd MRA

 To determine where to position the 3D Volume, first find the celiac and SMA, the
right and left kidneys.
 Place the tracker on the aorta at the level of the SMA. I prefer to place the tracker
on a sagittal image of the aorta (make the tracker 7-10 cm long and 30-40 mm
wide and position on aorta completely below SMA). However it is sometimes
difficult to find the aorta on a sagittal image and occasionally it is inadvertently
placed on the IVC with disastrous results. Fot these reasons, some users find it
easier to place the tracker using an axial image. For axial image placement, make
the tracker 3-4 cm long by 30-40 cm wide and place on a slice of aorta well below
renal arteries.
 Position 3D volume with

o top: 3-4 cm above celiac axis

o posterior: border at posterior margin of kidneys or at least sufficently
posterior to include >1/2 of each kidney
o anterior: border anterior to aorta and anterior to SMA
 o Make sure the acquisition time is short enough so that the patient can
suspend breathing for the entire scan. To make the scan time shorter
consider
 Decreasing matrix to 128
 Decreasing number of slices and
increase slice thickness
 Covering only the essential
anatomy
 Decreasing NEX to 0.5 but be
careful because 0.5 NEX
produces more k-space artifact
o Use "fallback" for optimal right-left
alignment
o Check "#of Locs Before Pause" to be
sure it is set to 1.
o Place the patient’s arms over the head or
on cushions to get them out from along
side the patient where they will wrap
around into the imaging volume.
o Test the iv with saline and then fill the
SmartSet with Gd contrast (about 5 ml).
o Instruct the patient on when to suspend
breathing: "This is the most important scan. You will need to hold your
breath for 1/2 of the scan, the second half. You can tell when to hold your
breath by the change in the sound. Just to be sure there is no confusion, I
will squeeze your arm when the sound changes so that you will know
exactly when to take in a deep breath and hold it."
o Start scan: Do not begin injecting until the clock begins to count down:
about 15 seconds after starting the scan.
o When the clock begins counting down, start injecting at about 1-2 cc/sec
( as fast as you can, for a person of average strength using Gd: DTPA with
a 20 gauge iv).
o When the sound changes (bolus detected), signal the patient to Breath
Hold by squeezing the patient's arm.
o When Gd infusion is complete, flush with 20 cc normal saline.
o At the end of the arterial phase scan, have the patient take 3-4 quick
breaths and then scan again to catch the portal venous phase.

Series 4: Axial 3D Phase Contrast

This sequence provides another high resolution look at the renal arteries and helps in the
evaluation of the hemodynamic significance of any renal artery lesions that are present.
 Scanning Range for 3D PC Axial 3D Phase Contrast
 ADDITIONAL PARAMETERS

o Vascular Screen:
 Projection: 0
 Flow Recon Type: Phase Diff
 Velocity Encoding: 40
 Acq. Flow: Direction ALL
 Collapse: on
 Flow Analysis: off
 Additional Flow Images: none

 Set the Venc = 40cm/sec as the default. Lower it to 30 cm/sec in patients who also
have renal insufficiency with serum creatinine >2.0 mg/dl, in patients older than
70 years of age, patients with AAA or CHF. In patients with more than one of
these factors or serum creatinine > 2.5 mg/dl reduce the Venc to 25 cm/sec. In
young healthy hypertensive patients, raise the Venc to 50 cm/sec and in athletes
raise it to 60 cm/sec to avoid aliasing.
 When positioning the 3D volume, remember that the position of the kidneys will
be lower during the breathhold in inspiration for the 3D Gd:MRA. Anticipate that
the kidney will move 1-2 cm superiorly during free breathing for the 3D PC.
 It is acceptable to have the FOV slightly smaller than the right-left dimension of
the patient’s thorax since phase is mapped A-P and frequency is R-L.
 If there are accessory renal arteries, than instead of 28 slices that each 2.5 mm
thick, change to 60 slices each 2.0 mm thick with 128 phase encoding steps in
order to cover more S-I distance.

Series 5: Delayed 3D Gd Excretory Phase:

Series 6: Cine PC
Filming Instructions
Routinely, the 3D gadolinium images are processed on the computer workstation. A
montage 12 on 1 sheet or two 6 on 1 sheets are created including:

 The overall 3D view from the arterial phase (1 image)

 each renal artery in the coronal plane (2-3 images)
 each renal artery in the axial plane (1 image)
 Sagittal celiac and SMA origins (1 image)
 Length of each kidney from the sagittal locator or from the 3D Gd:MRA sequence
(venous phase) (2 images)
 3D PC MIP of both renal arteries (1-2 images)
 Oblique magnified MIPs of iliac arteries (2 images)

 MIP of excretory phase

 Any additional pertinent images to show pathology

 The 3D PC images are printed from a SET BATCH-MOVIE LOOP option
available on the computer workstation. From a coronal 3D image of the entire
imaging volume, overlapping MIP images are created. The FOV is set to 18 cm.

Billing:
 MRI of Abdomen 74181
 MRA of Abdomen 4185

ICD9 Codes:
441.00 Dissecting aneurysm of aorta, unspecified site
441.02 Dissecting of aorta (ruptured), abdominal
441.03 Disssecting aneurysm of aorta (ruptured), thoracoabdominal
441.4 Abdominal aneurysm, without mention of rupture
441.7 Thoracoabdominal aneurysm, without mention of rupture
441.9 Aortic aneurysm of unspecified site without mention of rupture
442.1 Otheraneurysm of renal artery
442.2 Other aneurysm of iliac artery
442.83 Aneurysm of splenic artery
442.84 Aneurysm of other visceral artery
444.0 Arterial embolism and thrombosis of abdominal aorta
444.81 Arterial embolism and thrombosis of iliac artery
Renal MRA Report Template
Re:
Exam: Renal MRA
Exam Date:

Clinical Statement:

Technique:
Sagittal T1 of abdomen and pelvis
Axial T2 of kidneys
Coronal 3D Gd:MRA of abdominal aorta and renal arteries
Axial 3D phase contrast MRA post-gadolinium
3D MRA data was reconstructed on a computer workstation
Findings:
Abdominal aorta:
Celiac axis:
Superior mesenteric A.
Inferior mesenteric A.

The right kidney measure ? cm in length. No right renal masses are identified.
There is a single right renal artery which is ? .
The left kidney measures ? cm in length. No left renal masses are identified.
There is a single left renal artery which is ? .

Right common iliac artery:

Right external iliac artery:
Right internal iliac artery:

Left common iliac artery:

left external iliac artery:
Left internal iliac artery:

No abdominal masses or retroperitoneal adenopathy is identified.

Impression:

Accuracy of 3D Gd:MRA for diagnosing Renal Artery

for Stenosis.
Number of Degree of
Investigator Year Technique Sensitivity Specificity
Patients Stenosis
Prince 1995 19 3D Gd 100% 93% 75%
 Grist 1996 35 3D Gd 89% 95% >55%
Holland 1996 63 3D Gd 100% 100% >50%
Snidow 1996 47 3D Gd 100% 89% NA
Steffens 1997 50 3D Gd 96% 95% NA
Hany 1997 39   93% 98% >50%
De Cobelli 1997 55 3D Gd 100% 97% >50%
Rieumont 1997 30 3D Gd 100% 71% >50%
Hany 1998 103 3D Gd 93% 90% NA
Bakker 1998 50 3D Gd 97% 92% >50%
Thornton 1999 62 3D Gd 88% 98%  
Schoenberg 1999 26 3D Gd 94-100% 96-100%  
Miller 1999 32 3D PC 93% 81%  
Cambria 1999 25 3D Gd + PC 97% 100%  
Thornton 1999 42 3D Gd 100% 98%  
Ghantous 1999 12 3D Gd --- 100%  
Marchand 2000   3D Gd 88-100% 71-100%  
Shetty 2000 51 3D Gd 96% 92%  
Winterer 2000 23 3D Gd 100% 98%  
Weishaupt 2000 20 blood pool 3D 82% 98%  
Bongers 2000 43 3D Gd 100% 94%  
time resolved 3D
Volk 2000 40 93% 83%  
Gd
Oberholzer 2000 23 3D Gd at 1T 96% 97%  
Korst 2000 38 3D Gd 100% 85%  
De Corbelli 2000 45 3D Gd 94% 93%