MR and CT venography for imaging venous obstruction
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1 MR and CT venography for imaging venous obstruction Hendrik von Tengg-Kobligk University Hospitals Inselspital Bern
2 Disclosure Speaker name:...hendrik von Tengg-Kobligk... I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) I do not have any potential conflict of interest
3 Proximal venous outflow obstruction (PVOO) - Increasingly recognized - Lower extremity findings: - varicose veins - deep vein thrombosis - edema, ulceration - postphlebitic syndrome, and - venous reflux
4 Proximal venous outflow obstruction (PVOO) Post-thrombotic Segmental with wall fibrosis and trabeculations Non-thrombotic iliac vein lesions (NIVL s) Subsegmental May-Thurner Syndrom etc. Mixed lesions Lamba R, Radiographics, 2014
5 Open Question - Which imaging modality is key?
6 Imaging: venography options Gloviczki et al, JVS 2011
7 CE-MR venography protocol (Bern) Standard clinical 3 Tesla MR System 1. T2-weighted morphological imaging (ax, cor) 2. Gd-based i.v. contrast agent with prolonged intravascular half-life 3. MR angiography (cor): 3 phases, ~20s each, 1mm sl. thickness 4. Steady state (cor): approx. 5 min., 0.8mm sl. thickness
8 Case #1 39 yo female with chronic pelvic pain
9 First pass 3D ANGIO ARTERIAL
10 3D ANGIO, VENOUS PHASE, MPR NUTCRACKER
11 Axial T1w GRE, fat sat
12 3D T1w GRE, fat sat, STEADY STATE
13 EMBOLIZATION AND STENTING Performed by Prof. Nils Kucher, Inselspital, Bern
14 EMBOLIZATION AND STENTING Performed by Prof. Nils Kucher, Inselspital, Bern
15 MDCT venography 53-yo w, chronic abd pain, weight loss. R. Lamba et al, 2014 GASTROINTESTINAL IMAGING
16 Case #2 23 yo male with post thrombotic syndrome
17 3D ANGIO ARTERIAL
18 T1w GRE FS, axial IVC OCCLUSION ASCENDING LUMBAR VEINS
19 T1w GRE FS COR STEADYSTATE 3D Planning - IVC OCCLUSION
20 RECANALIZATION AND STENTING Performed by Prof. Nils Kucher, Inselspital, Bern
21 Case #3 55 yo male with retroperitoneal tumour
22 3D ANGIO ARTERIAL
23 Axial GRE T1w, FS IVC OCLUSION FROM TUMOUR
24 Coronal T1w, GRE, FS PARTIAL ILIAC OCCLUSION
25 ANGIOGRAM AND STENTING Performed by Prof. Nils Kucher, Inselspital, Bern
26 Imaging Options Modality Gold SD Advantages Disadvantages Bern DSV - direct CTV x High spatial & temporal resol. Radiation, luminography, underfilling, intervention, CM - direct High venous CNR, no art. overlay; surrounding struct. Radiation, underfilling, peripheral venous access, CM - indirect Fast, easy Radiation, limited venous CNR, art. overlay, CM CE-MRV - direct No radiation, high venous CNR, no art. overlay, surrounding struct. - indirect No radiation, high spatial resolution in steady-state Advanced protocol, long acquisition, peripheral venous access, underfilling, CM Advanced protocol, long acquisition, art. overlay, CM NCE-MRV No CM Flow artefacts, small imaging volume IVUS x No CM, high spatial resol. Limited surrounding tissue; intervention x (x) x x
27 Arnoldussen CW et al, Phlebology 2013 Arnoldussen CW et al. Phlebology 2015 CT vs. MR venography PI-Follow up
28 Conclusion MR and CT venography provide detailed 3D anatomy for planning of intervention and complication management. IVUS / DSV still diagnostic gold standard Post-therapy control: consider ionizing radiation and device related imaging artefacts with care to evaluate long term efficacy.
29 MR and CT venography for imaging venous obstruction Hendrik von Tengg-Kobligk University Hospitals Inselspital Bern
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