Updates in Magnetic Resonance Venous Imaging

Abstract

For years, magnetic resonance angiography (MRA) has been a leading imaging modality in the assessment of venous disease involving the pelvis and lower extremities. Current advancement in noncontrast MRA techniques enables imaging of a larger subset of patients previously excluded due to allergy or renal insufficiency, allowing for preintervention assessment and planning. In this article, the current status of MR venography, with a focus on current advancements, will be presented. Protocols and parameters for MR venographic imaging of the pelvis and lower extremities, including contrast and noncontrast enhanced techniques, will be reviewed based on a recent literature review of applied MR venographic techniques. Finally, several disease-specific entities, including pelvic congestion and compression syndromes, will be discussed with a focus on imaging parameters that may best characterize these disease processes and optimize anatomical planning prior to intervention.

Keywords: QISS; TR-MR angiography; interventional radiology; noninvasive imaging; pelvic MR venography.

Fig. 1

Contrast-enhanced magnetic resonance angiography (MRA) with maximum intensity projection. Volume-rendered image of coronal 3D gadolinium-enhanced MRA of the lower extremities in a 53-year-old woman with Parkes-Weber syndrome. There are numerous dilated tortuous arteries and superficial veins encircling the right ankle. The diffuse nature of the shunting and lack of a clear focal nidus exemplifies the difficulty in managing and treating these malformations with embolization.

Fig. 2

( a–c ) Time-resolved magnetic resonance angiography (TR-MRA; time-resolved angiography with interleaved stochastic trajectories [TWIST]). TR-MRA imaging of the lower extremities in a 53-year-old woman with Parkes-Weber syndrome. Coronal arterial phase time-resolved imaging shows arterial collateralization consistent with aberrant arteriovenous communications/fistulas. Time-resolved imaging allows anatomic localization of fistulous connections. MRA after mask subtraction allows visualization of smaller distal branches.

Fig. 3

Composed quiescent-interval single-shot images. Noncontrast MRA ( a ) and MRV ( b ) of the abdominal aorta and lower extremity vasculature. Venous imaging obtained by flipping the traveling saturation pulse to above the slice.

Fig. 4

( a, b ) High-resolution quiescent-interval single shot with 1.5 ST. Removal of saturation pulse results in venous and arterial signal; however, the venous anatomy is extremely well defined with this high-resolution noncontrast technique.

Fig. 5

Subtracted 3D time resolved magnetic resonance angiography (MRA). ( a ) Coronal time-resolved MRA images demonstrate filling of the left renal vein (solid arrow) with early retrograde filling of a dilated left gonadal vein open (arrow) and dilated para uterine vessels (arrowhead). ( b ) Post–coil embolization angiography with successful elimination of the retrograde left gonadal vein opacification. Arrow—coils.

Fig. 6

( a, b ) Time-resolved magnetic resonance angiography imaging with early retrograde filling of the proximal left gonadal vein (arrow, b ). The left ovarian vein is not dilated and may have not met criteria for pelvic congestion syndrome on non-dynamic imaging.

Fig. 7

Stage 3 recurrent anterior predominant vaginal vault prolapse. ( a ) Preoperative imaging for sacral colpopexy. ( b ) Multiple tortuous presacral varices bridging the left and right internal iliac veins measuring up to 1.2 cm in diameter.

Fig. 8

( a–c ) 3D high-resolution coronal magnetic resonance venography sequences through the pelvis with extended delayed imaging to evaluate late filling vascular malformations in the subcutaneous tissues and pelvic musculature related to patient's history of blue rubber bleb nevus syndrome.