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Prior Authorization Review Panel MCO Policy Submission
A separate copy of this form must accompany each policy submitted for review. Policies submitted without this form will not be considered for review.
Plan: Aetna Better Health Submission Date:06/01/2020
Policy Number: 0094 Effective Date: Revision Date:
Policy Name: Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV)
Type of Submission – Check all that apply:
New Policy Revised Policy* Annual Review – No Revisions Statewide PDL
*All revisions to the policy must be highlighted using track changes throughout the document.
Please provide any clarifying information for the policy below:
CPB 0094 Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV)
Policy is new to Aetna Better Health of Pennsylvania. Evicore is using policy for review.
Name of Authorized Individual (Please type or print):
Benjamin Alouf, MD, MBA, FAAP
Signature of Authorized Individual:
Proprietary Revised July 22, 2019
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Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV) ... Page 1 of 81
(https://www.aetna.com/)
Magnetic Resonance Angiography (MRA) and MagneticResonance Venography (MRV)
Policy History
Last Review
03/23/2020
Effective: 01/12/1996
Next
Review: 01/28/2021
Review History
Definitions
Ad d i t ion al Information
Clinical Policy Bulletin
Notes
Number: 0094
Policy *Please see amendment for Pennsylvania Medicaid at the end of this CPB.
Magnetic Resonance Angiography (MRA)
I. Aetna considers magnetic resonance angiography (MRA)
medically necessary according to the selection criteria
outlined below. MRA is considered appropriate when it
can replace a more invasive test (e.g., contrast
angiography) and reduce risk for members. While MRA
is a rapidly evolving technology, its clinical safety and
effectiveness for all anatomical regions have not been
established by the peer- reviewed medical literature.
Head and Neck
MRA of the head and neck is considered medically
necessary for any of the following conditions:
A. As a follow-up study for a known arterio-venous
malformation (AVM), and for a known non-ruptured
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intra-cranial aneurysm (ICA) that is greater than 3
mm in size; or
B. As a follow-up of ICA after coiling; or
C. To definitively establish presence of stenoses or
other abnormalities of the vertebrobasilar system in
members with symptoms highly suggestive of
vertebrobasilar syndrome (binocular vision loss,
diplopia, dysarthria, dysphagia, positional vertigo); or
D. To evaluate members with signs/symptoms highly
suggestive of leaking/ruptured ICA or AVM (i.e., blood
in the cerebral spinal fluid, stiff neck, sudden
explosive headache); or
E. To evaluate pulsatile tinnitus in members with signs
or symptoms suggestive of a vascular lesion; or
F. To rule out ICA, including aneurysms of the circle of
Willis, in members who are thought to be at higher
risk (e.g., history of ICA in a first-degree relative or
presence of polycystic kidney disease); or
G. To evaluate conditions of the carotid arteries such
as:
▪ Aneurysm tumor
▪ Cervicocranial arterial dissection in members with
suggestive signs or symptoms (e.g., amaurosis
fugax, oculo-sympathetic palsy, symptoms of
focal brain ischemia, and unilateral headache)
▪ Injury to the carotid artery
▪ Stenotic/occlusive disease in asymptomatic
members who are candidates for carotid
endarterectomy surgery (CEA) when a Duplex
Doppler scan is abnormal
▪ Stenotic/occlusive disease in symptomatic
members (e.g., cerebro-vascular disease or
transient ischemic attack).
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Note : As MRA is considered an alternative to
angiography for evaluation of the carotids, a
subsequent angiography would only be considered
medically necessary if there was a significant
discrepancy between the findings of Duplex
ultrasonography and MRA that would impact on surgical
planning.
Chest
MRA of the chest is considered medically necessary for
any of the following indications:
A. For diagnosis, treatment planning, and post
operative follow-up for conditions of the thoracic
aorta such as aneurysm (true or pseudoaneurysm),
dissection, or stenotic/occlusive vascular disease; or
B. For diagnosis, treatment planning, and post
operative surgical shunt evaluation in members with
congenital heart disease (CHD) or developmental
anomalies of the thoracic vasculature (e.g., atresia or
hypoplasia of the pulmonary arteries, coarctation of
the aorta, double aortic arch, interrupted inferior
vena cava, partial anomalous venous connection,
persistent left superior vena cava, right-sided aortic
arch, total anomalous pulmonary venous
connection, and truncus arteriosus); or
C. For diagnosing a suspected pulmonary embolism
when the use of intravascular iodinated contrast
material is contraindicated, or as a substitute for
pulmonary angiography when a
ventilation/perfusion (V/Q) scan does not provide
sufficient information for treatment decisions; or
D. For pulmonary venous and left atrial evaluation, pre
and post-radiofrequency ablation for atrial
fibrillation.
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Spine
MRA of the spinal canal is considered medically necessary for
individuals with known cases of spinal cord arterio-venous
fistula and arterio-venous malformation. MRA of the spinal
canal is considered experimental and investigational for all other
indications.
Abdomen
MRA of the abdomen is considered medically necessary
for any of the following indications:
A. To assess of the main renal arteries for the
evaluation of renal artery stenosis in persons with
refractory uncontrolled hypertension* not due to
pheochromocytoma; or
B. To assess persons with sickle cell disease; or
C. To assess pelvic (e.g., aorto-iliac) arteries for
stenoses in members with peripheral vascular
disease; or
D. To evaluate endoleaks following endovascular repair
of abdominal aortic aneurysm; or
E. To evaluate hepatic vasculature prior to transjugular
intrahepatic portosystemic shunt (TIPS); or
F. To determine the extent of an abdominal aortic
aneurysm and associated occlusive disease in
members undergoing elective repair; or
G. Evaluation of the body part from which the free
tissue transfer flap is being taken for breast
reconstruction preoperative planning (e.g., MRA of
the abdomen and pelvis for DIEP flap); or
H. To evaluate for chronic mesenteric ischemia.
* Refractory hypertension is defined as diastolic blood
pressure consistently greater than 100 mm Hg on 3 or
more blood pressure medications.
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Lower Extremity
MRA of the lower extremities is considered medically necessary
as an initial test for diagnosis and surgical planning in the
treatment of peripheral arterial disease of the lower extremity. A
subsequent angiography study is only required if the inflow
vessel is not identified on the MRA. If conventional catheter
angiography is performed first, doing a subsequent MRA may be
indicated if a distal run-off vessel is not identified. Both tests
should not be routinely performed.
Allergy, etc.
The use of MRA is considered medically necessary in members
with documented allergy to iodinated contrast material, and in
members who have accelerating hypertension and/or accelerating
renal insufficiency.
II. Aetna considers the use of gadofosveset trisodium
(Ablavar, previously marketed as Vasovist injection) an
appropriate agent for medically necessary contrast-
enhanced MRA of blood vessels in the abdomen and
lower extremities in adults.
III. Aetna considers MRA to be experimental and
investigational for all other indications because its
effectiveness for indications other than the ones listed
above has not been established, including any of the
following:
A. Cardiac MRI for velocity flow mapping; or
B. Diagnosing cerebral arteriovenous malformations; or
C. Evaluating accessory renal arteries in prospective
renal donors, including potential living kidney
donors; or
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D. Evaluating members with symptoms suggestive of
dural, sagittal or cavernous sinus
thrombosis/occlusion; or
E. Evaluating microvascular compression associated
with trigeminal neuralgia; or
F. Evaluating premature ventricular contraction; or
G. Evaluating recurrent cystic hygroma of the axilla; or
H. Evaluating varices at hepatico-jejunostomy after liver
transplantation; or
I. Evaluating vasa previa; or
J. Predicting pulmonary hypertension; or
K. Ruling out ICA in members who have vague central
nervous system symptoms (e.g., dizziness, headache,
non-specific sensory loss, or vertigo); or
L. Screening for renovascular hypertension; or
M. Screening of the general population for ICAs; or
N. Surveillance of individuals with brain cancer
following radiotherapy
IV. Aetna considers ferumoxytol-enhanced MRA for
evaluation of transplant renal artery stenosis
experimental and investigational because its
effectiveness has not been established.
Magnetic Resonance Venography (MRV)
I. Aetna considers MRV medically necessary for any of the
following indications:
A. For evaluation of thrombosis or compression by
tumor of the cerebral venous sinus in members who
are at risk (e.g., hyper-coagulable disorders,
meningitis, oral contraceptive use, otitis media,
sinusitis, underlying malignant process) or have signs
or symptoms (e.g., drowsiness and confusion
accompanying a headache, focal motor or sensory
deficits, papilledema, or seizures); or
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B. For evaluation of cerebral venous infarction
identified on CT or MRI of the head; or
C. For evaluation of venous thrombosis or occlusion in
the large systemic veins (e.g., superior vena cava,
subclavian, or other deep veins in the chest); or
D. For evaluation of venous thrombosis or occlusion in
the portal and/or hepatic venous system (e.g., Budd-
Chiari syndrome); or
E. For chronic pelvic pain, when pelvic congestion
syndrome is suspected and ultrasound findings are
equivocal.
II. Aetna considers MRV experimental and investigational
for diagnosis of deep vein thrombosis in the arms or
legs because the peer-reviewed medical literature has
not established MRV to be superior to Duplex
ultrasonography for this purpose. MRV is considered
experimental and investigational for all other
indications (e.g., diagnosis of chronic cerebrospinal
venous insufficiency, and prediction of outcome in
tuberculous meningitis) because its effectiveness for
indications other than the ones listed above has not
been established.
III. Aetna considers pelvic MRV for diagnostic evaluation of
cryptogenic stroke experimental and investigational
because its effectiveness for this indication has not been
established.
IV. Aetna considers quantitative MRV for measurement of
venous flow after cerebral venous sinus stenting
experimental and investigational because its
effectiveness has not been established.
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V. Aetna considers ferumoxytol-enhanced MRV for the
diagnosis of chronic kidney disease experimental and
investigational because its effectiveness has not been
established.
Background
Magnetic resonance angiography (MRA) is an application of
magnetic resonance imaging (MRI) that provides visualization
of blood flow, as well as images of normal and diseased blood
vessels. While MRA appears to be a rapidly developing
technology, the clinical safety and effectiveness of this
procedure for all anatomical regions has not been proven.
The use of MRA in evaluating flow in the carotid arteries, the
circle of Willis, the anterior, middle or posterior cerebral
arteries, the vertebral or basilar arteries, or the venous sinuses
have been the most well researched applications. Numerous
articles have demonstrated that MRA can image the vessels
with a high degree of sensitivity and specificity. However, the
appropriate use of MRA in this setting must be coordinated
with the use of the competing technologies,Duplex
ultrasonography and angiography. There is no mention in the
literature that all 3 technologies should be used routinely in the
work-up of carotid artery disease. In terms of screening
patients with symptoms suggestive of disease, duplex
ultrasonography has been shown to be equivalent to MRA,
and thus this test is recommended as the initial diagnostic
test. In terms of surgical planning, MRA has been shown to be
competitive with angiography, therefore this test can be the
second definitive test used for surgical planning. In this
scenario, an angiography would only be considered medically
necessary if the ultrasonography and MRA showed major
discrepancies. Finally, in a more limited role, MRA has been
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suggested as an alternative to angiography in those patients
unable to undergo an angiogram due to allergy to contrast
material.
Patients with transient ischemic attacks or strokes typically
undergo MRI as part of the initial work-up to identify infarcted
areas in the brain. An intra-cranial MRA can be easily
appended to the MRI and for that reason has been frequently
ordered. However, an intra-cranial MRA is considered not
medically necessary. MRI can adequately image any infarcted
areas, and in the case of transient ischemic attacks, by
definition, one would not expect to see any vascular
abnormalities. The use of MRA in the work-up of patients with
the vertebrobasilar syndrome must be considered on a case-
by-case basis. The MRA may be appropriate in patients when
other sources of emboli have been ruled out, and the MRA is
considered as an alternative to an angiogram in order to
establish the diagnosis of vertebral artery disease.
Although MRA provides additional imaging capabilities for intra-
cranial aneurysms (ICAs) and vascular lesions, it is not clear
from the literature how this information will impact on patient
management. In particular, patients who present subacutely
with symptoms consistent with aneurysm or vascular
malformations will probably undergo a conventional spin-echo
MRI followed by angiography, if indicated. It is unclear from the
literature how MRA would alter this imaging hierarchy. Several
authors commented that the anatomic detail provided by MRA
is not sufficient to replace an angiogram. Magnetic resonance
angiography has also been suggested as a novel screening
technique for patients at high risk for aneurysm; however, its
clinical relevance is unknown because of a lack of
understanding of the natural history of aneurysms and which
aneurysms represent a high risk of rupture. Due to its low
diagnostic yield, MRA is considered not medically necessary for
the routine work-up of patients with non-specific, non-focal
symptoms, such as headache or dizziness.
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Magnetic resonance angiography is an effective non-invasive
technique for establishing a diagnosis and evaluating the
extent and severity of nearly all diseases of the thoracic aorta.
Studies have shown that MRA of the chest has a high level of
diagnostic accuracy for pre-operative and post-operative
evaluation of aortic dissection of aneurysm. Depending on the
clinical presentation, MRA may be used as an alternative to
other non-invasive imaging technologies (e.g., trans-
esophageal echocardiography and CT).
Saremi and Tafti (2009) noted that cardiac ablation procedures
have become the standard of therapy for various arrhythmias
including atrial fibrillation (AF). Understanding the
morphological characteristics of the left atrium (LA) and
pulmonary vein (PV) in detail and identification of its anatomic
variants is crucial to perform a successful ablation procedure
and minimize complications. The current techniques for
radiofrequency ablation of AF include targeting the PVs or the
tissue in the antrum of the LA. Localization of the anatomic
structures within the LA is performed by using fluoroscopy,
electro-anatomic mapping, and intra-cardiac
echocardiography. Multi-dimensional CT and MRA are
invaluable techniques for better visualization of the anatomic
landmarks that are essential for cardiac ablation procedures
as well as prompt diagnosis and, in selected cases, prevention
of procedure-related complications. Some of the
complications of ablation procedures may include cardiac
tamponade, PV stenosis, as well as esophageal and phrenic
nerve injuries.
Holmes et al (2009) stated that ablation procedures for AF are
being performed with increasing frequency. One of the most
serious complications is the development of pulmonary vein
stenosis, which occurs in 1 % to 3 % of current series. The
presentation of pulmonary vein stenosis varies widely. The
majority of patients are symptomatic although specific referral
bias patterns can affect this. Symptoms may include dyspnea
or hemoptysis or may be consistent with bronchitis. These
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symptoms are affected by the number of stenotic veins as well
as the severity of the stenosis. The more severe the stenosis
and the greater number of stenosed veins result in more
symptoms. Because of the variability in symptoms, clinicians
must have heightened sensitivity to the presence of the
condition. Diagnostic tests of value include MRA and
computed tomography. Although echocardiography has been
used, it does not usually provide adequate assessment.
Progression of stenosis is unpredictable and may be rapid.
The specific anatomy of the stenosis varies widely and affects
management. Because of the presence of antral fusion of the
origin of the left superior and left inferior pulmonary vein, a
stenosis involving 1 or the other can impinge and affect
outcome. In this setting, bifurcation techniques familiar to
interventional cardiology are very helpful. Controversy
currently exists about the optimal treatment approach. The
use of balloons and larger stents (approximately 10 mm)
results in more optimal results than just balloon angioplasty
alone; however, even with stent implantation, recurrent re-
stenosis may occur in 30 % to 50 % of patients. Follow-up of
these patients typically involves computed tomography
imaging to document re-stenosis. If significant re-stenosis is
identified, it should be treated promptly because of the
potential for progression to total occlusion.
Furthermore, a CMS decision memo (2010) noted that it has
received a position statement in the form of a combined
comment from the AmericanCollege of Cardiology (ACC),
American College of Radiology (ACR), American Society of
Neuroradiology (ASNR), North American Society for
Cardiovascular Imaging (NASCI), and the Society for
Cardiovascular Magnetic Resonance (SCMR). They were in
favor of combining the currently separate NCDs, allowing local
Medicare contractor discretion to cover use of MRA for
additional indications which are currently non-covered, and
they recommended national coverage for MRA of the
pulmonary veins before and after radiofrequency ablation for
AF.
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Current scientific data shows that diagnostic pulmonary MRAs
are improving due to recent developments such as faster
imaging capabilities and gadolinium-enhancement. However,
these advances in MRA are not significant enough to warrant
replacement of pulmonary angiography in the diagnosis of
pulmonary embolism for patients who have no contraindication
to receiving intravenous iodinated contrast material. The
tortuous pulsatile nature of the coronary arteries presents an
imposing technical challenge to MRA. The application of MRA
for this purpose is still in its infancy.
Studies have proven that MRA is considered a reliable
diagnostic tool for the pre-operative evaluation of patients who
will undergo elective abdominal aortic aneurysm (AAA) repair.
In addition, scientific data has revealed that MRA is
considered comparable to conventional angiography in
determining the extent of the AAA, as well as evaluation of
aorto-illiac occlusion disease and renal artery pathology that
may be necessary in the surgical planning for AAA repair. If pre-
operative angiography is not necessary, then patients are not
exposed to the risks associated with invasive contrast
procedures, namely allergic reactions, end-organ damage or
arterial injury. Magnetic resonance angiography has also
become accepted as a method to detect suspected stenosis in
the main renal arteries; its inability to image distal lesions and
accessory arteries limits its diagnostic abilities.
Although MRA assessment for the evaluation of renal artery
stenosis is acceptable, the accuracy of MRA as a screening
method for renovascular hypertension is unproven, and MRA
is inadequate in the identification of accessory renal arteries
because it has not achieved the level of accuracy needed to
replace conventional angiography in the evaluation of potential
living renal donors.
Surgical planning for peripheral arterial occlusive disease in
the lower extremities depends on identification of adequate
inflow and distal run off vessels. Magnetic resonance
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angiography has been shown to be a superior technique in
identifying distal run-off vessels and is competitive with
angiography in identifying appropriate inflow vessels.
Therefore, MRA can be used as an initial test for surgical
planning, with a subsequent angiography only if the inflow
vessel is not identified. If angiography is performed first, an
MRA may be appropriate if a distal run-off vessel is not
identified because MRA is capable of detecting a viable run-off
vessel for bypass not seen on traditional angiography,
especially when exploratory surgery is not believed to be a
reasonable medical course of action for the patient.
On December 24, 2008, the United States Food and Drug
Administration (FDA) approved Vasovist injection
(gadofosveset trisodium, now marketed as Ablavar), the first
contrast imaging agent for use in patients undergoing MRA.
Gadofosveset reversibly binds to albumin providing extended
intravascular enhancement compared with existing
extracellular magnetic resonance contrast agents.
Administration of gadofosveset provides a clearer image in
patients who are suspected of having blockages or other
problems with the blood vessels in their abdomen or
extremities. The safety and effectiveness of Vasovist was
established in 2 clinical trials of patients with known or
suspected aorto-iliac disease. In the studies, patients
underwent MRA with and without Vasovist and their scans
were compared to standard X-ray pictures using contrast.
Magnetic resonance angiography with Vasovist detected more
arterial disease than MRA performed without Vasovist and the
pictures were of improved technical quality.
Bosch et al (2008) evaluated the safety and effectiveness of
gadofosveset in patients with pedal arterial disease. A total of
185 adult patients with known or suspected pedal arterial
disease were randomized in a group receiving 0.03 mmol/kg
and a group receiving 0.05 mmol/kg of gadofosveset for MRA
of the pedal arteries. Gadofosveset-enhanced and
unenhanced time-of-flight MR angiograms were compared
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with conventional angiograms for the presence of vascular
stenosis. All patients underwent drug safety analysis. For
each of 3 blinded readers, the specificity (21 to 35 %) of
gadofosveset-enhanced MRA was a statistically significant (p
< 0.010) improvement over that of unenhanced MRA in the
detection of clinically significant (greater than 50 %) stenosis.
The sensitivities of the 2 techniques were similar. For all
blinded readers of MR angiograms, sensitivity, specificity, and
accuracy were higher with use of the 0.03-mmol/kg dose of
gadofosveset than with the 0.05-mmol/kg dose. In the 0.03-
mmol/kg group, 28 % of patients reported a total of 50 adverse
events, 96 % of which were reported as mild or moderate. In
the 0.05-mmol/kg group, 28 % of patients reported a total of 55
adverse events, 98 % of which were reported as mild or
moderate. No patients died; 1 patient left the study because of
myocardial infarction considered unrelated to the study drug.
The authors concluded that because of markedly better
efficacy than no contrast agent and a minimal and transient
side-effect profile, 0.03 mmol/kg of gadofosveset was found
safe and effective for MRA of patients with pedal arterial
disease.
In a multi-center, comparative, phase III single-dose clinical
study, McGregor et al (2008) examined the effectiveness of
gadofosveset-enhanced MRA for evaluation of renal artery
disease. Gadofosveset (0.03 mmol/kg) was administered to
adult patients with known or suspected renal arterial disease;
the drug allows collection of images in the first-pass and
steady-state phases. The combination of these images was
compared to non-contrast MRA, using catheter X-ray
angiography (XRA) as the standard of reference. All MRA
images were collected at 1.5 T in 1 imaging session for direct
comparison, and XRA within 30 days. Sensitivity, specificity,
and accuracy for diagnosing significant disease (stenosis
greater than or equal to 50 %) were calculated for MRA using
3 independent blinded readers. Patient safety was monitored
for 72 to 96 hours. A total of 145 patients were enrolled and
received gadofosveset; the 127 with complete efficacy data
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entered the primary efficacy analysis. Gadofosveset-
enhanced MRA led to significant improvement (p < 0.01) in
sensitivity (+25 %, +26 %, +42 %), specificity (+23 %, +25 %,
+29 %), and accuracy (+23 %, +28 %, +29 %) over non-
enhanced MRA for the 3 readers. The rate of uninterpretable
examinations decreased from 30 % to less than 2 %. There
were no serious adverse events, and the most common
adverse events were nausea, pruritis, and headache (8 %
each). No significant trends in clinical chemistry parameters,
nor significant changes in serum creatinine, were found
following administration of gadofosveset. The authors
concluded that in patients with known or suspected renal
arterial disease, gadofosveset-enhanced MRA significantly
improves sensitivity, specificity, and accuracy versus non-
enhanced MRA. Gadofosveset was safe and well-tolerated in
this patient population.
There is evidence that MRA, as an adjunct to conventional
MRI, is useful in the evaluation of the of spinal cord. Farb et al
(2002) described the cases of 9 patients with initial MRI and
clinical findings suggestive of spinal dural arterio-venous
fistula (AVF) who underwent spinal MRA with an auto-
triggered elliptic centric ordered three-dimensional (3-D)
gadolinium-enhanced technique (hereafter, this MRA
technique) before conventional intra-arterial angiography. In
all 9 patients, findings with this MRA technique correctly and
precisely localized the spinal dural AVF. Observer error
resulted in 1 case in which the site of the fistula was not
prospectively reported, but was easily identified retrospectively
on the spinal MR angiogram.
Saraf-Lavi E et al (2002) studied the sensitivity, specificity, and
accuracy of MRI alone compared with MRI plus MRA in
determining whether dural AVF are present and established
the accuracy of MRA in predicting fistula level. A total of
20 patients with surgically proven dural AVF (diagnosed with
radiographic digital subtraction angiography) and 11 control
patients who had normal digital subtraction angiography
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findings underwent routine MRI plus 3-D contrast-enhanced
MRA of the spine. Images were reviewed in 2 stages (stage I,
MRI only; stage II, MRI plus MRA) by 3 neuroradiologists who
were blinded to the final diagnoses. The sensitivity, specificity,
and accuracy of the 3 reviewers in detecting the presence of
fistulae ranged from 85 % to 90 %, from 82 % to 100 %, and
from 87 % to 90 %, respectively, for stage I, compared with
values of 80 % to 100 %, 82 %, and 81 % to 94 %,
respectively, for stage II. For each reviewer, there were no
significant differences between the values for stage I and
stage II; however, among the reviewers, one of the more
experienced neuroradiologists had significantly greater
sensitivity than a less experienced neuroradiologist for stage
II. On average, the percentage of true positive results for
which the correct fistula level was predicted increased from 15
% for stage I to 50 % for stage II, and the correct level +/- one
level was predicted in 73 % for stage II. MR evidence of
increased intra-dural vascularity was significantly greater in
patients with dural AVF. The authors concluded that the
addition of MRA to standard MRI of the spine may improve
sensitivity in the detection of spinal dural fistulae. The
principal benefit of MRA is in the improved localization of the
vertebral level of the fistula, which potentially expedites the
subsequent digital subtraction angiography study.
Luetmer et al (2005) tested the hypothesis that elliptic centric
contrast-enhanced MRA can be used to detect spinal dural
AVFs, predict the level of fistulas, and reduce the radiation
dose and volume of iodinated contrast material associated
with conventional angiography. These researchers examined
31 patients who presented with suspected spinal dural AVF.
All patients underwent MRA and conventional angiography.
The effect of MRA on subsequent conventional angiography
was assessed by analyzing total fluoroscopy time and volume
of iodinated contrast material used. At angiography, spinal
dural AVFs were diagnosed in 22 of 31 patients, and MRA
depicted an AVF in 20 of the 22 patients. Magnectic
resonance angiographic findings correctly predicted a negative
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angiogram in 7 of 9 cases. Of the 20 true-positive MRA
results, the level of the fistula was included in the imaging
volume in 14. In 13 of these 14 cases, MRA results correctly
predicted the side and the level of the fistula to within 1
vertebral level. Fluoroscopy time and the volume of contrast
agent was reduced by more than 50 % in the 13 patients with
a spinal dural AVF in whom MRA prospectively indicated the
correct level. The authors concluded that contrast-enhanced
MRA can be used to detect spinal dural AVFs, predict the level
of fistulas, and substantially reduce the radiation dose and
volume of contrast agent associated with catheter spinal
angiography.
Meckel et al (2007) stated that digital subtraction angiography
(DSA) is the method of reference for imaging of dural AVF
(DAVF). The goal of this study was to analyze the value of
different MR images including 3-D contrast-enhanced MRA
with a high temporal resolution in diagnostic and follow-up
imaging of DAVFs. A total of 18 MR/MRA examinations from
14 patients with untreated (n = 9) and/or treated (n = 9) DAVFs
were evaluated. Two observers assessed all MR and MRA
investigations for signs indicating the presence of a DAVF, for
fistula characteristics such as fistula grading, location of
fistulous point, and fistula obliteration after treatment. All
results were compared with DSA findings. On time-resolved
3-D contrast-enhanced (TR 3-D) MRA, the side and presence
of all patent fistulas (n = 13) were correctly indicated, and no
false-positive findings were observed in occluded DAVFs (n =
5). Grading of fistulas with this imaging technique was correct
in 77 % and 85 % of patent fistulas for both readers,
respectively. On T2-weighted images, signs indicative of a
DAVF were encountered only in fistulas with cortical venous
reflux (56 %), whereas on 3-D time-of-flight (TOF) MRA, most
fistulas (88 %) were correctly detected. In complete fistula
occlusion, false-positive findings were encountered on both T2-
weighted images and on TOF MRA images. The authors
concluded that TR 3-D MRA proved reliable in detecting
DAVFs and suitable for follow-up imaging. The technique
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allowed -- within limitations -- to grade DAVFs. Although 3-D
TOF MRA can depict signs of DAVFs, its value for follow-up
imaging is limited.
Mull et al (2007) examined the validity of MRA for identification
of spinal arterio-venous (AV) abnormalities. A total of 34
consecutive patients with suspicion of spinal vascular
abnormalities underwent digital subtraction angiography (DSA)
after MRA. The level and side of the suspected spinal DAVF
(SDAVF) and the feeding arteries in spinal AV malformations
(SAVMs) were determined from MRA and compared with
DSA. DSA revealed SDAVF in 20 abnormalities of which 19
were spinal and 1 was tentorial with spinal drainage, as well as
SAVM in 11 patients. In 3 patients, MRA and DSA were both
normal. For detection of spinal AV abnormalities, neither
false-positive nor false-negative MRA result was obtained.
The MRA-derived level of the feeding artery in SDAVF agreed
with DSA in 14 of 19 cases. In 5 cases, a mis-match of 1
vertebral level (not side) was noted for the feeding artery. For
the tentorial AVF, only the spinal drainage was depicted; the
feeding artery was outside the MRA field of view. In intra-dural
SAVM, the main feeding artery was identified by MRA in 10 of
11 patients. Magnetic resonance angiography could
differentiate between gl omerular and fistulous SAVM in 4 of 6
cases and between sacral SDAVF and filum terminale SAVM
in 2 of 5 cases. The authors concluded that MRA reliably
detects or excludes various types of spinal AV abnormalities
and localizes the (predominant) arterial feeder of most spinal
AV shunts. Although classification of the subtype of SAVMs
remains difficult, with MRA it greatly helps to focus subsequent
DSA.
Sharma and Westesson (2008) noted that contrast-enhanced
MRA has been increasingly used in the evaluation of spinal
vascular malformations. Furthermore, in a review on
advances in spinal cord MRA, Backes and Nijenhuis (2008)
noted that current fast contrast-enhanced MR techniques are
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able to (i) visualize vessels supplying or draining the spinal
cord and (ii) differentiate spinal cord arteries from veins.
The localization of the Adamkiewicz artery, the largest artery
supplying the thoraco-lumbar spinal cord, has become
possible in a reproducible and reliable manner. Knowledge of
the anatomic location of this artery and its arterial supplier may
be of benefit in the work-up for aortic aneurysm surgery to
reduce incidences of ischemic injury. Spinal cord MRA is
ready to become a diagnostic tool that can compete with
catheter angiography for detecting and localizing arterial
feeders of vascular lesions and is strongly advised for use
prior to invasive catheter angiography.
An UpToDate review on "Prevalence and evaluation of
ventricular premature beats" (Podrid, 2012) does not mention
the use of magnetic resonance angiography.
Lookstein et al (2004) compared the findings of time resolved-
MRA (TR-MRA) with conventional angiography for the
characterization of endoleaks. Between June 2002 and June
2003, 12 patients with documented endoleaks following
endovascular repair of aortic aneurysms (10 abdominal and 2
thoracic) underwent TR-MRA to identify and characterize the
endoleak. All patients had nitinol-based aortic stent grafts.
MRA was performed on a 1.5-Tesla magnet (Sonata class;
Siemens Medical Systems, Iselin, NJ). The TR-MRA studies
were reviewed under continuous observation as a "cine MR
angiogram". These MRA data sets were used to classify the
endoleaks into types 1 through 3. The patients underwent
conventional angiography following the MRA to confirm the
findings and to plan treatment. The MRA findings were
compared with the findings made at conventional
arteriography. TR-MRA identified 7 patients with type 1 leaks,
including 4 proximal and 3 distal. Four patients had type 2
leaks, including 2 arising from the inferior mesenteric artery
and 2 from an ilio-lumbar artery. One patient had a type 3
leak. Conventional angiography confirmed the type of
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endoleak in all 12 patients. The authors concluded that these
initial results demonstrated TR-MRA to be an effective non-
invasive method for classifying endoleaks. This technique
may allow for screening of patients with endoleaks to identify
those requiring urgent repair.
The American College of Radiology (ACR)/North American
Society for Cardiovascular Imaging (NASCI)/Society for
Pediatric Radiology (SPR)’s practice guideline on “The
performance of pediatric and adult body magnetic resonance
angiography (MRA)” (ACR-NASCI-SPR, 2010) stated that
abdominal and pelvic MRA can be used for post-procedure
assessment for detection of suspected leak following aortic
aneurysm surgery or MR-compatible aortic stent graft
placement”. Moreover, the ACR’s Appropriateness Criteria on
“Abdominal Aortic Aneurysm: Interventional Planning and
Follow-up” (2012) stated that “For detection and sizing of
endoleak, MRA is at least as sensitive as, and probably better
than CTA …. 3D contrast-enhanced MRA and time resolved
MRA are highly sensitive to endoleaks”. The ACR’s
recommendation was given a “7” rating; and 7, 8, and 9
“ratings” denote “Usually appropriate”.
Furthermore, an UpToDate review on “Endovascular repair of
abdominal aortic aneurysm” (Chaer, 2014) states that “CT
angiography with delayed images is the most widely used
modality for follow-up after endovascular aneurysm repair
(EVAR). It is accurate for maximal diameter measurement,
and for the detection of endoleak and other device-related
complications. However, CT angiography is costly and
repeated radiation exposure is associated with an increased
lifetime cancer risk. Repeated administration of intravenous
contrast may also contribute to a progressive decline in renal
function that has been observed following EVAR. The
guidelines for the management of abdominal aortic aneurysm
(AAA) from the Society for Vascular Surgery advocate CT
angiography at 1 and 12 months during the first year after
EVAR. Imaging at six months is no longer routinely
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recommended unless an endoleak or other device-related
abnormality is identified at the one-month imaging study after
EVAR. If an endoleak or aneurysm enlargement is not
documented during the first year after EVAR, DU [duplex
ultrasonography] is an alternative to CT angiography for
ongoing postoperative surveillance …. MR imaging is not a
standard modality for EVAR surveillance, but can be used in
specific situations where CT angiography is contraindicated.
The advantage of MR imaging is the lack of exposure to
ionizing radiation. Disadvantages are its lack of wide
availability and difficulty evaluating device integrity due to
artifact. The placement of stent-grafts made of nitinol does not
preclude MR imaging, though MR imaging is contraindicated
for stainless-steel-based grafts (e.g., Cook, Zenith)”.
Miller et al (2009) stated that neuro-vascular compression
(NVC) of the trigeminal nerve is associated with trigeminal
neuralgia (TN), but also occurs in many patients without facial
pain. These researchers identified anatomical characteristics
of NVC associated with TN. A total of 30 patients with type 1
TN (intermittent shock-like pain) and 15 patients without facial
pain underwent imaging for analysis of 30 trigeminal nerves
ipsilateral to TN symptoms, 30 contralateral to TN symptoms,
and 30 in asymptomatic patients were include in this study.
Patients underwent 3-T MRI including balanced fast-field echo
and MRA. Images were fused and reconstructed into virtual
cisternoscopy images that were evaluated to determine the
presence and degree of NVC. Reconstructed coronal images
were used to measure nerve diameter and cross-sectional
area. The incidence of arterial NVC in asymptomatic nerves,
nerves contralateral to TN symptoms, and nerves ipsilateral to
TN symptoms was 17 %, 43 %, and 57 %, respectively. The
difference between symptomatic and asymptomatic nerves
was significant regarding the presence of NVC, nerve
distortion, and the site of compression (p < 0.001, Fisher exact
test). The most significant predictors of TN were compression
of the proximal nerve (odds ratio 10.4) and nerve indentation
or displacement (odds ratio 4.3). There was a tendency for
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the development of increasingly severe nerve compression
with more advanced patient age across all groups. Decreased
nerve size was observed in patients with TN but did not
correlate with the presence or extent of NVC. The authors
concluded that trigeminal NVC occurs in asymptomatic
patients but is more severe and more proximal in patients with
TN. Moreover, they stated that this information may help
identify patients who are likely to benefit from micro-vascular
decompression (MVD).
Zacest et al (2010) stated that TN is a neuropathic pain
syndrome that is often associated with NVC of the TN and may
be effectively treated with MVD. The authors used high-
resolution MRI with 3D reconstruction in patients with constant
facial pain (type 2 TN) to determine the presence/absence of
NVC and thus a potential MVD benefit. They retrospectively
contacted patients to evaluate outcome. All patients who
reported spontaneous onset of constant facial pain (type 2
TN), which occurred at least 50 % of the time, who had
undergone high-resolution 3-TMRI with 3D reconstruction
were retrospectively selected for this study. Clinical history,
facial pain questionnaire data, physical examination findings,
and results from 3-T 3D MRI reconstruction were recorded for
all patients. Intra-operative findings and clinical pain outcome
were recorded for all patients who underwent MVD. Data
obtained in 27 patients were assessed. On the basis of history
and 3D MRI reconstruction findings, 13 patients were selected
for MVD (Group A) and 14 underwent conservative treatment
(Group B). Typical or suspected artery- or vein-induced NVC
was predicted pre-operatively in 100 % of Group A patients
and in 0 % of Group B patients.At the time of MVD, definitive
NVC was confirmed in 11 (84.6 %) of 13 Group A patients.
Following MVD, facial pain was completely relieved in 3 (23
%), improved in 7 (53.8 %), and no better in 3 (23 %) of 13
Group A patients. A history of episodic (type 1 TN) pain at any
time was reported in 100 % and 50 % of Group A and Group B
patients, respectively. A type 1 TN pain component was
reportedly improved/relieved in all Group A patients, but the
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type 2 TN pain component was improved in only 7 (53.8 %) of
13 patients. The mean post-operative follow-up duration was
13 months. The authors concluded that high-resolution 3D
MRI reconstruction in patients with constant facial pain (type 2
TN) can help determine the presence/absence of NVC. They
stated that surgical selection based on both clinical and
radiological criteria has the potential to improve surgical
outcome in patients with type 2 TN who may potentially benefit
from MVD. However, even in such selected patients, pain
relief is likely to be incomplete.
Leal et al (2014) prospectively evaluated atrophic changes in
trigeminal nerves (TGNs) using measurements of volume (V)
and cross-sectional area (CSA) from high-resolution 3-T MR
images obtained in patients with unilateral TN, and correlated
these data with patient and NVC characteristics and with
clinical outcomes. Anatomical TGN parameters (V and CSA)
were obtained in 50 patients (30 women and 20 men; mean
age of 56.42 years, range of 22 to 79 years) with classic TN
before treatment with MVD. Parameters were compared
between the symptomatic (ipsilateralTN) and asymptomatic
(contralateralTN) sides of the face; 20 normal control subjects
were also included. Two independent observers blinded to the
side of pain separately analyzed the images. Measurements
of V (from the pons to the entrance of the nerve into Meckel's
cave) and CSA (at 5 mm from the entry of the TGN into the
pons) for each TGN were performed using imaging software
and axial and coronal projections, respectively. These data
were correlated with patient characteristics (age, duration of
symptoms before MVD, side of pain, sex, and area of pain
distribution), NVC characteristics (type of vessel involved in
NVC, location of compression along the nerve, site of
compression around the circumference of the root, and degree
of compression), and clinical outcomes at the 2-year follow-up
after surgery. Comparisons were made using Bonferroni's
test. Inter-observer variability was assessed using the
Pearson correlation coefficient. The mean V of the TGN on
the ipsilateralTN (60.35 ± 21.74 mm(3)) was significantly
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smaller (p < 0.05) than those for the contralateralTN and
controls (78.62 ± 24.62 mm(3) and 89.09 ± 14.72 mm(3),
respectively). The mean CSA of the TGN on the ipsilateralTN
(4.17 ± 1.74 mm(2)) was significantly smaller than those for
the contralateralTN and controls (5.41 ± 1.89 mm(2) and 5.64
± 0.85 mm(2), respectively). The ipsilateralTN with NVC
Grade III (marked indentation) had a significantly smaller mean
V than the ipsilateralTN with NVC Grade I (mere contact),
although it was not significantly smaller than that of the
ipsilateralTN with NVC Grade II (displacement or distortion of
root). The ipsilateralTN with NVC Grade III had a significantly
smaller mean CSA than the ipsilateralTN with NVC Grades I
and II (p < 0.05). The TGN on the ipsilateralTN in cured
patients had a smaller mean CSA than that on the
ipsilateralTN of patients with partial pain relief or treatment
failure (p < 0.05). The same finding was almost found in
relation to measurements of V, but the p value was slightly
higher at 0.05. The authors concluded that the findings of this
study showed that TGN atrophy in patients with TN can be
demonstrated by high-resolution imaging. Moreover, they
stated that these data suggested that atrophic changes in
TGNs, which significantly correlated with the severity of
compression and clinical outcomes, may help to predict long-
term prognosis after vascular decompression.
An UpToDate review on “Trigeminal neuralgia” (Bajwa et al,
2014) states that “Neuroimaging with head CT or MRI is useful
for identifying the small proportion of patients who have a
structural lesion (e.g., tumor in the cerebellopontine angle,
demyelinating lesions including multiple sclerosis) as the
cause of painful trigeminal neuropathy. In addition, high
resolution MRI and magnetic resonance angiography (MRA)
may be useful for identifying vascular compression as the
etiology of classic TN, but the utility of these studies has not
been established …. The 2008 AAN/EFNS practice parameter
identified seven studies that performed high-resolution brain
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MRI and/or magnetic resonance angiography (MRA) to
demonstrate neurovascular compression in patients with TN.
The following observations were made:
▪ There was wide variation among the included studies
for both sensitivity (range 52 to 100 %) and specificity
(29 to 93 %).
▪ In 3 of the 5 highest-quality MRI studies (cohort surveys
with prospective data collection), the difference in rate
of neurovascular trigeminal nerve compression on the
symptomatic side compared with asymptomatic side
was statistically non-significant.
Given these inconsistent results, the AAN/EFNS concluded
that there is insufficient evidence to support or refute the utility
of MRI to identify neurovascular compression in classic TN, or
to indicate the most reliable MRI technique”.
Magnetic Resonance Angiography (MRA) for the Diagnosis of Cerebral Arteriovenous Malformation
In a retrospective, observational study, Chowdhury et al (2015)
compared MRA and DSA in diagnosis of cerebral arterio-
venous malformation (AVM). A total of 30 patients with
hemorrhagic stroke age ranging from 13 to 65 years were
selected on the basis of inclusion and exclusion criteria as the
study sample. MRA and DSA were done in all the selected
patients. The mean age of the patients of hemorrhagic stroke
was 30.3 ± 14.3 years and male to female ratio was 2.7:1.
Regarding the venous drainage of AVM 13 and 12 were
superficial and deep, respectively, and evaluated 100 % by
MRA. In the diagnosis of cerebral AVM nidus size S1: less
than 3 and S2: 3 to 6 cm sensitivity was 100 % but accuracy
was 100 % and 73.3 %, respectively. DSA was 100 %
sensitive in the diagnosis of superficial and deep venous
drainage AVM. Regarding the eloquence of brain area 15 had
no eloquence by both MRA and DSA and identification of
eloquence of brain area sensitivity was 73.3 % and accuracy
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was 86.7 %. The main feeding vessels were found (22, 73.3
%) in both DSA and MRA findings. Distal vessels was seen
(8, 26.7 %) in DSA butnot seen in MRA findings. Intra-nidal
aneurysm and angiopathic AVM were seen in 3 (10.0 %) and 4
(13.3 %), respectively in DSA. This study was carried out to
diagnose the patients presented with cerebral AVM by MRA
and DSA. The authors concluded that MRA could not be
evaluated flow status of AVM, distal feeding arteries, intra-
nidal aneurysm and angiopathic AVM, which could be
detected by DSA. So, DSA is superior to MRA in diagnosis of
cerebral AVM.
MRA for the Diagnosis and Treatment Response in Individuals with Moyamoya Disease
Uchino et al (2015) stated that noncontrast-enhanced time-
resolved 4-dimensional MRA using an arterial spin labeling
technique (ASL-4D MRA) is emerging as a next generation
angiography for the management of neurovascular diseases.
This study evaluated the feasibility of ASL-4D MRA for the
diagnosis of Moyamoya disease (MMD) and MMD staging by
using DSA and TOF MRA as current standards. A total of 11
consecutive non-operated patients who underwent DSA for the
diagnosis of MMD were recruited. Two independent observers
evaluated the 3 tests. The data were analyzed for inter-
observer and inter-modality agreements on MMD stage; 9 of
22 hemispheres underwent surgical re-vascularization and ASL-
4D MRA was repeated post-operatively. Time-resolved inflow of
blood through the cerebral vessels, including moyamoya
vessels, was visualized in all the 22 non-operated hemispheres.
MMD stages assessed by DSA and ASL-4D MRA were
completely matched in 18 hemispheres, with a significant
positive correlation between these modalities (r = 0.93, p <
0.001). Inter-observer agreement with ASL-4D MRA (κ = 0.91 ±
0.04, p < 0.001) and inter-modality agreement between ASL-4D
MRA and DSA (κ = 0.93 ± 0.04, p < 0.001)
were both excellent. MMD stages assessed by ASL-4D MRA
have also a significant positive correlation with those assessed
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by TOF MRA (r = 0.68, p = 0.004).Repeated ASL-4D MRA
clearly demonstrated the bypassed arteries and changes in
the dynamic flow patterns of cerebral arteries in all the 9
hemispheres after surgical re-vascularization. Of these, post-
operative focal hyper-perfusion was detected by single photon
emission tomography in 7 hemispheres. In 5 of the 7
hemispheres (71 %) with post-operative hyper-perfusion, ASL-
4D MRA demonstrated focal hyper-intense signals in the
bypassed arteries, although TOF MRA did not. The authors
concluded that noninvasive ASL-4D MRA is feasible for the
diagnosis of MMD staging. This next generation angiography
may be useful for monitoring disease evolution and treatment
response in cerebral arteries after revascularization surgery in
MMD. These preliminary findings need to be validated by well-
designed studies.
MRA for the Evaluation of Aneurysm Coiling
In a systematic review and meta-analysis, Ernst et al (2015)
examined the inter-rater reliability of visual rating of aneurysm
occlusion as study end-point. Electronic databases
(MEDLINE, EMBASE, PubMed, and the Cochrane Library)
were searched up to June 2014. Assessment of risk for bias
was based on the Quality Appraisal Tool for Studies of
Diagnostic Reliability and the Guidelines for Reporting
Reliability and Agreement studies. Inter-rater reliability
estimates were pooled across studies using meta-analysis,
and the influence of several factors (e.g., imaging methods,
grading scales, and occlusion rate) was tested with meta-
regression. From 1,193 titles, 644 abstracts and 87 full-text
versions were reviewed. A total of 26 articles met the inclusion
criteria and provided 77 reliability estimates; 21 different rating
scales were used, and statistical analysis varied. Mean inter-
rater agreementof the pooled studies was substantial (κ =
0.65; 95 % confidence interval [CI]: 0.60 to 0.69). Reliability
varied significantly as a function of imaging methods, grading
scales, occlusion rates, and their interaction. Observer
agreement substantially increased with increasing occlusion
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rate in digital subtraction angiography but not in MA.
Reliability was higher in studies using 2- or 3-value grading
scales than in studies with 4-value grading scales. The
authors concluded that there was significant heterogeneity
between studies evaluating the reliability of visual evaluation of
aneurysm coiling. On the basis of this analysis, these
researchers found that the combination of MRA, 3-value
grading scale, and 2 trained raters appeared most promising
for usage as surrogate study end-points.
Marciano and colleagues (2017) noted that data about non-
invasive follow-up of aneurysm after stent-assisted coiling is
scarce. In a retrospective, single-center study, these
investigators compared TOF MRA (3D-TOF-MRA) and contrast-
enhanced MRA (CE-MRA) at 3-Tesla, with DSA for evaluating
aneurysm occlusion and parent artery patency after stent-
assisted coiling. Patients were included if they had an
intracranial aneurysm treated by stent-assisted coiling
between March 2008 and June 2015, followed with both MRA
sequences (3D-TOF-MRA and CE-MRA) at 3-Tesla and DSA,
performed in an interval of less than 48 hours. A total of 35
aneurysms were included. Regarding aneurysm occlusion
evaluation, agreement with DSA was better for CE-MRA (K =
0.53) than 3D-TOF-MRA (K = 0.28). Diagnostic accuracies for
aneurysm remnant depiction were similar for 3D-TOF-MRA
and CE-MRA (p = 1). Both 3D-TOF-MRA (K = 0.05) and CE-
MRA (K = -0.04) were unable to detect pathological vessel
compared to DSA, without difference in accuracy (p = 0.68).
For parent artery occlusion detection, agreement with DSA
was substantial for 3D-TOF-MRA (K = 0.64) and moderate for
CE-MRA (K = 0.45), with similar good diagnostic accuracies (p
= 1). The authors concluded that after stent-assisted coiling
treatment, 3D-TOF-MRA and CE-MRA demonstrated good
accuracy to detect aneurysm remnant (but tended to over-
estimation). They stated that although CE-MRA agreement
with DSA was better, there was no statistical difference
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between 3D-TOF-MRA and CE-MRA accuracies. Both MRAs
were unable to provide a precise evaluation of in-stent status;
but could detect parent vessel occlusion.
Ernst and associates (2018) stated that understanding
aneurysm growth is critical for the appropriate follow-up of
patients after coil embolization and the need for re-treatment.
These researchers stratified the growth dynamics of aneurysm
recurrences after coiling by volumetric analysis and
determined predictive factors for aneurysm recurrences.
Source images of follow-up 3D-TOF-MRA scans were
compared with the first post-interventional TOF-MRA scan and
analyzed for residual flow after co-registration using ANALYZE-
software. In the event of incomplete occlusion, the residual
volume was segmented and calculated. Growth dynamic was
determined for each aneurysm after embolization. These
researchers analyzed 326 patients with 345 aneurysms from 2
centers. Each case had at least 2 TOF- MRA examinations after
endovascular therapy. The mean observation interval was 59
months. Volumetric analysis of 1,139 follow-up MRAs revealed
that 218/345 aneurysms (63.2
%) showed complete occlusion on initial follow-up imaging,
and of these 95.0 % remained stable. A steady increase in
intra-aneurysmal flow was observed in 83/345 (24.1 %). Less
frequent observations were a steep increase (21/345; 6.1 %)
and a decrease (27/345; 7.8 %). Independent predictors of
increasing residual flow were greatest aneurysm diameter,
total coil length, and incomplete occlusion. The authors
concluded that volumetric analysis of registered 3D-TOF-MRA
follow-up datasets allowed the detection of different growth
patterns with high precision, avoided the low inter-rater
reliability, and represented a promising approach for future
studies that include analysis of more complex predictors of
residual flow. In cases of aneurysm recurrence after coiling,
the major pattern appeared to be a steady increase in intra-
aneurysmal flow over several months.
MRA for the Evaluation of Varices at Hepatico-
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Jejunostomy after Liver Transplantation
Jimbo et al (20150 reported the case of a 7-year old Japanese
girl who had undergone living-donor liver transplantation (LT)
at the age of 10 months for decompensated liver cirrhosis
caused by biliary atresia presented with recurrent episodes of
obscure gastrointestinal bleeding (GIB) with anemia. Over the
following 6 years, she experienced 5 episodes of GIB requiring
hospitalization. Subsequent evaluations including repeat
esophagogastroduodenoscopy (EGD), colonoscopy (CS),
contrast-enhanced computed tomography (CT), and Meckel's
scan all failed to reveal a bleeding source. However, varices
at the site of hepatico-jejunostomy were detected on
abdominal ultrasonography and MRA at the age of 7 years.
The authors concluded that MRA might be more helpful than
contrast-enhanced C T for identifying s uch bleeding. These
preliminary findings need to be validated by well-designed
studies.
MRA for the Surveillance of Individuals with Brain Cancer Following Radiotherapy
In a feasibility study, Bullitt et al (2007) examined if MRA can
depict intracranial vascular morphologic changes during
treatment of brain metastases from breast cancer and if serial
quantitative vessel tortuosity measurements can be used to
predict tumor treatment response sooner than traditional
methods. Institutional review board approval and informed
consent were obtained for this HIPAA-compliant study. A total
of 22 women aged 31 to 61 years underwent brain MRA prior
to and 2 months after initiation of lapatinib therapy for brain
metastases from breast cancer. Vessels were extracted from
MR angiograms with a computer program. Changes in vessel
number, radius, and tortuosity were calculated mathematically,
normalized with values obtained in 34 healthy control subjects
(19 women, 15 men; age range of 19 to 72 years), and
compared with subsequent assessments of tumor volume and
clinical course. All patients exhibited abnormal vessel
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tortuosity at baseline. Nineteen (86 %) patients did notexhibit
improvement in vessel tortuosity at 2-month follow-up, and all
patients demonstrated tumor growth at 4-month follow-up.
Vessel tortuosity measurements enabled these researchers to
correctly predict treatment failure 1 to 2 months earlier than did
traditional methods. Three (14 %) patients had quantitative
improvement in vessel tortuosity at 2-month follow-up, with
drop-out of small abnormal vessels and straightening of large
vessels. Each of the 2 patients for whom further follow-up
data were available responded to treatment for more than 6
months. The authors concluded that these findings
established the feasibility of using MRA to quantify vessel
shape changes during therapy. Moreover, they stated that
although further research is required, results suggested that
changes in vessel tortuosity might enable early prediction of
tumor treatment response.
An Information Sheet on “Further tests for brain tumours” from
Cancer Research UK (Last updated November 25, 2013) did
not mention annual MRA as a surveillance tool for patients
with brain cancer.
A “Brain Tumor Glossary of Terms” from the Brain Tumor Trial
Collaborative (2015) states that “MRA does not have
significant application for the detection or definition of cancer
of the brain”.
Also, an UpToDate review on “Assessment of disease status
and surveillance after treatment in patients with brain
tumors” (Wen, 2015) does not mention MRA as a
management tool.
Furthermore, National Comprehensive Cancer Network
(NCCN)’s clinical practice guideline on “Central nervous
system cancers” (Version 1.2015) states that “Cerebral
angiography is occasionally performed, often for surgical
planning ….”; it does not mention MRA as a management tool.
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The use of an MRA/MRV as part of the work-up of a patient
with suspected cerebral thrombosis (i.e., dural sagittal or
cavernous sinus thrombosis) must be considered on a case by
case basis. Magnetic resonance imaging is considered the
imaging method of choice for establishing the diagnosis, but
MRA/MRV may be useful in following the course of the
disease.
Magnetic resonance venography (MRV) is now very effective
for the evaluation of diseases of larger veins. The specific
indications for using MRV for evaluating the vena cavae are
diagnosis of vena caval thrombus, differentiation of tumor
thrombus and blood clot of the vena cava, diagnosis of
superior vena caval syndrome, identification of superior vena
caval invasion or encasement by lung or mediastinal tumors,
diagnosis of the Budd-Chiari syndrome, diagnosis of caval
anomalies such as persistent left superior vena cava and
interrupted inferior vena cava, and identification of the
presence and cause of obstruction or occlusion of the
brachiocephalic, subclavian, and jugular veins.
Duplex ultrasonography is the typical initial diagnostic test for
deep vein thrombosis (DVT). Magnetic resonance venography
has not been shown to be superior to ultrasonography, except
in imaging the deep femoral and hypogastric vessels.
However, information about these vessels is frequently not
needed to make patient management decisions, except
perhaps in patients with pulmonary emboli where the source of
the emboli has not been identified by ultrasonography. McRae
and Ginsberg (2004) MRV has the potential to be used as a
stand-alone test for DVT but requires further evaluation.
Moreover, in a retrospective study (n = 973), Borer et al (2005)
found that discontinuation of screening by means of ultrasound
and MRV for the diagnosis of DVT did not change the rate of
pulmonary embolism in patients with closed fractures of the
pelvis or acetabulum.
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Bates et al (2012) stated that objective testing for DVT is
crucial because clinical assessment alone is unreliable and the
consequences of misdiagnosis are serious. This guideline
focused on the identification of optimal strategies for the
diagnosis of DVT in ambulatory adults. The methods of this
guideline followed those described in Methodology for the
Development of Antithrombotic Therapy and Prevention of
Thrombosis Guidelines: Antithrombotic Therapy and
Prevention of Thrombosis, 9th ed: American College of Chest
Physicians Evidence-Based Clinical Practice Guidelines.
These investigators suggested that clinical assessment of pre-
test probability of DVT, rather than performing the same tests
in all patients, should guide the diagnostic process for a first
lower extremity DVT (Grade 2B). In patients with a low pre-
test probability of first lower extremity DVT, these researchers
recommended initial testing with D-dimer or ultrasound (US) of
the proximal veins over no diagnostic testing (Grade 1B),
venography (Grade 1B), or whole-leg US (Grade 2B). In
patients with moderate pre-test probability, they recommended
initial testing with a highly sensitive D-dimer, proximal
compression US, or whole-leg US rather than no testing
(Grade 1B) or venography (Grade 1B). In patients with a high
pre-test probability, they recommended proximal compression
or whole-leg US over no testing (Grade 1B) or venography
(Grade 1B). The authors concluded that favored strategies for
diagnosis of first DVT combined use of pre-test probability
assessment, D-dimer, and US. There is lower-quality
evidence available to guide diagnosis of recurrent DVT, upper
extremity DVT, and DVT during pregnancy.
The role of chronic cerebrospinal venous insufficiency
(CCSVI) in the pathogenesis of multiple sclerosis (MS) is a
matter of debate. Chronic cerebrospinal venous insufficiency
was first diagnosed using specialized trans-cranial and extra-
cranial Doppler ultrasonography. Some have advocated the
use of MRV in place of trans-cranial Doppler because the
results of MRV are less operator dependent. However, there
are limited data to support the use of MRV in diagnosis of
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CCSVI. I n a pilot study, Hojnacki et al (2010) the value of
neck MRV for the diagnosis of CCSVI compared to Doppler
sonography (DS) and selective venography (SV) in patients
with MS and in healthy controls (HC). A total of 10 MS
patients and 7 HC underwent DS, 2D-Time-Of-Flight (TOF)
venography and 3D-Time Resolved Imaging of Contrast
Kinetics angiography (TRICKS). Patients with MS also
underwent SV. The internal jugular veins (IJVs) and the
vertebral veins (VVs) were assessed by both MRV sequences,
and the findings were validated against SV and DS; SV has
been considered the diagnostic gold standard for MS patients.
All MS patients and none of the HC presented CCSVI,
according to the DS criteria. This was confirmed by SV. For
CCSVI diagnosis, DS showed sensitivity, specificity, accuracy,
positive-predictive value (PPV) and negative-predictive value
(NPV) of 100 %, whereas the figures were 40 %, 85 %, 58 %,
80 % and 50 % for 3D-TRICKS, and 30 %, 85 %, 52 %, 75 %
and 46 % for 2D-TOF in the IJVs. In MS patients, compared to
SV, DS showed sensitivity, specificity, accuracy, PPV and
NPV of 100 %, 75 %, 95 %, 94 % and 100 %, whereas the
figures were 31 %, 100 %, 45 %, 100 % and 26 % for 3D-
TRICKS and 25 %, 100 %, 40 %, 100 % and 25 % for 2D-TOF
in the IJVs. The authors concluded that the use of MRV for
diagnosis of CCSVI in MS patients has limited value, and the
findings should be interpreted with caution and confirmed by
other imaging techniques such as DS and SV.
Abdalla et al (2015) searched the literature for further evidence
for the use of MRV in the detection of suspected DVT and re-
evaluated the accuracy of MRV in the detection of suspected
DVT. PubMed, EMBASE, Scopus, Cochrane, and Web of
Science were searched. Study quality and the risk of bias
were evaluated using the QUADAS 2. A random effects meta-
analysis including subgroup and sensitivity analyses were
performed. The search resulted in 23 observational studies all
from academic centers; 16 articles were included in the meta-
analysis. The summary estimates for MRV as a diagnostic non-
invasive tool revealed a sensitivity of 93 % (95 % CI: 89 %
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to 95 %) and specificity of 96 % (95 % CI: 94 % to 97 %). The
heterogeneity of the studies was high. Inconsistency (I2) for
sensitivity and specificity was 80.7 % and 77.9 %,
respectively. The authors concluded that further studies
investigating the use of MRV in the detection of suspected
DVT did not offer further evidence to support the replacement
of US with MRV as the first-line investigation. However, they
stated that MRV may offer an alternative tool in the
detection/diagnosis of DVT for whom US is inadequate or not
feasible (such as in the obese patient).
MRA for Evaluation of Vasa Previa
Iwahashi and associates (2016) noted that vasa previa is a
rare complication, and rupture of vasa previa during pregnancy
may lead to significant perinatal mortality. These investigators
reported a case of vasa previa evaluated prenatally using non-
contrast time-of-flight MRA (TOF-MRA). A 22-year old
primiparous woman was referred to the authors’ hospital due
to suspicion of vasa previa. Trans-vaginal US showed 2
vessels running over the internal os. To obtain further
information, MRI and TOF-MRA were performed. Caesarean
section was performed, and macroscopic findings of the
vascular distribution on the fetal membrane were consistent
with those identified by TOF-MRA. The authors concluded
that TOF-MRA in addition to MRI may be an option for prenatal
identification of the precise 3D vascular distribution in patients
with vasa previa. The role of MRA for evaluation of patients
with vasa previa needs to be further investigated.
Ferumoxytol-Enhanced MRA for Evaluation of Transplant Renal Artery Stenosis
Fananapazir and co-workers (2017) determined the accuracy
of ferumoxytol-enhanced MRA in assessing the severity of
transplant renal artery stenosis (TRAS), using digital
subtraction angiography (DSA) as the reference standard.
The authors’ Institutional Review Board approved this
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retrospective, Health Insurance Portability and Accountability
Act-compliant study. A total of 33 patients with documented
clinical suspicion for TRAS (elevated serum creatinine,
refractory hypertension, edema, and/or audible bruit) and/or
concerning sonographic findings (elevated renal artery velocity
and/or intra-parenchymal parvus tardus waveforms)
underwenta 1.5T MRA with ferumoxytolprior to DSA. All
DSAs were independently reviewed by an interventional
radiologist and served as the reference standard. The MRAs
were reviewed by 3 readers who were blinded to the US and
DSA findings for the presence and severity of TRAS.
Sensitivity, specificity, and accuracy for identifying substantial
stenoses (greater than 50 %) were determined. Intra-class
correlation coefficients (ICCs) were calculated among
readers. Mean differences between the percent stenosis from
each MRA reader and DSA were calculated. On DSA, a total
of 42 stenoses were identified in the 33 patients. The
sensitivity, specificity, and accuracy of MRA in detecting
substantial stenoses were 100 %, 75 to 87.5 %, and 95.2 to
97.6 %, respectively, among the readers. There was excellent
agreement among readers as to the percent stenosis (ICC =0.82);
MRA over-estimated the degree of stenosis by 3.9 to 9.6
% compared to DSA. The authors concluded that ferumoxytol-
enhanced MRA provided high sensitivity, specificity, and
accuracy for determining the severity of TRAS. They stated
that these findings suggested that ferumoxytol-enhanced MRA
can potentially be used as a non-invasive examination
following US to reduce the number of unnecessary
conventional angiograms. These preliminary findings need to
be validated by well-designed studies.
Ferumoxytol-Enhanced MRA for Evaluation of Potential Kidney Transplant Recipients
Stoumpos and associates (2018) stated that traditional
contrast-enhanced methods for scanning blood vessels using
MRI or CT carry potential risks for patients with advanced
kidney disease. Ferumoxytol is a super-paramagnetic iron
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oxide nanoparticle preparation that has potential as an MRI
contrast agent in assessing the vasculature. A total of 20
patients with advanced kidney disease requiring aorto-iliac
vascular imaging as part of pre-operative kidney transplant
candidacy assessment underwent ferumoxytol-enhanced MRA
(FeMRA) between December 2015 and August 2016. All
scans were performed for clinical indications where standard
imaging techniques were deemed potentially harmful or
inconclusive. Image quality was evaluated for both arterial
and venous compartments. First-pass and steady-state
FeMRA using incremental doses of up to 4 mg/kg body weight
of ferumoxytol as intravenous contrast agent for vascular
enhancement was performed. Good arterial and venous
enhancements were achieved, and FeMRA was not limited by
calcification in assessing the arterial lumen. The scans were
diagnostic and all patients completed their studies without
adverse events (AEs). The authors concluded that their
preliminary experience supported the feasibility and utility of
FeMRA for vascular imaging in patients with advanced kidney
disease due for transplant listing, which has the advantages of
obtaining both arteriography and venography using a single
test without nephrotoxicity. These preliminary findings need to
be validated by well-designed studies.
Ferumoxytol-Enhanced MRV for Diagnosis of Chronic Kidney Disease
Luhar and associates (2016) noted that ferumoxytol is an ultra-
small superparamagnetic iron oxide (USPIO) particle that is
FDA-approved for parenteral treatment of iron deficiency
anemia in adults with chronic kidney disease (CKD). Because
of the association between gadolinium-based contrast agents
and nephrogenic systemic fibrosis in patients with severe
CKD, these researchers evaluated the diagnostic role of
ferumoxytol-enhanced MRV in children with CKD. A total of 20
children underwent 22 high-resolution ferumoxytol-enhanced
MRV examinations at 3.0 T. High-resolution 3D contrast-
enhanced imaging was performed at a minimum of 3 time-
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points following injection of ferumoxytol at a total dose of 4
mg/kg of body weight. Two blinded pediatric radiologists
independently scored 6 named veins on ferumoxytol-
enhanced MRV examinations according to a 3-point subjective
score, where a score greater than or equal to 2 was
considered diagnostic. Additionally, all relevant venous
structures in the included field of view were analyzed for
occlusive or non-occlusive thrombosis, compression and
presence of collaterals. All patients underwent ferumoxytol-
enhanced MRV successfully and without adverse event (AE).
The overall scores of the reviewing radiologists for all venous
structures were 2.7 to 2.9. In all cases, the reviewers were
confident basing t heir diagnoses on the ferumoxytol-enhanced
MRV findings. In 12 of 22 examinations, findings on follow-up
imaging or invasive procedures were available to correlate
with the findings on ferumoxytol-enhanced M V. There was
complete concordance bet ween the findings from follow-up
imaging and invasive procedures with findings from
ferumoxytol-enhanced M V. The authors concluded that
ferumoxytol holds promise as a powerful alternative to
gadolinium-based contrast agents for reliable, high-resolution
MRV in children with CKD.
MRA for Prediction of Pulmonary Hypertension
Rengier and colleagues (2016) demonstrated the feasibility of
automated 3D volumetry of central pulmonary arteries based
on MRA to evaluate pulmonary artery volumes in patients with
pulmonary hypertension compared to healthy controls, and
examined the potential of the technique for predicting
pulmonary hypertension. Magnetic resonance angiography of
pulmonary arteries was acquired at 1.5T in 20 patients with
pulmonary arterial hypertension and 21 healthy normotensive
controls; 3D model-based image analysis software was used
for automated segmentation of main, right and left pulmonary
arteries (MPA, RPA and LPA). Volumes indexedto vessel
length and mean, minimum and maximum diameters along the
entire vessel course were assessed and corrected for body
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surface area (BSA). For comparison, diameters were also
manually measured on axial reconstructions and double
oblique multi-planar reformations. Analyses were performed
by 2 cardiovascular radiologists, and by 1 radiologist again
after 6 months. Mean volumes of MPA, RPA and LPA for
patients/controls were 5,508 ± 1,236/3,438 ± 749, 3,522 ±
934/1,664 ± 468 and 3,093 ± 692/1,812 ± 474 μl/(cm length x
m2 BSA) (all p < 0.001). Mean, minimum and maximum
diameters along the entire vessel course were also
significantly increased in patients compared to controls (all p <
0.001). Intra- and inter-observer agreement were excellent for
both volume and diameter measurements using 3D
segmentation (ICCs 0.971 to 0.999, p < 0.001). Area under
the curve for predicting pulmonary hypertension using volume
was 0.998 (95 % CI: 0.990 to 1.0, p < 0.001), compared to
0.967 using manually measured MPA diameter (95 % CI:
0.910 to 1.0, p < 0.001). The authors concluded that
automated MRA-based 3D volumetry of central pulmonary
arteries is feasible and demonstrated significantly increased
volumes and diameters in patients with pulmonary arterial
hypertension compared to healthy controls. They stated that
pulmonary artery volume may serve as a superior predictor for
pulmonary hypertension compared to manual measurements
on axial images; but verification in a larger study population is
needed.
MRA for Evaluation of Individuals with Blunt Vertebral Artery
Karagiorgas and colleagues (2017) noted that the role of MRA
in the evaluation of patients with blunt vertebral artery has not
been fully established. These researchers examined the
diagnostic accuracy of MRA in comparison to DSA for the
detection of blunt vertebral artery injury in trauma patients. A
computer-assisted literature search of the PubMed, Scopus,
Highwire, Web of Science, and LILACS was conducted, in
order to identify studies reporting on the sensitivity and
specificity of MRA in comparison to DSA for the detection of
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blunt vertebral artery injury in trauma patients. The Database
search retrieved 91 studies; 5 studies fulfilled the eligibility
criteria; 2 authors assessed the risk of bias and applicability
concerns using QUADAS-2. Two-by-two contingency tables
were constructed on a per-vessel level. Heterogeneity was
tested by the statistical significance of Cochran's Q, and was
quantified by the Higgins's I2 metric. The pooled estimates of
sensitivity and specificity for blunt vertebral artery injury
detection with MRA in comparison to DSA were calculated
based on the bi-variate model. The meta-analysis was
supplemented by subgroup and sensitivity analysis, as well as
analysis for publication bias. There was significant clinical
heterogeneity in the targeted population, inclusion criteria, and
MRA related parameters. The reporting bias and applicability
concerns were moderate and low, respectively. In the overall
analysis, the sensitivity ranged from 25 % to 85 %, while the
specificity varied from 65 % to 99 %, across studies.
According to the bi-variate model, the pooled sensitivity and
specificity of MRA in the evaluation of patients with blunt
vertebral artery was as high as 55 % (95 % CI: 32.1 % to 76.7
%), and 91 % (95 % CI: 66.3 % to 98.2 %), respectively.
Subgroup analysis in terms of MRA sequence sensitivity of
phase, the contrasted MRA (75 % [95 % CI: 43 % to 92 %])
appeared to be superior to the time-of-flight (TOF) MRA (46 %
[95 % CI: 20 % to 74 %]). The addition of contrast
enhancement did not appear to improve the diagnostic yield of
MRA. The Egger's test did not identify any significant
publication bias (p = 0.2). The authors concluded that MRA
had a moderate diagnostic accuracy in the diagnosis of blunt
vertebral artery injuries. They stated that further studies on
high-field magnetic resonance scanners are recommended.
The current meta-analysis had 2 major drawbacks: (i) the
small number of eligible studies, and (ii) the lack of studies
on newer, high-field MR scanners.
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MRA for Mapping of Perforators Prior to DIEP Flap Breast Reconstruction
Wade and colleagues (2018) stated that prior to DIEP flap
breast reconstruction, mapping the perforators of the lower
abdominal wall US, computed tomography angiography (CTA)
or MRA reduces the risk of flap failure. These investigators
examined the additional potential benefit of a reduction in
operating time. They systematically searched the literature for
studies concerning adult women undergoing D IEP flap breast
reconstruction, which directly compared the operating times
and adverse outcomes for those with and without pre-
operative perforator mapping by US, CTA or MRA. Outcomes
were extracted, data meta-analyzed and the quality of the
evidence appraised. A total of 14 articles were included. Pre-
operative perforator mapping by CTA or MRA significantly
reduced operating time (mean reduction of 54 mins [95 % CI:
3 to 105], p = 0.04), when directly compared to DIEP flap
breast reconstruction with no perforator mapping. Further,
perforator mapping by CTA was superior to US, as CTA saved
more time in theater (mean reduction of 58 mins [95 % CI: 25
to 91], p < 0.001) and was associated with a lower risk of
partial flap failure ( relative risk [RR] 0.15 [95 % CI: 0.04 to 0.6],
p = 0.007). All studies were at risk of methodological bias and
the quality of the evidence was very low. The authors
concluded that the quality of research regarding perforator
mapping prior to DIEP flap breast reconstruction was poor and
although pre-operative angiography appeared to save
operative time, reduce morbidity and confer cost savings,
higher quality research is needed.
MRA for Detection of Jugular Venous Reflux and Non-Pulsatile Subjective Tinnitus
Yildirim and colleagues (2019) examined if there is an
association between jugular venous reflux and non-pulsatile
subjective tinnitus (NPST) using real-time four-dimensional
(4D) MRA. Patients with unilateral NPST who underwent
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contrast-enhanced MRI with a special protocol were included
in the study. Thick slab dynamic maximum intensity projection
images were obtained including interleaved stochastic
trajectories (TWIST)-MRI examination. All patients were
requested to perform Valsalva maneuver during the
sequence . Jugular venous reflux grading was performed as
follows: absence of reflux or if reflux did not reach the base of
the skull: Grade 0; if reflux reached the jugular bulb, but no
intra-cranial contrast was observed: Grade 1; and if reflux
extended into the intra-cranial cortical veins and/or the
cavernous sinus above the jugular bulb: Grade 2. This trial
included a total of 30 patients, 23 male and 7 female; mean
age of 49 years (range of 17 to 74 years). Jugular venous
reflux was not identified (Grade 0) in 20 patients; Grade 1
reflux was determined in 7 cases and Grade 2 reflux was
observed in 3 cases. Notably, only patients with Grade 2
reflux described worsening of their tinnitus symptoms during
the examination and their daily activities as well. The authors
concluded that NST might also be associated with
hemodynamic problems of the venous system and the MRI
protocol starting with TWIST accompanied with Valsalva
maneuver is not well-known, yet appeared to be a feasible and
beneficial method to detect potential jugular venous reflux in
NPST patients.
The authors stated that this study had several drawbacks.
First, and most important according this trial consisted of
relatively small numbers of patients (n = 30). Thus, these
researchers considered this trial as a preliminary study.
Selection of patients who had only unilateral and reflux
disease caused this limitation. These investigators noted that
that they would work in a wider group as the series expands.
Second, MRI artifacts occurred secondary to movements of
the patients during Valsalva maneuver; however, the authors
substantially surpassed these artifacts with the high temporal
resolution of the MRI sequence that they used. These
preliminary findings need to be validated by well-designed
studies.
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MRA for Diagnosis of Intra-Cranial Artery Stenosis
Jaiswal and colleagues (2019) stated that one of the most
common causes of acute cerebral infarction (ACI) is intra-
cranial artery stenosis (ICAS). These researchers examined
the accuracy of trans-cranial Doppler (TCD) compared with
MRA for diagnosing I CAS in patients with ACI. Consecutive
patients presenting with ACI to the neurology department
underwent both MRA and TCD examination within 6 hours of
difference. To calculate the agreement between the results of
MRA and TCD, kappa coefficient test was used. Sensitivity,
specificity, PPV and NPV for TCD were calculated in
comparison with MRA. A total of 115 patients were included in
this trial. There were 77 men (66.95 %) and 38 women (33.04
%). The mean age of patients was 68.32 ± 10.66 years (range
of 29 to 80). The agreement between TCD and MRA in
detecting stenosis was 0.56 for anterior circulation artery
(ACA), and 0.40 for posterior circulation artery (PCA). For the
detection of ICAS, sensitivity, specificity, PPV, and NPV were
85.9, 90.0, 98.2, and 50.0 % for ACA and 73.5, 86.7, 96.2, and
40.0 % for PCA, respectively. The authors concluded that
moderate agreement of ACA stenosis and fair agreement for
PCA stenosis was found between TCD and MRA in the
evaluation of ICAS. In anterior circulation, the diagnostic
accuracy of TCD was higher compared with the posterior
circulation.
The authors stated that this study has several drawbacks.
First, this was a single-center study. Second, the sample size
was very small (n = 115). Third, some patients were excluded
because they did not have an acoustic bone window and
others had contraindications for MRA. Fourth, TCD is an
operator-dependent technique that requires considerable
experience in intra-cranial arterial anatomy and understanding.
MRA for Evaluation of Thoracic Outlet Syndrome
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Zhang and colleagues (2019) introduced a novel method
combining contrast-enhanced MRA (CE-MRA), short inversion
time inversion recovery sampling perfection with application-
optimized contrasts using different flip angle evolutions (T2-
STIR-SPACE) and volumetric interpolated breath-hold
examination (VIBE) sequences in the assessment of thoracic
outlet syndrome (TOS). CE-MRA, T2-STIR-SPACE, and VIBE
techniques were employed to evaluate neurovascular bundles
in 27 patients clinically suspected of TOS. Images were
evaluated to determine the cause of neurovascular bundle
compression. Surgical exploration was performed in patients
with abnormal MRI results. A total of 20 patients were found to
be abnormal: 6 cases showed only neurogenic TOS and the
correlates included infra-clavicular hemangiomas (n = 1) and
transverse cervical artery (n = 5). Arterial-neurogenic TOS
was found in 4 cases, including subclavian lymph node
metastasis from breast cancer (n = 3) and schwannoma (n =
1). Arterial-venous-neurogenic TOS was found in 1 subject,
and the correlates included a fibrous band from the cervical rib
and elongated C7 transverse process. In this case, the
subclavian artery/vein was compressed dynamically. Venous-
neurogenic TOS was noted in 1 subject; 9 patients were
considered as post-traumatic TOS, including brachial plexus
edema (n = 3), the brachial plexus rupture (n = 2), peri-
brachial plexus effusion (n = 3), and stenosis of the SCA (n =
1). In the remaining 7 patients, MRI did not detect
abnormalities. The authors concluded that TOS could be
evaluated by CE-MRA, T2-STIR-SPACE, and VIBE during a
single examination, with a reduced contrast material dose.
This imaging modality performed well in showing the
anatomical structure of the neurovascular bundle and the
cause of the compression.
The authors stated that this study had several drawbacks.
First, bone abnormalities could be difficult to identify at MR
imaging but are best identified on plain radiograph. Second,
gadolinium is a contrast agent that is toxic to people with
kidney and liver disease; MRA cannot be performed in patients
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with low glomerular filtration rate. Third, these researchers did
not examine the differences in findings of MRI at neutral and
provocative locations. Lastly, these subjects had various
causes of brachial plexus diseases. The authors stated that
further prospective studies are recommended in future work to
focus on certain types of brachial plexus neuropathy.
Magnetic Resonance Venography (MRV) for Diagnosis of Pelvic Congestion Syndrome
Champaneria and colleagues (2016) stated that pelvic
congestion syndrome (PCS) is described as chronic pelvic
pain (CPP) arising from dilated and refluxing pelvic veins,
although the causal relationship between pelvic vein
incompetence (PVI) and CPP is not established. Non-invasive
screening methods such as Doppler US and MRV are used
before confirmation by venography. Percutaneous
embolization has become the principal treatment for PCS, with
high success rates often cited. These researchers
systematically reviewed the definitions and diagnostic criteria
of PCS, the association between PVI and CPP, the accuracy
of various non-invasive imaging techniques and the
effectiveness of embolization for PVI; and identified factors
associated with successful outcome. They also surveyed
clinicians and patients to assess awareness and management
of PCS and gauge the enthusiasm for further research. A
comprehensive search strategy encompassing various terms
for pelvic congestion, pain, imaging techniques and
embolization was deployed in 17 bibliographic databases,
including Medline, Embase and Web of Science. There was
no restriction on study design. Methodological quality was
assessed using appropriate tools. Online surveys were sent to
clinicians and patients. The quality and heterogeneity
generally precluded meta-analysis and so results were
tabulated and described narratively. These investigators
identified 6 association studies, 10 studies involving US, 2
studies involving MRV, 21 case series and 1 poor-quality
randomized trial of embolization. There were no consistent
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diagnostic criteria for PCS. These researchers found that the
associations between CPP and PVI were generally fairly
similar, with 3 of 5 studies with sufficient data showing
statistically significantassociations (OR of between 31 and
117). The prevalence of PVI ranged widely, although the
majority of women with PVI had CPP. Trans-vaginal Doppler
US and MRV are both useful screening methods, although the
data on accuracy were limited. Early substantial relief from
pain symptoms was observed in approximately 75 % of
women undergoing embolization, a figure which generally
increased over time and was sustained. Re-intervention rates
were generally low. Transient pain was a common occurrence
following foam embolization,while there was a less than 2 %
risk of coil migration. Confidence in the embolization
technique was reasonably high, although there was a desire to
strengthen the evidence base. Even among women with CPP,
fewer than 50 % had any knowledge about PCS. The authors
concluded that the data supporting the diagnosis and
treatment of PCS were limited and of variable methodological
quality. There is some evidence to tentatively support a
causative association, but it cannot be categorically stated that
PVI is the cause of CPP in women with no other pathology, as
the 6 most pertinent studies drew on clinically disparate
populations and defined PVI inconsistently. Embolization
appeared to provide symptomatic relief in the majority of
women and is safe. However, the majority of included studies
of embolization were relatively small case series and only the
randomized controlled trial (RCT) was considered at risk of
potential biases. The authors concluded that there is scope
and demand for considerable further research. They stated
that the question of the association of PVI and CPP requires a
well-designed and well-powered case-control study, which will
also provide data to derive a diagnostic standard. An
adequately powered randomized trial is essential to provide
evidence on the effectiveness of embolization, but this faces
methodological challenges.
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Steenbeek and colleagues (2018) stated that in the work-up of
patients with suspected pelvic congestion syndrome (PCS),
venography is currently the gold standard. Yet if non-invasive
diagnostic tools are found to be accurate, invasive venography
might no longer be indicated as necessary. These
investigators carried out a literature search in PubMed and
Embase from inception until May 6, 2017. Studies comparing
non-invasive diagnostic tools to a reference standard in the
work-up of patients with (suspected) PCS were included.
Relevant data were extracted and methodological quality of
individual included studies was assessed by the Quality
Assessment of Diagnostic Accuracy Studies (QUADAS-2)
tool. A total of 9 studies matched the inclusion criteria; 6
studies compared US to venography and 3 studies described
a MRI technique. In using transvaginal US (TVUS), the
occurrence of a vein greater than 5 mm crossing the uterine
body had a specificity of 91 % (95 % CI: 77 to 98 %) and
occurrence of pelvic varicoceles a sensitivity and specificity of
100 % (95 % CI: 89 to 100 %) and 83 % (95 % CI: 66 to 93 %),
respectively. In transabdominal US, reversed caudal flow in
the ovarian vein accounted for a sensitivity of 100 % (95 % CI:
84 to 100 %). Detection of PCS with MRI techniques resulted
in a sensitivity varying from 88 to 100 %. The authors
concluded that the sensitivity of US and MRI appeared to be
adequate, which indicated a role for both tests in an early
stage of the diagnostic work-up. However, these researchers
stated that due to methodological flaws and diversity in
outcome parameters, more high standard research is needed
to establish a clear advice for clinical practice. These
investigators discussed the study by Asciutto et al (2008),
which examined the application of MRV in the assessment of
women with PCS. They stated that MRV seemed to be highly
sensitive for insufficiency in pelvic plexus, ovarian or
hypogastric veins; especially hypogastric vein insufficiency
accounted for a high sensitivity (100 %), but the specificity was
low, which resulted in a high prevalence of false‐positive
results.
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MRV for the Diagnostic Evaluation of Cryptogenic Stroke
Liberman et al (2014) stated that paradoxical embolization is
frequently posited as a mechanism of ischemic stroke in
patients with patent foramen ovale (PFO). Several studies
have suggested that the deep lower extremity (LE) and pelvic
veins might be an embolic source in cryptogenic stroke (CS)
patients with PFO. In this single-center, retrospective,
observational study, consecutive adult patients with ischemic
stroke or transient ischemic attack (TIA) and a PFO who
underwent pelvic MRV as part of an inpatient diagnostic
evaluation were included in this study to determine pelvic and
LE DVT prevalence in CS versus non-CS stroke subtypes.
Among the 131 patients who met inclusion criteria, 126 (96.2
%) also had LE duplex US data. DVT prevalence overall was
7.6 % (95 % CI: 4.1 to 13.6), pelvic DVT 1.5 % (9 5 % CI: 0.1 to
5.8) , and LE DVT 7.1 % (95 % CI: 3.6 to 13.2). One patient
with a pelvic DVT also had a LE DVT. Comparing patients
with CS (n = 98) with non-CS subtypes (n = 33), there was no
significant difference i n the prevalence of pelvic DVT (2.1 %
versus 0 %, p = 1), LE DVT (6.2 % versus 10.3 %, p = 0.43),
or any DVT (7.2 % versus 9.1 %, p = 0.71). The authors
concluded that among patients with ischemic stroke/TIA and
PFO, the majority of detected DVTs were in LE veins rather
than the pelvic veins and did not differ by stroke subtype.
They stated that the routine inclusion of pelvic MRV in the
diagnostic evaluation of CS warrants further prospective
investigation.
Osgood et al (2015) noted that substantial proportion of
ischemic strokes has no identified underlying cause. Notably,
the prevalence of a PFO is increased in CS populations, which
may serve as a conduit for paradoxical emboli originating from
DVT including the pelvic veins. Yet, there are no published
guidelines for the assessment of pelvic veins as part of the
stroke work-up and few studies have systematically
investigated pelvic veins as a potential source for paradoxical
emboli in CS patients. Further, there is a relative paucity of
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data regarding pelvic DVT in CS and results have been
conflicting. These investigators determined the prevalence of
pelvic DVT in select CS patients with PFO who underwent
MRV. They retrospectively identified patients (n = 50) who
underwent contrast-enhanced pelvic MRV at the discretion of
the treating physician for the evaluation of CS in the presence
of a PFO during hospitalization at a single academic stroke
center between January 2011 through December 2013.
Multivariable logistic regression analyses were used to assess
for factors independently associated with the presence of an
abnormal MRV pelvis. Patients (47 ± 13 years of age) had
MRV performed 4 ± 3 days after their incident stroke; 9
patients had an abnormal MRV (18 %). Of these, 4 (8 %) had
pelvic vein thrombosis and 5 (10 %) a May-Thurner anatomic
variant. All patients with pelvic DVT were subsequently anti-
coagulated with warfarin (none had abnormal
hypercoagulability testing). Clinical clues suggesting
paradoxical embolism were present in as many as 40 % of
patients. On multivariable logistic regression, a history of any
risk factors predisposing to DVT (odds ratios [OR] 6.7;
coefficient1.9;BCa 95 % CI: 0.08 to 20.2; p = 0.014) as well
as the number of predisposing risk factors (OR 3.9; coefficient
1.4; BCa 95 % CI: 0.25-4.2; p = 0.005) predicted the presence
of pelvic vein pathology on MRV. The authors demonstrated a
relatively high prevalence of pelvic DVT among select CS
patients emphasizing the importance of considering the pelvic
veins as a potential source for emboli particularly in the
presence of risk factors known to predispose DVT. Because
patients were included at the treating physician's discretion,
these findings reflected “real-life” practice. They stated that
the results may be of clinical importance as inclusion of pelvic
vein imaging in CS patients with PFO had impactful
therapeutic and nosologic implications. These researchers
noted that further study is needed to define patients most likely
to benefit from pelvic vein imaging.
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MRV for Screening Venous Thromboembolism Following Mu sculoskeletal Trauma
On behalf of the Orthopaedic Trauma Association Evidence
Based Quality Value and Safety Committee, Sagi and
colleagues (2015) (i) provided a summation of the current
practice patterns of North American orthopedic surgeons for
venous thrombo-embolism (VTE) prophylaxis after
musculoskeletal trauma, and (ii) established a set of guidelines
and recommendations based on the most current and best
available evidence for VTE prophylaxis after musculoskeletal
trauma. A 24 item questionnaire titled "OTA VTE Prophylaxis
Survey" was sent to active members of the Orthopedic Trauma
Association. PubMed and OVID/MEDLINE were used to
search the current published literature regarding VTE
prophylaxis in trauma patients using the following search
terms: deep venous thrombosis, DVT, pulmonary embolism,
PE, venous thromboembolism, VTE, prophylaxis, trauma,
fracture, pneumatic compression device, PCD, sequential
compression device, SCD, screening, ultrasound, duplex,
ultrasonography, DUS, venography, magnetic resonance
venography, MRV, inferior vena cava, IVC, filter, and IVCF.
Each recommendation was graded using articles that were
considered by the subcommittee as "the best available
evidence" using the grading system adopted and endorsed by
the American Academy of Orthopedic Surgeons' Evidenced
Based Quality and Value committee. Overall, 185 of 1,545
members completed the online survey. The range and variety
of prophylaxis and screening methods used among orthopedic
trauma surgeons in North America is large, with a number of
agents or methods for which no literature exists to support
their use in musculoskeletal trauma. A set of
recommendations and guidelines were constructed based on
the results of the literature analysis and graded according to
guidelines mentioned above. The authors concluded that due
to the wide variability in practice patterns, poor scientific
support for various therapeutic regimens and important medical-
legal implications highlighted by the survey, a
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standardized set of guidelines and recommendations for VTE
prophylaxis after musculoskeletal trauma will be critical in
helping to improve patient care and minimize surgeons'
exposure to potentially litigious activity.
Quantitative MRV for Measurement of Venous Flow after Cerebral Venous Sinus Stenting
Esfahani et al (2015) stated that endovascular stenting is an
effective treatment for patients with clinically significant
cerebral venous sinus stenosis. Traditionally, stenting is
indicated in elevated intravenous pressures on conventional
venography; however, non-invasive monitoring is more
desirable. Quantitative MRV (qMRV) is an imaging modality
that measures blood flow non-invasively. Established in the
arterial system, applications to the venous sinuses have been
limited. These researchers examined qMRV in the
measurement of venous sinus flow in patients undergoing
endovascular stenting and identified a relationship with
intravenous pressures. A total of 5 patients with intra-cranial
hypertension secondary to venous sinus stenosis underwent
cerebral venous stenting between 2009 and 2013 at a single
institution. Pre-operatively, venous sinus flow was determined
by using qMRV, and intravenous pressure was measured
during venography. After stenting, intravenous pressure,
qMRV flow, and clinical outcomes were assessed and
compared. A mean pre-stenotic intravenous pressure of 45.2
mm Hg was recorded before stenting, which decreased to 27.4
mm Hg afterward (Wilcoxon signed rank testp = 0.04). Total
jugular outflow on qMRV increased by 260.2 ml/min. Analysis
of the change in intravenous pressure and qMRV flow
identified a linear relationship (Pearson correlation r = 0.926).
All patients displayed visual improvement at 6 weeks.The
authors concluded that venous outflow by qMRV increased
after endovascular stenting and correlated with significantly
improved intravenous pressures. They stated that these
findings introduced qMRV as a potential adjunct to measure
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venous flow after stenting, and as a plausible tool in the
selection and post-operative surveillance of the patient who
has cerebral venous sinus stenosis.
Non-Contrast-Enhanced MRV Using Magnetization - Prepared Rapid Gradient-Echo in the Pre-Operative Evaluation of Living Liver Donor Candidates
Yamashita and co-workers (2017) compared t he diagnostic
performance of non-contrast-enhanced magnetic resonance
venography using magnetization-prepared r apid gradient-echo
(MPRAGE-MRV) and conventional CT venography (CTV) in
pre-operative evaluation of venous tributaries for living donor
liver transplantation. Institutional review board approval and
written informed c onsent were obtained f or this prospective
study of 73 donor candidates. Of these, 23 underwent right-
sided graft hepatectomy without middle hepatic vein. One or
more tributaries, other than the right hepatic vein, were
reconstructed for 20 of the 23 grafts. For these 20 grafts, the
number and location of the tributaries requiring reconstruction
were evaluated based on venography, and diagnostic
performance was analyzed using surgical records as a
reference standard. For each candidate, the number of small
tributaries directly joining the inferior vena cava was counted in
each venographic image; a paired-sample t-test was used to
assess differences. The severity of respiratory artifacts in
MPRAGE-MRV was qualitatively evaluated, and compared
using Wilcoxon's rank-sum test. All reconstructed venous
tributaries were prospectively identified using both methods.
MPRAGE-MRV tended to provide a greater number of small
tributaries than conventional CTV (mean of 2; 95 % CI: [1.66 to
2.34], and 1.74; [1.44 to 2.04], respectively), although the
difference was not significant (p = 0.10); MPRAGE-MRV was
superior or equal to CTV in 52 subjects (71.2 %), and inferior
in 21 subjects (28.8 %). Respiratory artifacts were significantly
less severe in the former subjects (p < 0.0001). The authors
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concluded that MPRAGE-MRV has the potential to replace
conventional CTV in the pre-operative evaluation of living liver
donor candidates.
MRV for Prediction of Outcome in Tuberculous Meningitis
Bansod and colleagues (2018) evaluated the prevalence and
predictors of venographic abnormalities in tuberculous
meningitis. Consecutive patients of tuberculous meningitis
were included in the study. Clinical evaluation, cerebro-spinal
fluid (CSF) examination and contrast-enhanced MRI of brain
were carried out. Every participant was subjected to time of
flight MRV. Presence of filling defects at superior sagittal
sinus, dominant transverse or sigmoid sinus, and non-
visualization of deep venous system was considered
suggestive of thrombosis. The presence of filling defects at non-
dominant transverse or sigmoid sinus was considered
suggestive of thrombosis only in the presence of
corresponding changes in T1, T2, and GRE sequences,
parenchymal changes or presence of collaterals. Patients
were followed-up for 6 months. A modifiedBarthel index of
less than or equal to 12 at 6 months was taken as poor
outcome. Of the 107 patients, MRV was found to be abnormal
in 12 patients (11.2 %). The superior sagittal sinus was the
most commonly involved sinus. On uni-variate analysis, the
presence of vomiting (p = 0.004), altered sensorium
(p = 0.004), seizures (p < 0.001), vision impairment (p = 0.038),
papilledema (p < 0.001), diplopia, oculomotor palsies,basal
exudates (p = 0.004) and modified Barthel index (MBI) of less
than or equal to 12 at baseline (p = 0.004) were significantly
associated with an abnormal MRV. On multi-variate analysis,
none of the above factors was found to be significant. No
association was found between an abnormal MRV and poor
outcome. The authors concluded that MRV abnormalities
suggestive of venous sinus thrombosis could occur in
approximately 11 % patients; superior sagittal sinus is the
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most commonly involved sinus. Moreover, they stated that an
abnormal MRV may not predict a poor outcome in patients
with tuberculous meningitis.
MRV for Diagnosis of Central Venous Occlusion
Shahrouki and colleagues (2019) noted that although
cardiovascular MRV (CMRV) is generally regarded as the
technique of choice for imaging the central veins, conventional
CMRV is not ideal. Gadolinium-based contrast agents (GBCA)
are less suited to steady-state venous imaging than to first-
pass arterial imaging and they may be contraindicated in
patients with renal impairment where evaluation of venous
anatomy is frequently required. These researchers examined
the diagnostic performance of 3-dimensional (3D) ferumoxytol-
enhanced CMRV (FE-CMRV) for suspected central venous
occlusion (CVO) in patients with renal failure and to evaluate
its clinical impact on patient management. In this institutional
review board (IRB)-approved and HIPAA-compliant study, a
total of 52 consecutive adult patients (47 years, inter-quartile
range [IQR] 32 to 61; 29 men) with renal impairment and
suspected venous occlusion underwent FE-CMRV, following
infusion of ferumoxytol. Breath-held, high resolution, 3D steady-
state FE-CMRV was performed through the chest, abdomen and
pelvis. Two blinded reviewers independently scored 21 named
venous segments for quality and patency.
Correlative catheter venography in 14 patients was used as
the reference standard f or diagnostic accuracy. Retrospective
chart review was conducted to determine clinical impact of FE-
CMRV. Inter-observer agreement was determined using
Gwet's AC1 statistic. All patients underwent technically
successful FE-CMRV without any AEs; 99.5 % (1,033/1,038)
of venous segments were of diagnostic quality (score greater
than or equal to 2/4) with very good inter-observer agreement
(AC1 = 0.91). Inter-observer agreement for venous occlusion
was also very good (AC1 = 0.93). The overall accuracy of FE-
CMRV compared to catheter venography was perfect (100.0
%). No additional imaging w as needed before a clinical
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management decision in any of the 52 patients; 24 successful
and uncomplicated venous interventions were performed
following pre-procedural vascular mapping with FE-CMRV.
The authors concluded that 3D FE-CMRV was a practical,
accurate and robust technique for high-resolution mapping of
central thoracic, abdominal and pelvic veins, and could be
used to inform image-guided therapy. It may play a pivotal
role in the care of patients in whom conventional contrast
agents may be contraindicated or ineffective.
The authors stated that this study had several drawbacks.
First, the number of vessels used for the diagnostic accuracy
assessment was relatively low. The limiting f actor was the
number of catheter images because these were available only
for vessels that were injected and relevant to the clinical
procedure. Nonetheless, the analysis spanned t he majority of
venous segments and thus decreased the risk of a potential
selection bias. The long interval between the FE-CMRV and
some catheter studies (up to 98 days) could cause a length
time bias. Despite this, the agreement between both
modalities was very high. FE-CMRV of the central veins has
already shown promising r esults in small pediatric cohorts and
in patients with pelvic vein thrombosis, but this study
addressed a large adult cohort and established diagnostic
accuracy and value added to patient care and management.
CPT Codes / HCPCS Codes / ICD-10 Codes
Information in the [brackets] below has been added for clarification purposes. Codes requiring a 7th character are represented by "+":
Code Code Description
Ma gnetic Resonance Angiography (MRA) & Venography ( MRV):
Hea d and neck:
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Code Code Description
CPT codes covered if selection criteria are met:
70544 Magnetic resonance angiography, head;
without contrast material(s)
70545 with contrast material(s)
70546 without contrast material(s), followed by
contrast material(s) and further sequences
70547 Magnetic resonance angiography, neck; without
contrast material(s)
70548 with contrast material(s)
70549 without contrast material(s), followed by
contrast material(s) and further sequences
ICD-10 codes covered if selection criteria are met for MRA:
A52.05 Other cerebrovascular syphilis [intracranial
aneurysm]
D43.0 -
D43.9
Neoplasm of uncertain behavior of brain and
central nervous system
G08 Intracranial and intraspinal phlebitis and
thrombophelbitis [intracranial aneurysm]
G44.1 Vascular headache, not elsewhere classified
[sudden explosive headache, unilateral
headache]
G45.0 -
G45.9
Transient cerebral ischemic attacks and related
syndromes
H34.00 -
H34.03
Transient retinal artery occlusion
H49.00 -
H49.03
Third [oculomotor] nerve palsy
H53.2 Diplopia
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Code Code Description
H54.3 Unqualified v isual loss, both eyes
H81.10 -
H81.13
Benign paroxysmal vertigo
H81.41 -
H81.49
Vertigo of central origin
H93.11 -
H93.19
Tinnitus
H93.A1 -
H93.A9
Pulsatile tinnitus
I60.00 -
I 60.9
Nontraumatic subarachnoid hem orrhage
I67.0 -
I 67.9
Other cerebrovascular diseases
I71.02 -
I71.03
Dissection of abdominal or thoracoabdominal
aorta
I71.3 -
I 71.4
Abdominal aortic aneurysm, ruptured or without
rupture
I71.5 -
I 71.6
Thoracoabdominal aneurysm, ruptured or
without mention of rupture
I77.71 Dissection of carotid artery
I77.74 Dissection of vertebral artery
M43.6 Torticollis
Q28.2 Arteriovenous malformation of cerebral vessels
[not covered for magnetic resonance
angiography for diagnosis]
R13.10 -
R13.19
Dysphagia
R42 Dizziness and giddiness
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Code Code Description
R43.0 -
R 43.9
Disturbances of smell and taste
R47.02 -
R 47.9
Speech disturbances, not elsewhere classified
R 51 Headache [sudden explosive headache,
unilateral headache]
R 55 Syncope and collapse
R 83.9 Unspecified abnormal findings in cerebrospinal
fluid [blood in CSF]
S15.001+
-
S15.099+
Injury of carotid artery of neck
Z82.3 Family history of stroke
ICD-10 codes not covered for indications listed in the CPB fo r MRA:
C71.0 -
C 71.9
Malignantneoplasm of brain
C 76.0 Malignant neoplasm of head, face and neck
C 79.31 Secondary malignant neoplasm of brain
D33.0 -
D33.2
Benign neoplasm of brain
G50.0 Trigeminal neuralgia [not covered for the
evaluation of microvascular compression]
T86.49 Other complications of liver transplant [varices
at hepatico-jejunostomy]
ICD-10 codes covered if selection criteria are met for MRV:
C71.0 -
C 71.9
Malignantneoplasm of brain
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Code Code Description
C 76.0 Malignant neoplasm of head and neck
D33.0 -
D33.2
Benign neoplasm of brain
D43.0 -
D43.9
Neoplasm of uncertain behavior of brain and
central nervous system
G00.0 -
G03.9
Meningitis
G44.1 Vascular headache, not elsewhere classified
H47.10 -
H47.13
Papilledema
H65.00 -
H67.9
Otitis media
I 63.6 Cerebral infarction due to cerebral venous
thrombosis, nonpyogenic [identified by CT or
MRI of the head]
J01.00 -
J01.91
Acute sinusitis
J32.0 -
J 32.9
Chronic sinusitis
R29.810 -
R29.91
Other symptoms involving nervous and
musculoskeletal systems [focal or sensory
deficits]
R 51 Headache
R56.00 -
R 56.9
Convulsions, not elsewhere classified [seizures]
Z79.3 Long-term (current) use of hormonal
contraceptives
ICD-10 codes not covered for indications listed in the CPB fo r MRV:
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Code Code Description
G45.0 -
G45.9
Transient cerebral ischemic attacks and rela ted
syndromes [diagnosis of chronic cerebro-spina l
venous insufficiency]
I67.0 -
I 67.9
Other cerebrovascular diseases [diagnosis of
chronic cerebro-spinal venous insufficiency]
Chest:
CPT codes covered if selection criteria are met:
71555 Magnetic resonance angiography, chest
(excluding myocardium), with or without
contrast material(s)
Other CPT codes related to the CPB:
75557-
75564
Cardiac magnetic resonance imaging for
velocity flow mapping
HCP CS codes covered if selection criteria are met:
C 8909 Magnetic resonance angiography with contrast,
chest (excluding myocardium)
C 8910 Magnetic resonance angiography without
contrast, chest (excluding myocardium)
C 8911 Magnetic resonance angiography without
contrast followed by with contrast, chest
(excluding myocardium)
ICD-10 codes covered if selection criteria are met for MRA:
I26.01 -
I26.99
Pulmonary embolism
I48.0
I48.2,
I48.91
Atrial fibrillation
I71.01 Dissection of thoracic aorta
I 71.1 Thoracic aortic aneurysm, ruptured
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Code Code Description
I 71.2 Thoracic aortic aneurysm, without rupture
Q20.0 -
Q28.9
Congenital malformations of the circulatory
system
ICD-10 codes not covered for indications listed in the CPB fo r MRA:
I 49.3 Ventricular premature depolarization
ICD-10 codes covered if selection criteria are met for MRV:
I82.B11 -
I82.B29
Embolism and thrombosis of subclavian vein
I82.210 -
I82.211
Embolism and thrombosis of superior vena
cava
I82.290 Acute venous embolism and thrombosis of
other thoracic veins
Spine:
CPT codes covered if selection criteria are met:
72159 Magnetic resonance angiography, spinal canal
and contents, with or without contrast materials
(s)
C 8931 Magnetic resonance angiography with contrast,
spinal canal and contents
C 8932 Magnetic resonance angiography without
contrast, spinal canal and contents
C 8933 Magnetic resonance angiography without
contrast followed by with contrast, spinal canal
and contents
ICD-10 codes covered if selection criteria are met for MRA:
I 77.0 Arteriovenous fistula, acquired [spinal cord]
Q27.9 Congenital malformation of peripheral vascular
system, unspecified [ spinal cord]
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Code Code Description
Abdomen/Pelvis:
CPT codes covered if selection criteria are met:
72198 Magnetic resonance angiography, pelvis, with
or without contrast material(s)
74185 Magnetic resonance angiography, abdomen,
with or without contrast material(s)
O ther CPT codes related to the CPB:
37182 Insertion of transvenous intrahepatic
portosystemic shunt(s) (TIPS) (includes venous
access, hepatic and portal vein catheterization,
portography with hemodynamic evaluation,
intrahepatic tract formation/dilatation, stent
placement and all associated imaging guidance
and documentation)
HCP CS codes covered if selection criteria are met:
A9583 Injection, Gadofosveset Trisodium, 1 ml
[Ablavar, Vasovist]
C 8900 Magnetic resonance angiography with contrast,
abdomen
C 8901 Magnetic resonance angiography without
contrast, abdomen
C 8902 Magnetic resonance angiography without
contrast followed by with contrast, abdomen
ICD-10 codes covered if selection criteria are met for MRA:
D57.00 -
D57.819
Sickle-cell disorders
I10 - I16.2 Hypertensive diseases
I 70.1 Atherosclerosis of renal artery
I71.02 Dissection of abdominal aorta
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Code Code Description
I71.03 Dissection of thoracoabdominal aorta
I74.01 -
I74.09
Embolism and thrombosis of abdominal aorta
I77.3 -
I 77.6
Other disorders of arteries and arterioles
[aortoiliac stenosis]
K55.011 -
K 55.9
Vascular disorders of intestine [chronic
mesenteric ischemia]
K 76.6 Portal hypertension
Z91.041 Radiographic dye allergy status [contrast
allergy, renal insufficiency]
ICD-10 codes not covered for indications listed in the CPB for MRA:
D35.00 -
D35.02
Benign neoplasm of adrenal gland
O69.4xx0
-
O69.4xx9
Labor and delivery complicated by vasa previa
Z13.6 Encounter for screening for cardiovascular
disorders
Z52.4 Kidney donor
ICD-10 codes covered if selection criteria are met for MRV:
D68.0 -
D68.9
Other coagulation defects
I 82.0 Budd-Chiari syndrome
I 82.1 Thrombophlebitis migrans
I82.220 -
I82.221
Embolism and thrombosis of inferior vena cava
I 82.3 Embolism and thrombosis of renal vein
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Code Code Description
K 75.1 Phelbitis of portal vein
R 10.2 Pelvic and perineal pain [pelvic pain when
pelvic congestion syndrome is suspected and
pelvic ultrasound findings are equivocal]
ICD-10 codes not covered for indications listed in the CPB fo r MRV:
I63.0 -
I 63.9
Cerebral infarction
Ferumoxytol-enhanced MRA and MRV - no specific code:
ICD-10 codes not covered for indications listed in the CPB fo r MRA:
I 70.1 Atherosclerosis of renal artery
N18.1 -
N18.9
Chronic kidney disease (CKD)
Lower extremity:
CPT codes covered if selection criteria are met:
73725 Magnetic resonance angiography, lower
extremity, with or without contrast material(s)
HCP CS codes covered if selection criteria are met:
A9583 Injection, Gadofosveset Trisodium, 1 ml
[Ablavar, Vasovist]
C 8912 Magnetic resonance angiography with contrast,
lower extremity
C 8913 Magnetic resonance angiography without
contrast, lower extremity
C 8914 Magnetic resonance angiography without
contrast, followed by with contrast, lower
extremity
ICD-10 codes covered if selection criteria are met for MRA:
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Code Code Description
I 74.3 Embolism and thrombosis of arteries of the
lower extremities
I 79.8 Disorders of arteries, arterioles and capillaries
in diseases classified elsewhere
ICD-10 codes not covered for indications listed in the CPB fo r MRV:
A17.0 Tuberculous meningitis
I80.10 -
I80.299
Phlebitis and thrombophlebitis of other and
unspecified deep vessels of lower extremities
I82.401 -
I82.5z9
Acute and chronic embolism and thrombosis of
deep veins of lower extremities
Upper extremity:
Other CPT codes related to the CPB:
72159 Magnetic resonance angiography, spinal canal
and contents, with or without contrast material
(s)
73225 Magnetic resonance angiography, upper
extremity, with or without contrast material(s)
ICD-10 codes not covered for indications listed in the CPB fo r MRV:
A17.0 Tuberculous meningitis
I 80.8 Phlebitis and thrombophlebitis of other sites
I82.a11 -
I82.a19
Acute embolism and thrombosis of axillary
veins
I82.601 -
I82.729
Acute and chronic embolism and thrombosis of
superficial and deep veins of upper extremity
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The above policy is based on the following references:
1. Abdalla G, Fawzi Matuk R, Venugopal V, et al. The
diagnostic accuracy of magnetic resonance
venography in the detection of deep venous
thrombosis: A systematic review and meta-analysis.
Clin Radiol. 2015;70(8):858-871.
2. Alley MT, Shifrin RY, Pelc NJ, Herfkens RJ. Ultrafast
contrast-enhanced three-dimensional MR
angiography: State of the art. Radiographics. 1998;18
(2):273-285.
3. American College of Radiology (ACR), North American
Society for Cardiovascular Imaging (NASCI), Society for
Pediatric Radiology (SPR). ACR-NASCI-SPR practice
guideline for the performance of pediatric and adult
body magnetic resonance angiography (MRA) [online
publication]. Reston, VA: American College of
Radiology (ACR); 2010.
4. American College of Radiology. Appropriateness
Criteria. Abdominal Aortic Aneurysm: Interventional
Planning and Follow-up. Reston, VA: American College
of Radiology; reviewed 2012. Available at:
http://www.acr.org/Quality-Safety/Appropriateness
Criteria/~/media/C551BC29AC144772A4C2ECBFA4384382.pdf.
Accessed 10/16/2014.
5. Asciutto G, Mumme A, Marpe B, et al. MR venography
in the detection of pelvic venous congestion. Eur J Vasc
Endovasc Surg. 2008;36(4):491-496.
6. Backes WH, Nijenhuis RJ. Advances in spinal cord MR
angiography. AJNR Am J Neuroradiol. 2008;29(4):619
631.
7. Bajwa ZH, Ho CC, Khan SA. Trigeminal neuralgia.
UpToDate [online serial]. Waltham, MA:
UpToDate; reviewed September 2014.
8. Bansod A, Garg RK, Rizvi I, et al. Magnetic resonance
venographic findings in patients with tuberculous
Proprietary
Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MR... Page 67 of 81
meningitis: Predictors and outcome. Magn Reson
Imaging. 2018;54:8-14.
9. Bates SM, Jaeschke R, Stevens SM, et al; American
College of Chest Physicians. Diagnosis of DVT:
Antithrombotic therapy and prevention of thrombosis,
9th ed: American College of Chest Physicians evidence-
based clinical practice guidelines. Chest. 2012;141(2
Suppl):e351S-e418S.
10. Berry E, Kelly S, Westwood ME, et al. The cost-
effectiveness of magnetic resonance angiography for
carotid artery stenosis and peripheral vascular
disease: A systematic review. Health Technol Assess.
2002;6(7):1-155.
11. Bokhari SW, Faxon DP. Current advances in the
diagnosis and treatment of renal artery stenosis. Rev
Cardiovasc Med. 2004;5(4):204-215.
12. Bongartz GM, Boos M, Winter K, et al. Clinical utility of
contrast-enhanced MR angiography. Eur Radiol. 1997;7
(Suppl 5):178-186.
13. Borer DS, Starr AJ, Reinert CM, et al. The effect of
screening for deep vein thrombosis on the prevalence
of pulmonary embolism in patients with fractures of
the pelvis or acetabulum: A review of 973 patients. J
Orthop Trauma. 2005;19(2):92-95.
14. Bosch E, Kreitner KF, Peirano MF, et al. Safety and
efficacy of gadofosveset-enhanced MR angiography for
evaluation of pedal arterial disease: Multicenter
comparative phase 3 study. AJR Am J Roentgenol.
2008;190(1):179-186.
15. Bruzzone MG, Grisoli M, De Simone T, Regna-Gladin C.
Neuroradiological features of vertigo. Neurol Sci.
2004;25 Suppl 1:S20-S23.
16. Bullitt E, Lin NU, Smith JK, et al. Blood vessel
morphologic changes depicted with MR angiography
during treatment of brain metastases: A feasibility
study. Radiology. 2007;245(3):824-830.
Proprietary
Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MR... Page 68 of 81
17. Cambria RP, Kaufman JA, L'Italien GJ, et al. Magnetic
resonance angiography in the management of lower
extremity arterial occlusive disease: A prospective
study. J Vasc Surg. 1997;25(2):380-389.
18. Carpenter JP, Holland GA, Baum RA, et al. Magnetic
resonance venography for the detection of deep
venous thrombosis: Comparison with contrast
venography and duplex Doppler ultrasonography. J
Vasc Surg. 1993;18:734-741.
19. Carpenter JP, Owen RS, Holland GA, et al. Magnetic
resonance angiography of the aorta, iliac, and femoral
arteries. Surgery. 1994;116:17-23.
20. Carriero A, Iezzi A, Magarelli N, et al. Magnetic
resonance angiography and colour-Doppler
sonography in the evaluation of abdominal aortic
aneurysms. Eur Radiol. 1997;7(9):1495-1500.
21. Center for Medicare and Medicaid Services
(CMS). National Coverage Analysis (NCA): Magnetic
resonance angiography of the abdomen and
pelvis. CMS Decision Memorandum. Administrative
FIle #CAG-00142N. Baltimore, MD: CMS; April 15, 2003.
22. Chaer RA. Endovascular repair of abdominal aortic
aneurysm. UpToDate [online serial]. Waltham, MA:
UpToDate; reviewed September 2014.
23. Champaneria R, Shah L, Moss J, et al. The relationship
between pelvic vein incompetence and chronic pelvic
pain in women: Systematic reviews of diagnosis and
treatment effectiveness. Health Technol Assess.
2016;20(5):1-108.
24. Chowdhury AH, Ghose SK, Mohammad QD, et al.
Digital subtraction angiography is superior to magnetic
resonance angiography in diagnosis of cerebral
arteriovenous malformation. Mymensingh Med J.
2015;24(2):356-365.
25. Collins R, Cranny G, Burch J, et al. A systematic review
of duplex ultrasound, magnetic resonance
angiography and computed tomography angiography
Proprietary
Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MR... Page 69 of 81
for the diagnosis and assessment of symptomatic,
lower limb peripheral arterial disease. Health Technol
Assess. 2007;11(20):iii-iv, xi-xiii, 1-184.
26. Connor SE, Jarosz JM. Magnetic resonance imaging of
cerebral venous sinus thrombosis. Clin Radiol. 2002;57
(6):449-461.
27. Crawley F, Clifton A, Brown MM. Should we screen for
familial intracranial aneurysm? Stroke. 1999;30(2):312
316.
28. Desjardins B, Dill KE, Flamm SD, et al; American
College of Radiology. ACR Appropriateness Criteria
pulsatile abdominal mass, suspected abdominal aortic
aneurysm. Int J Cardiovasc Imaging. 2013;29(1):177
183.
29. Digre KB. Idiopathic intracranial hypertension
headache. Curr Pain Headache Rep. 2002;6(3):217-225.
30. Duerinckx AJ. MRI of coronary arteries. Int J Card
Imaging. 1997;13(3):191-197.
31. Durham JR, Hackworth CA, Tober JC, et al. Magnetic
resonance angiography in the preoperative evaluation
of abdominal aortic aneurysms. Am J Surg.
1993;166:173-178.
32. Ernst M, Buchholz A, Bourcier R, et al. Voxel based
analysis of recurrence dynamics in intracranial
aneurysms after coiling. J Neurointerv Surg. 2018;10
(6):571-576.
33. Ernst M, Yoo AJ, Kriston L, et al. Is visual evaluation of
aneurysm coiling a reliable study end point?
Systematic review and meta-analysis. Stroke. 2015;46
(6):1574-1581.
34. Esfahani DR, Stevenson M, Moss HE, et al. Quantitative
magnetic resonance venography is correlated with
intravenous pressures before and after venous sinus
stenting: Implications for treatment and monitoring.
Neurosurgery. 2015;77(2):254-260.
35. Fananapazir G, Bashir MR, Corwin MT, et al.
Comparison of ferumoxytol-enhanced MRA with
Proprietary
Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MR... Page 70 of 81
conventional angiography for assessment of severity
of transplant renal artery stenosis. J Magn Reson
Imaging. 2017;45(3):779-785.
36. Farb RI, Kim JK, Willinsky RA, et al. Spinal dural
arteriovenous fistula localization with a technique of
first-pass gadolinium-enhanced MR angiography:
Initial experience. Radiology. 2002;222(3):843-850.
37. Gourlay WA, Yucel EK, Hakaim AG, et al. Magnetic
resonance angiography in the evaluation of living-
related renal donors. Transplantation. 1995;60
(11):1363-1366.
38. Graves MJ. Magnetic resonance angiography. Br J
Radiol. 1997;70:6-28.
39. Gupta A, Frazer CK, Ferguson JM, et al. Acute
pulmonary embolism: Diagnosis with MR angiography.
Radiology. 1999;210(2):353-359.
40. Ho VB, Prince MR. Thoracic MR angiography: Imaging
techniques and strategies. Radiographics. 1998;18
(2):287-309.
41. Hoeffner EG. MRA in cerebrovascular disease. Clin
Neurosci. 1997;4(3):117-122.
42. Hojnacki D, Zamboni P, Lopez-Soriano A, et al. Use of
neck magnetic resonance venography, Doppler
sonography and selective venography for diagnosis of
chronic cerebrospinal venous insufficiency: A pilot
study in multiple sclerosis patients and healthy
controls. Int Angiol. 2010;29(2):127-139.
43. Holmes DR Jr, Monahan KH, Packer D. Pulmonary vein
stenosis complicating ablation for atrial fibrillation:
Clinical spectrum and interventional considerations.
JACC Cardiovasc Interv. 2009;2(4):267-276.
44. Huber TS, Back MR, Ballinger RJ, et al. Utility of
magnetic resonance arteriography for distal lower
extremity revascularization. J Vasc Surg. 1997;26
(3):415-423.
45. Iwahashi N, Ota N, Shiro M, et al. Vasa previa
evaluated by noncontrast time-of-flight magnetic
Proprietary
Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MR... Page 71 of 81
resonance angiography. Taiwan J Obstet Gynecol.
2016;55(4):585-587.
46. Jager HR, Grieve JP. Advances in non-invasive imaging
of intracranial vascular disease. Ann R Coll Surg Engl.
2000;82(1):1-5.
47. Jaiswal SK, Fu-Ling Y, Gu L, et al. Accuracy of
transcranial Doppler ultrasound compared with
magnetic resonance angiography in the diagnosis of
intracranial artery stenosis. J Neurosci Rural Pract.
2019;10(3):400-404.
48. Jimbo K, Suzuki M, Fujii T, et al. Usefulness of magnetic
resonance angiography for the evaluation of varices at
hepaticojejunostomy after liver transplantation. Acta
Radiol Open. 2015;4(5):2058460115578600.
49. Johnson NR. Vulvovaginal varicosities and pelvic
congestion syndrome. . UpToDate Inc., Waltham, MA.
Last reviewed October 2018.
50. Karagiorgas GP, Brotis AG, Giannis T, et al. The
diagnostic accuracy of magnetic resonance
angiography for blunt vertebral artery injury detection
in trauma patients: A systematic review and meta-
analysis. Clin Neurol Neurosurg. 2017;160:152-163.
51. Kesava PP, Turski PA. MR Angiography of vascular
malformations. Neuroimaging Clin N Am. 1998;8
(2):349-370.
52. King BF Jr. MR angiography of the renal arteries. Semin
Ultrasound CT MR. 1996;17(4):398-403.
53. Koelemay MJ, Lijmer JG, Stoker J, et al. Magnetic
resonance angiography for the evaluation of lower
extremity arterial disease: A meta-analysis. JAMA.
2001;285(10):1338-1345.
54. Krinsky GA, Reuss PM, Lee VS, et al. Thoracic aorta:
Comparison of single-dose breath-hold and double-
dose non-breath-hold gadolinium-enhanced three-
dimensional MR angiography. Am J Roentgenol.
1999;173(1):145-150.
Proprietary
Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MR... Page 72 of 81
55. Krinsky GA, Rofsky NM, DeCorato DR, et al. Thoracic
aorta: Comparison of gadolinium-enhanced three-
dimensional MR angiography with conventional MR
imaging. Radiology. 1997;202(1):183-193.
56. Kuzma BB, Goodman JM. Non-visualization of known
cerebral aneurysm on MRA. Surg Neurol. 1999;51
(1):110-112.
57. L’Agence Nationale d’Accreditation d’Evaluation en
Sante (ANAES). MR-Angiography, CT-angiography and
Doppler ultrasonography in preoperative investigation
of proximal stenosis of the cervical internal carotid
artery [summary]. Paris, France: ANAES; 2001.
58. L'Agence Nationale d'Accreditation d'Evaluation en
Sante (ANAES). MR angiography, CT angiography and
doppler ultrasonography (PTCA) and coronary arterial
bypass grafting (CABG) in the management of patients
with coronary disease other than myocardial infarction
[summary]. Paris, France: ANAES; 2001.
59. Laissy JP, Dell'Isola B, Petitjean C, et al. Magnetic
resonance angiography: Fields of exploration, main
indications and limitations. J Mal Vasc. 1997;22(5):287
302.
60. Lakshminarayan R, Simpson JO, Ettles DF. Magnetic
resonance angiography: Current status in the planning
and follow-up of endovascular treatment in lower-limb
arterial disease. Cardiovasc Intervent Radiol. 2009;32
(3):397-405.
61. Leach JL, Wolujewicz M, Strub WM. Partially
recanalized chronic dural sinus thrombosis: findings
on MR imaging, time-of-flight MR venography, and
contrast-enhanced MR venography. AJNR Am J
Neuroradiol. 2007;28(4):782-789.
62. Leal PR, Barbier C, Hermier M, et al. Atrophic changes
in the trigeminal nerves of patients with trigeminal
neuralgia due to neurovascular compression and their
association with the severity of compression and
clinical outcomes. J Neurosurg. 2014;120(6):1484-1495.
Proprietary
Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MR... Page 73 of 81
63. Leclerc X, Pruvo JP. Recent advances in magnetic
resonance angiography of carotid and vertebral
arteries. Curr Opin Neurol. 2000;13(1):75-82.
64. Leisser C, Zandieh S, Hirnschall N, Findl O. Reduced
caliber of the ophthalmic artery in magnetic resonance
angiography in patients after retinal artery occlusion.
Klin Monbl Augenheilkd. 2019 Oct 25 [Epub ahead of
print]
65. Leung DA, Hagspiel KD, Angle JF, et al. MR angiography
of the renal arteries. Radiol Clin North Am. 2002;40
(4):847-865.
66. Li J, Feng L, Li J, Tang J. Diagnostic accuracy of magnetic
resonance angiography for acute pulmonary
embolism - a systematic review and meta-analysis.
Vasa. 2016;45(2):149-154.
67. Liauw L, van Buchem MA, Spilt A, et al. MR
angiography of the intracranial venous system.
Radiology. 2000;214(3):678-682.
68. Liberman AL, Daruwalla VJ, Collins JD, et al. Diagnostic
yield of pelvic magnetic resonance venography in
patients with cryptogenic stroke and patent foramen
ovale. Stroke. 2014;45(8):2324-2329.
69. Line BR. Pathophysiology and diagnosis of deep
venous thrombosis. Semin Nucl Med. 2001;31(2):90
101.
70. Lookstein RA, Goldman J, Pukin L, Marin ML. Time-
resolved magnetic resonance angiography as a
noninvasive method to characterize endoleaks: Initial
results compared with conventional angiography. J
Vasc Surg. 2004;39(1):27-33.
71. Luetmer PH, Lane JI, Gilbertson JR, et al.
Preangiographic evaluation of spinal dural
arteriovenous fistulas with elliptic centric contrast-
enhanced MR angiography and effect on radiation
dose and volume of iodinated contrast material. AJNR
Am J Neuroradiol. 2005;26(4):711-718.
Proprietary
Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MR... Page 74 of 81
72. Luhar A, Khan S, Finn JP, et al. Contrast-enhanced
magnetic resonance venography in pediatric patients
with chronic kidney disease: Initial experience with
ferumoxytol. Pediatr Radiol. 2016;46(9):1332-1340.
73. Marciano D, Soize S, Metaxas G, et al. Follow-up of
intracranial aneurysms treated with stent-assisted
coiling: Comparison of contrast-enhanced MRA, time-
of-flight MRA, and digital subtraction angiography. J
Neuroradiol. 2017;44(1):44-51.
74. McGregor R, Vymazal J, Martinez-Lopez M, et al. A multi-
center, comparative, phase 3 study to determine the
efficacy of gadofosveset-enhanced magnetic resonance
angiography for evaluation of renal artery disease. Eur J
Radiol. 2008;65(2):316-325.
75. McRae SJ, Ginsberg JS. The diagnostic evaluation of
deep vein thrombosis. Am Heart Hosp J. 2004;2(4):205
210.
76. Meckel S, Maier M, Ruiz DS, et al. MR angiography of
dural arteriovenous fistulas: Diagnosis and follow-up
after treatment using a time-resolved 3D contrast-
enhanced technique. AJNR Am J Neuroradiol. 2007;28
(5):877-884.
77. Medical Services Advisory Committee (MSAC).
Diagnostic and therapeutic modalities for coronary
artery disease. Horizon Scanning 003. Canberra, ACT:
MSAC; 2003.
78. Meenan R T, Saha S, Chou R, et al. Effectiveness and
cost-effectiveness of echocardiography and carotid
imaging in the management of stroke. Evidence
Report/Technology Assessment 49. Rockville, MD:
Agency for Healthcare Research and Quality (AHRQ);
2002.
79. Meenan RT, Saha S, Chou R, et al. Effectiveness and
cost-effectiveness of echocardiography and carotid
imaging in the management of stroke. Evidence
Report/Technology Assessment 49. Rockville, MD:
Proprietary
Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MR... Page 75 of 81
Agency for Healthcare Research and Quality (AHRQ);
2002.
80. Menke J, Larsen J. Meta-analysis: Accuracy of contrast-
enhanced magnetic resonance angiography for
assessing steno-occlusions in peripheral arterial
disease. Ann Intern Med. 2010;153(5):325-334.
81. Miller JP, Acar F, Hamilton BE, Burchiel KJ. Radiographic
evaluation of trigeminal neurovascular compression in
patients with and without trigeminal neuralgia. J
Neurosurg. 2009;110(4):627-632.
82. Mortensen M, Pratt L. Cerebral aneurysms: A review
and what's new. Axone. 1999;21(1):10-17.
83. Mull M, Nijenhuis RJ, Backes WH, et al. Value and
limitations of contrast-enhanced MR angiography in
spinal arteriovenous malformations and dural
arteriovenous fistulas. AJNR Am J Neuroradiol. 2007;28
(7):1249-1258.
84. National Comprehensive Cancer Network. Clinical
practice guideline on: Central nervous system cancers.
Version 1.2015. NCCN: Fort Washington, PA.
85. National Horizon Scanning Centre (NHSC). Magnetic
resonance angiography (MRA) imaging for the
detection of coronary artery disease. Horizon Scanning
Technology Briefing.
Birmingham, UK: National Horizon Scanning Centre
(NHSC); 2007.
86. Osgood M, Budman E, Carandang R, et al. Prevalence
of pelvic vein pathology in patients with cryptogenic
stroke and patent foramen ovale undergoing MRV
pelvis. Cerebrovasc Dis. 2015;39(3-4):216-223.
87. Palareti G, Cosmi B, Legnani C. Diagnosis of deep vein
thrombosis. Semin Thromb Hemost. 2006;32(7):659
672.
88. Pascual-Castroviejo I, Pascual-Pascual SI. Congenital
vascular malformations in childhood. Semin Pediatr
Neurol. 2002;9(4):254-273.
Proprietary
Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MR... Page 76 of 81
89. Perkins TG, Mishra RK, Siddiqui Y, et al. Magnetic
resonance venography and genetics of a female
patient with pelvic venous thrombosis. J Thromb
Thrombolysis. 2010;30(2):233-239.
90. Pichon Riviere A, Augustovski F, Cernadas C, et al.
Magnetic resonance angiography: Diagnostic
effectiveness and indications [summary]. Report IRR
No. 5. Buenos Aires, Argentina: Institute for Clinical
Effectiveness and Health Policy (IECS); 2003.
91. Podrid PJ. Prevalence and evaluation of ventricular
premature beats. UpToDate [online serial]. Waltham,
MA: UpToDate; reviewed September 2012.
92. Polak JF. MR coronary angiography: Are we there yet?
Radiology. 2000;214(3):649-650.
93. Postma CT, Joosten FB, Rosenbusch G, Thien T.
Magnetic resonance angiography has a high reliability
in the detection of renal artery stenosis. Am J
Hypertens. 1997;10(9 Pt 1):957-963.
94. Poutignat N. Diagnosis of renal artery stenosis
[summary]. Paris, France: L'Agence Nationale
d'Accreditation d'Evaluation en Sante (ANAES); 2004.
95. Prince MR, Schoenberg SO, Ward JS, et al.
Hemodynamically significant atherosclerotic renal
artery stenosis: MR angiographic features. Radiology.
1997;205(1):128-136.
96. Provenzale JM, Sarikaya B. Comparison of test
performance characteristics of MRI, MR angiography,
and CT angiography in the diagnosis of carotid and
vertebral artery dissection: A review of the medical
literature. AJR Am J Roentgenol. 2009;193(4):1167
1174.
97. Qureshi AI, Isa A, Cinnamon J, et al. Magnetic
resonance angiography in patients with brain
infarction. J Neuroimaging. 1998;8(2):65-70.
98. Rajagopalan S, Prince M. Magnetic resonance
angiographic techniques for the diagnosis of arterial
disease. Cardiol Clin. 2002;20(4):501-512, v.
Proprietary
Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MR... Page 77 of 81
99. Reimer P, Boos M. Phase-contrast MR angiography of
peripheral arteries: Technique and clinical application.
Eur Radiol. 1999;9(1):122-127.
100. Rengier F, Worz S, Melzig C, et al. Automated 3D
volumetry of the pulmonary arteries based on
magnetic resonance angiography has potential for
predicting pulmonary hypertension. PLoS One.
2016;11(9):e0162516.
101. Safian RD, Textor SC. Renal-artery stenosis. N Engl J
Med. 2001;344(6):431-442.
102. Sagi HC, Ahn J, Ciesla D, et al; Orthopaedic Trauma
Association Evidence Based Quality Value and Safety
Committee. Venous thromboembolism prophylaxis in
orthopaedic trauma patients: A survey of OTA member
practice patterns and OTA expert panel
recommendations. J Orthop Trauma. 2015;29 (10):e355
e362.
103. Saraf-Lavi E, Bowen BC, Quencer RM, et al. Detection
of spinal dural arteriovenous fistulae with MR imaging
and contrast-enhanced MR angiography: Sensitivity,
specificity, and prediction of vertebral level. AJNR Am J
Neuroradiol. 2002;23(5):858-867.
104. Saremi F, Tafti M. The role of computed tomography
and magnetic resonance imaging in ablation
procedures for treatment of atrial fibrillation. Semin
Ultrasound CT MR. 2009;30(2):125-156.
105. Schoenberg SO, Prince MR, Knopp MV, et al. Renal MR
angiography. Magn Reson Imaging Clin N Am. 1998;6
(2):351-370.
106. Segal JB, Eng J, Jenckes MW, et al. Diagnosis and
treatment of deep venous thrombosis and pulmonary
embolism. Evidence Report/Technology Assessment
68. Rockville, MD: Agency for Healthcare Research and
Quality (AHRQ); 2003.
107. Shahrouki P, Moriarty JM, Khan SN, et al. High
resolution, 3-dimensional ferumoxytol-enhanced
cardiovascular magnetic resonance venography in
Proprietary
Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MR... Page 78 of 81
central venous occlusion. J Cardiovasc Magn Reson.
2019;21(1):17.
108. Sharma AK, Westesson PL. Preoperative evaluation of
spinal vascular malformation by MR angiography: How
reliable is the technique: Case report and review of
literature. Clin Neurol Neurosurg. 2008;110(5):521-524.
109. Shih MC, Hagspiel KD. CTA and MRA in mesenteric
ischemia: Part 1, Role in diagnosis and differential
diagnosis. AJR Am J Roentgenol. 2007;188(2):452-461.
110. Steenbeek MP, van der Vleuten CJM, Schultze Kool LJ,
Nieboer TE. Noninvasive diagnostic tools for pelvic
congestion syndrome: A systematic review. Acta
Obstet Gynecol Scand. 2018;97(7):776-786.
111. Stein PD, Woodard PK, Hull RD, et al. Gadolinium-
enhanced magnetic resonance angiography for
detection of acute pulmonary embolism: An in-depth
review. Chest. 2003;124(6):2324-2328.
112. Steinberg EP. Magnetic resonance coronary
angiography - Assessing an emerging technology. N
Eng J Med. 1993;328:879-880.
113. Stoumpos S, Hennessy M, Vesey AT, et al.
Ferumoxytol-enhanced magnetic resonance
angiography for the assessment of potential kidney
transplant recipients. Eur Radiol. 2018;28(1):115-123.
114. Strouse PJ. Magnetic resonance angiography of the
pediatric abdomen and pelvis. Magn Reson Imaging
Clin N Am. 2002;10(2):345-361.
115. Tutar B, Kantarci F, Cakmak OS, et al. Assessment of
deep venous thrombosis in the lower extremity in
Behçet's syndrome: MR venography versus Doppler
ultrasonography. Intern Emerg Med. 2019;14(5):705
711.
116. U.S. Department of Health and Human Services,
Health Care Financing Administration (HCFA), Medical
Technology Advisory Committee. Magnetic resonance
angiography (MRA) for aortic aneurysm of the
abdomen (AAA). Medical Technology Advisory
Proprietary
Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MR... Page 79 of 81
Committee Minutes, August 1997. Baltimore, MD:
HCFA; 1997.
117. U.S. Food and Drug Administration (FDA). FDA
approves first imaging agent to enhance scans of
blood flow. FDA News. Rockville, MD: FDA; December
24, 2008.
118. Uchino H, Ito M, Fujima N, et al. A novel application of
four-dimensional magnetic resonance angiography
using an arterial spin labeling technique for
noninvasive diagnosis of Moyamoya disease. Clin
Neurol Neurosurg. 2015;137:105-111.
119. Wade RG, Watford J, Wormald JCR, et al. Perforator
mapping reduces the operative time of DIEP flap
breast reconstruction: A systematic review and meta-
analysis of preoperative ultrasound, computed
tomography and magnetic resonance angiography. J
Plast Reconstr Aesthet Surg. 2018;71(4):468-477.
120. Wardlaw JM, Chappell FM, Stevenson M, et al.
Accurate, practical and cost-effective assessment of
carotid stenosis in the UK. Health Technol Assess.
2006;10(30):1-200.
121. Wen PY. Assessment of disease status and surveillance
after treatment in patients with brain tumors.
UpToDate Inc., Waltham, MA. Last reviewed
September 2015.
122. Wielopolski PA. Magnetic resonance pulmonary
angiography. Coron Artery Dis. 1999;10(3):157-175.
123. Wisconsin Physicians Service Insurance Corporation
(WPSIC). Michigan Medicare Part B. Magnetic
resonance angiography (MRA). Policy No. RAD-023.
Madison, WI: WPSIC; July 14, 1999.
124. Yamashita R, Isoda H, Arizono S, et al. Non-contrast
enhanced magnetic resonance venography using
magnetization-prepared rapid gradient-echo
(MPRAGE) in the preoperative evaluation of living liver
donor candidates: Comparison with conventional
Proprietary
Magnetic Resonance Angiography (MRA) and Magnetic Resonance Venography (MR... Page 80 of 81
computed tomography venography. Eur J Radiol.
2017;90:89-96.
125. Yildirim D, Alis D, Turkmen S, et al. Is there any
association between jugular venous reflux and
nonpulsatile subjective tinnitus? A preliminary study of
four-dimensional magnetic resonance angiography.
Niger J Clin Pract. 2019;22(10):1430-1434.
126. Yucel EK. Pulmonary MR angiography: Is it ready now?
Radiology. 1999;210(2):301-303.
127. Zacest AC, Magill ST, Miller J, Burchiel KJ. Preoperative
magnetic resonance imaging in Type 2 trigeminal
neuralgia. J Neurosurg. 2010;113(3):511-515.
128. Zamani A. MRA of intracranial aneurysms. Clin
Neurosci. 1997;4(3):123-129.
129. Zhang T, Xu Z, Chen J, et al. A Novel approach for
imaging of thoracic outlet syndrome using contrast-
enhanced magnetic resonance angiography (CE-MRA),
short inversion time inversion recovery sampling
perfection with application-optimized contrasts using
different flip angle evolutions (T2-STIR-SPACE), and
volumetric interpolated breath-hold examination
(VIBE). Med Sci Monit. 2019;25:7617-7623.
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services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors
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AETNA BETTER HEALTH® OF PENNSYLVANIA
Amendment to Aetna Clinical Policy Bulletin Number: 0094 Magnetic
Resonance Angiography (MRA) and Magnetic Resonance Venography (MRV)
There are no amendments for Medicaid.
www.aetnabetterhealth.com/pennsylvania new 06/01/2020
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