Intraluminal Assessment of Coronary Arteries With Ferumoxytol … · IMAGING VIGNETTE Intraluminal...
Transcript of Intraluminal Assessment of Coronary Arteries With Ferumoxytol … · IMAGING VIGNETTE Intraluminal...
FIGURE 1 3-Dimen
Cardiac/Respiratory
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(A) Four-chamber vi
(B) Sagittal reconstr
viewed superior to in
the ascending aorta
J A C C : C A R D I O V A S C U L A R I M A G I N G VO L . 1 1 , N O . 3 , 2 0 1 8
ª 2 0 1 8 B Y T H E AM E R I C A N C O L L E G E O F C A R D I O L O G Y F O UN DA T I O N
P U B L I S H E D B Y E L S E V I E R
IMAGING VIGNETTE
Intraluminal Assessment of CoronaryArteries With Ferumoxytol-EnhancedMagnetic Resonance Angiography
Matthew S. Chin, MD,a Michael Steigner, MD,b Wenqing Yin, MD, PHD,c Raymond Y. Kwong, MD, MPH,cAndrew M. Siedlecki, MDc
DIAGNOSTIC ANGIOGRAPHY IS SOMETIMES INEVITABLE IN PATIENTS WITH ESTIMATED GLOMERULAR
filtration rate (eGFR) of <30 ml/min/1.73 m2 who are not yet on dialysis. However, iodine- or gadolinium-basedcontrast agents pose a risk of acute kidney injury or nephrogenic systemic fibrosis, respectively (1).Ferumoxytol-enhanced cardiac magnetic resonance angiography (cMRA) (Figure 1) can be an alternative butanaphylactic reactions have been described. We present a brief pictorial overview of our experience of its usein 5 patients (Figures 2 to 5, Online Videos) for assessing the coronary artery tree without complications.
sional Reconstruction of the Heart After Intravenous Ferumoxytol Injection and Image Acquisition Using cMRA and
Gating and Ventricular Wall Subtraction
B C
ew, clockwise: main pulmonary artery, descending thoracic aorta, left ventricular chamber, right ventricular chamber, and ascending thoracic aorta.
uction with visualization of left coronary artery (arrow) and overlying main pulmonary artery. (C) Multiplanar reconstruction of the coronary tree
ferior showing distribution of right coronary, left main continuous with left anterior descending artery, and left circumflex beginning at the level of
(left to right, green lines). cMRA ¼ cardiac magnetic resonance angiography.
ISSN 1936-878X/$36.00 https://doi.org/10.1016/j.jcmg.2017.10.017
From the aDepartment of Radiology, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, Pennsylvania; bDepartment of
Radiology, Brigham and Women’s Hospital, Boston, Massachusetts; and the cDepartment of Internal Medicine, Brigham and
Women’s Hospital, Boston, Massachusetts. Ferumoxytol for Magnetic Resonance Imaging in Patients With Severe Kidney
Disease NCT02954510. Dr. Siedlecki is funded by grant K08DK089002 from the National Institutes of Health/National Institute
of Diabetes and Digestive and Kidney Diseases and by research grant #2016D004506 from AMAG Pharmaceuticals, Inc. All
authors have reported that they have no relationships relevant to the contents of this paper to disclose. Zahi Fayad, MD,
served as the Guest Editor for this paper.
Manuscript received August 1, 2017; revised manuscript received September 27, 2017, accepted October 18, 2017.
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B FIGURE 2 cMRA After Intravenous Ferumoxytol
Injection Correlated With Cardiac Catheterization
Performed 154 Days Previously in Patient #1
(Ai) Left heart cardiac catheterization with
demarcated section of left coronary artery (blue
arrow [ proximal; red arrow ¼ distal) corresponds
to MRA demarcation and Online Video 11. (Aii)
Three-dimensional reconstruction (with ventric-
ular wall subtraction) showing the path of vessel
descent and the axial cross section showing the left
lateral direction of vessel. Aortic root (asterisk).
(Bi)Multiplanar straight-line and (Bii) curvilinear
reconstruction shows ferumoxytol-containing left
main origin and left anterior descending (green
line) vessels. (Biii) Luminal cross section at the
proximal (left) and distal (right) segment,
respectively. Abbreviation as in Figure 1.
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B FIGURE 3 Ferumoxytol cMRA Correlation With
Cardiac Catheterization in Patient #1
(Ai) Right heart cardiac catheterization with
demarcated section of right coronary artery (blue
arrow ¼ proximal; red arrow ¼ distal) corresponds
to MRA demarcation and Online Video 12. (Aii)
Three-dimensional reconstruction (with ven-
tricular wall subtraction) showing path of vessel
descent and axial cross section showing right
lateral direction of vessel. Aortic root (asterisk).
(Bi) Multiplanar straight line and (Bii) curvilinear
reconstruction shows patent, continuous,
ferumoxytol-containing proximal-to-mid right
coronary artery (green line). (Biii) Luminal cross
section at the proximal (left) and distal (right)
segment, respectively. Scale bar ¼ 5 mm.
Abbreviation as in Figure 1.
Chin et al. J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 1 1 , N O . 3 , 2 0 1 8
Ferumoxytol Magnetic Resonance Angiography M A R C H 2 0 1 8 : 5 0 5 – 8
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B FIGURE 4 cMRA After Intravenous Ferumoxytol
Injection Performed 185 Days After Patient #2
Received a 3.75 � 23 mm Xience Drug-Eluting Stent to
the Mid-Left Anterior Descending Artery
(Ai) Post-deployment coronary angiography with
iodinated contrast identifies the stent (yellow arrow)
in the left anterior descending artery proximal to the
second diagonal branch and corresponding to MRA
demarcation and Online Video 13. (Aii) Three-
dimensional reconstruction (with ventricular wall
subtraction) and axial cross section showing left lateral
direction of vessel. Aortic root (asterisk). (Bi)
Multiplanar straight line and (Bii) curvilinear recon-
struction shows ferumoxytol-containing left anterior
ascending artery (stent, yellow bar). (Biii) Luminal cross
section at the proximal (left) and distal (right)
segments, respectively. Xience Drug-Eluting Stent
(Abbott Laboratories, Chicago, Illinois). Abbreviation as
in Figure 1.
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B FIGURE 5 cMRA After Intravenous Ferumoxytol
Injection Performed 185 Days After Patient #2
Received a 3.75 � 23 mm Xience Drug-Eluting Stent to
the Mid-Left Anterior Descending Artery and
Correlation With RCA Cardiac Catheterization
Showing Stenosis
(Ai) Seventy percent mid-right coronary artery lesion
(RCA) (red arrow) is visualized by right coronary artery
catheterization and corresponds to MRA demarcation
and Online Video 14. (Aii) Three-dimensional recon-
struction (with ventricular wall subtraction) and axial
cross section showing left lateral direction of vessel.
Aortic root (asterisk). (Bi) Multiplanar straight-line and
(Bii) curvilinear reconstruction shows RCA luminal
stenosis (red arrow). (Biii) Luminal cross section at
the proximal (left) and distal (right) segments,
respectively. Scale bar ¼ 5 mm. Abbreviation as in
Figure 1.
J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 1 1 , N O . 3 , 2 0 1 8 Chin et al.M A R C H 2 0 1 8 : 5 0 5 – 8 Ferumoxytol Magnetic Resonance Angiography
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Right Coronary Origin
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Left Coronary Origin LAD Circumflex FIGURE 6 Origins of Right
and Left Coronary Arteries,
LAD Artery, and Left
Circumflex Artery in
Patients #1 to #5
Axial cross section of right
coronary origin (first
column) and sagittal cross
sections of left main artery
origin (second column),
and representative
segments of left anterior
descending (LAD) (third
column) and left circum-
flex (fourth column) (red
arrows), traced to theirmost
distal points in corre-
sponding Online Videos 1,
2, 3, 4, 5, 6, 7, 8, 9, and 10 in
the axial and sagittal planes,
respectively (patient 1 ¼Online Videos 1 and 2;
Patient #2 ¼ Online Videos
3 and 4; Patient #3 ¼Online Videos 5 and 6;
Patient #4¼ Online Videos
7 and 8; Patient #5 ¼Online Videos 9 and 10).
Patients #1 to #4 were in
sinus rhythm throughout
the study, whereas Patient
#5 was in atrial fibrillation.
Patient #4 was 122.5 kg
and weighed at least
34.3% more than Patients
#1 to #3. Mean continuous
length of left and right
coronary circulation
measured was 6.53 � 1.26
cm and 6.08 � 2.8 cm
(n ¼ 5) from respective
origins that are also sum-
marized in Online Table 1.
Chin et al. J A C C : C A R D I O V A S C U L A R I M A G I N G , V O L . 1 1 , N O . 3 , 2 0 1 8
Ferumoxytol Magnetic Resonance Angiography M A R C H 2 0 1 8 : 5 0 5 – 8
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In summary, we built on previous work that depicted the resolution of ferumoxytol-enhanced cMRA invisualizing the right coronary artery. We demonstrated that the left coronary artery tree in adults could also bevisualized (Figure 6) and corresponded with findings of conventional coronary angiography, includingsegmental stenosis.
ADDRESS FOR CORRESPONDENCE: Dr. Andrew M. Siedlecki, Harvard Institutes of Medicine, 77 Avenue LouisPasteur, HIM Rm 568B, Boston, Massachusetts 02115. E-mail: [email protected].
RE F E RENCE
1. Fahling M, Seeliger E, Patzak A, Persson PB.Understanding and preventing contrast-inducedacute kidney injury. Nat Rev Nephrol 2017;13:169–80.
KEY WORDS cardiovascular disease,ferumoxytol, kidney disease, magneticresonance angiography
APPENDIX For a supplemental tableand videos, please see the online version ofthis paper.