Purpose: To test and validate magnetic resonance imaging (MRI) sequences for peripheral artery lesion characterization and relate the MRI characteristics to the amount of force required for a guidewire to puncture peripheral chronic total occlusions (CTOs) as a surrogate for immediate failure of endovascular therapy. Methods: Diseased superficial femoral, popliteal, and tibial artery segments containing 55 atherosclerotic lesions were excised from the amputated limbs of 7 patients with critical limb ischemia. The lesions were imaged at high resolution (75 μm3 voxels) with T2-weighted (T2W) and ultrashort echo time (UTE) sequences on a 7-T MR scanner. The MR images (n=15) were validated with micro–computed tomography and histology. CTOs (n=40) were classified by their MR signal characteristics as “soft” (signals indicating fat, thrombus, microchannels, or loose fibrous tissue), “hard” (collagen and/or speckled calcium signals), or “calcified” (calcified nodule signals). A 2-kg load cell advanced the back end of a 0.035-inch stiff guidewire at a fixed displacement rate (0.05 mm/s) through the CTOs, and the forces required to cross each lesion were measured. Results: T2W images showed fat as hyperintense and hardened tissue as hypointense. Calcium and thrombus appeared as a signal void in conventional MRI sequences but were easily identified in UTE images (thrombus was hyperintense and calcium hypointense). MRI accurately differentiated “hard,” “soft,” and “calcified” CTOs based on associated guidewire puncture force. The guidewire could not enter “calcified” CTOs (n=6) at all. “Hard” CTOs (n=9) required a significantly higher (p<0.001) puncture force of 1.71±0.51 N vs 0.43±0.36 N for “soft” CTOs (n=25). Conclusion: MRI characteristics of PAD lesions correlate with guidewire puncture forces, an important aspect of crossability. Future work will determine if clinical MR scanners can be used to predict success in peripheral vascular interventions.
BradburyAWAdamDJBeardJD. Bypass versus angioplasty in severe ischaemia of the leg (BASIL): Multicentre, randomised controlled trial. Lancet. 2005;366:1925–1934.
5.
JessicaPSSchanzerA.Lower extremity arterial disease: decision making and medical treatment. In: CronenwettJLJohnstonKW, eds. Rutherford’s Vascular Surgery. 8th ed.Philadelphia, PA: Elsevier; 2014:1675–1700.
6.
IidaOSogaYHiranoK. Long-term results of direct and indirect endovascular revascularization based on the angiosome concept in patients with critical limb ischemia presenting with isolated below-the-knee lesions. J Vasc Surg. 2012;55:363–370.
7.
TASC Steering Committee, JaffMRWhiteCJ. An update on methods for revascularization and expansion of the TASC lesion classification to include below-the-knee arteries: a supplement to the Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). J Endovasc Ther. 2015;22:663–677.
8.
RyerEJTrocciolaSMDerubertisB. Analysis of outcomes following failed endovascular treatment of chronic limb ischemia. Ann Vasc Surg. 2006;20:440–446.
9.
ShishehborMHMonteleonePP.A predictable propensity. J Am Heart Assoc. 2013;2:e000655.
10.
NolanBWDe MartinoRRStoneDH. Prior failed ipsilateral percutaneous endovascular intervention in patients with critical limb ischemia predicts poor outcome after lower extremity bypass. J Vasc Surg. 2011;54:730–736.
11.
JonesDWSchanzerAZhaoY. Growing impact of restenosis on the surgical treatment of peripheral arterial disease. J Am Heart Assoc. 2013;2:e000345.
12.
RoyTForbesTWrightG. Burning bridges : mechanisms and implications of endovascular failure in the treatment of peripheral artery disease. J Endovasc Ther. 2015;22:874–880.
13.
OpolskiMPAchenbachSSchuhbäckA. Coronary computed tomographic prediction rule for time-efficient guidewire crossing through chronic total occlusion: Insights from the CT-RECTOR multicenter registry (computed tomography registry of chronic total occlusion revascularization). JACC Cardiovasc Interv. 2015;8:257–267.
14.
CollinsRBurchJCrannyG. Duplex ultrasonography, magnetic resonance angiography, and computed tomography angiography for diagnosis and assessment of symptomatic, lower limb peripheral arterial disease: systematic review. BMJ. 2007;334:1257.
15.
SaamTHatsukamiTSTakayaN. The vulnerable, or high-risk, atherosclerotic plaque: noninvasive MR imaging for characterization and assessment. Radiology. 2007;244:64–77.
16.
KarolyiMSeifarthHLiewG. Classification of coronary atherosclerotic plaques ex vivo with T1, T2, and ultrashort echo time CMR. JACC Cardiovasc Imaging. 2013;6:466–474.
17.
SunBGiddensDPLongR. Characterization of coronary atherosclerotic plaque using multicontrast MRI acquired under simulated in vivo conditions. J Magn Reson Imaging. 2006;24:833–841.
18.
WalshMTCunnaneEMMulvihillJJ. Uniaxial tensile testing approaches for characterisation of atherosclerotic plaques. J Biomech. 2014;47:793–804.
19.
Van GerwenDJDankelmanJVan Den DobbelsteenJJ.Measurement and stochastic modeling of kidney puncture forces. Ann Biomed Eng. 2014;42:685–695.
20.
LandisJRKochGG.The measurement of observer agreement for categorical data. Biometrics. 1977;33:159–174.
21.
GomoriJMGrossmanRI.Mechanisms responsible for the MR appearance and evolution of intracranial hemorrhage. Radiographics. 1988;8:427–440.
22.
CaiJMHatsukamiTSFergusonMS. Classification of human carotid atherosclerotic lesions with in vivo multicontrast magnetic resonance imaging. Circulation. 2002;106:1368–1373.
23.
YuanCMitsumoriLMFergusonMS. In vivo accuracy of multispectral magnetic resonance imaging for identifying lipid-rich necrotic cores and intraplaque hemorrhage in advanced human carotid plaques. Circulation. 2001;104:2051–2056.
24.
HatsukamiTSRossRPolissarNL. Visualization of fibrous cap thickness and rupture in human atherosclerotic carotid plaque in vivo with high-resolution magnetic resonance imaging. Circulation. 2000;102:959–964.
25.
MaintzDOzgunMHoffmeierA. Selective coronary artery plaque visualization and differentiation by contrast-enhanced inversion prepared MRI. Eur Heart J. 2006;27:1732–1736.
26.
PolonskyTSLiuKTianL. High-risk plaque in the superficial femoral artery of people with peripheral artery disease: prevalence and associated clinical characteristics. Atherosclerosis. 2014;237:169–176.
27.
ZhangZFanZCarrollTJ. Three-dimensional T2-weighted MRI of the human femoral arterial vessel wall at 3.0Tesla. Invest Radiol. 2010;44:619–626.
28.
McDermottMMLiuKCarrJ. Superficial femoral artery plaque, the ankle-brachial index, and leg symptoms in peripheral arterial disease: Walking and Leg Circulation Study (WALCS) III. Circ Cardiovasc Imaging. 2011;4:246–252.
29.
GaliziaMSBarkerALiaoY. Wall morphology, blood flow and wall shear stress: MR findings in patients with peripheral artery disease. Eur Radiol. 2014;24:850–856.
30.
SampathSRavalANLedermanRJ. High-resolution 3D arteriography of chronic total peripheral occlusions using a T1-W turbo spin-echo sequence with inner-volume imaging. Magn Reson Med. 2007;57:40–49.
31.
NorgrenLHiattWRDormandyJA. Inter-Society Consensus for the management of peripheral arterial disease (TASC II). Int Angiol. 2007;26:82–157.
32.
FanelliFCannavaleAGazzettiM. Calcium burden assessment and impact on drug-eluting balloons in peripheral arterial disease. Cardiovasc Intervent Radiol. 2014;37:898–907.
FangT.Ancillary endovascular equipment: catheters, guidewires, and procedural considerations. In: FogartyTJWhiteRA, eds. Peripheral Endovascular Interventions. New York, NY: Springer Science+Business Media; 2010:165–179.
35.
SrivatsaSSEdwardsWDBoosCM. Histologic correlates of angiographic chronic total coronary artery occlusions. Influence of occlusion duration on neovascular channel patterns and intimal plaque composition. J Am Coll Cardiol. 1997;29:955–963.
36.
EslahpazirBAGoldstoneJAllemangMT. Principal considerations for the contemporary high-fidelity endovascular simulator design used in training and evaluation. J Vasc Surg. 2014;59:1154–1162.
37.
ThindASStraussBH.A novel method for the measurement of proximal fibrous cap puncture force in chronic total occlusions: the effect of increasing age. EuroIntervention. 2011;6:997–1002.
38.
KhoshnamMSkanesACPatelRV.Modeling and estimation of tip contact force for steerable ablation catheters. IEEE Trans Biomed Eng. 2015;62:1404–1415.
39.
PernaFHeistEKDanikSB. Assessment of catheter tip contact force resulting in cardiac perforation in swine atria using force sensing technology. Circ Arrhythmia Electrophysiol. 2011;4:218–224.
40.
TakashimaKTsuzukiSOoikeA. Numerical analysis and experimental observation of guidewire motion in a blood vessel model. Med Eng Phys. 2014;36:1672–1683.
41.
Di BiaseLNataleABarrettC. Relationship between catheter forces, lesion characteristics, “popping,” and char formation: experience with robotic navigation system. J Cardiovasc Electrophysiol. 2009;20:436–440.
42.
ZengLWeberGZollerIExamples of haptic system development. In: HatzfeldCKernTA, eds. Engineering Haptic Devices: A Beginner’s Guide. 2nd ed.New York, NY: Springer; 2014:443–444.
43.
MaeharaAMintzGSShimshakTM. Intravascular ultrasound evaluation of JETSTREAM atherectomy removal of superficial calcium in peripheral arteries. EuroIntervention. 2015;11:96–103.
44.
MintzGSPopmaJJPichardAD. Patterns of calcification in coronary artery disease. A statistical analysis of intravascular ultrasound and coronary angiography in 1155 lesions. Circulation. 1995;91:1959–1965.
45.
StraussBHOsherovABRadhakrishnanS. Collagenase total occlusion-1 (CTO-1) trial: A phase I, dose-escalation, safety study. Circulation. 2012;125:522–528.
46.
GoertzDEThindASKarshafianR. In vivo feasibility study of ultrasound potentiated collagenase therapy of chronic total occlusions. Ultrasonics. 2014;54:20–24.
