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164 Chapter 16 Computed tomography and MRI in venous disease
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16.26 IVC thrombosis. Partial volume maximum intensity pro-
16.25 Chronic IVC occlusion with collateral formation. Max-
imum intensity projection image from contrast-enhanced 3D
spoiled gradient echo acquisition demonstrates occlusion of
the IVC below the renal veins (arrow) with massive dilatation of
the left gonadal vein (arrowheads).
jection image from 3D spoiled gradient echo acquisition reveals
extensive bland thrombus in the IVC and left renal vein (arrows).
resolution results in reduced SNR. Breath-hold imaging is
not a requirement in some anatomic regions, such as the
uoroscopic triggering can be used to optimize the timing
of the acquisition to maximize venous rather than arterial
concentration: this reduces the total number of acquisi-
pelvis and extremities; in these cases, multiple acquisitions
can be performed with relatively high spatial resolution
and high SNR (Figure16.28).
tions, but does limit opportunities for subtraction of arterial-phase data.
A signicant advantage of 3D CE MRV relative to
time-of-ight MRV techniques is that the acquisition
times are generally short enough for acquisition in a single breath-hold. Since there is no reliance on vascular
inow effects, the plane of acquisition has no effect on the
vascular signal. The 3D acquisition volume can therefore
be optimized for maximum efciency: oblique coronal for
visualizing the IVC, pelvic veins, and extremity veins, for
example, achieving maximal volumetric coverage within
a breath-hold.
CE MRV has some limitations compared with the more
common MRA technique: the contrast bolus is less compact and more dilute by the time it reaches the venous
system, and therefore the maximal contrast enhancement
in veins is generally lower than that achieved in arteries.
techniques, such as reformatting, maximum intensity
projection, and volume rendering. Partial-volume minimum intensity projection images may be useful for
accentuating venous thrombosis. Subtraction techniques
are sometimes useful for removing background signal or
arterial signal. If pure arterial-phase images are acquired,
for example, these can be subtracted from venousphase images to generate a purely venous data set (Figure16.29b). Likewise, simply subtracting a precontrast
mask acquisition from the optimal venous phase data
will reduce the amount of background signal and may
improve the quality of the 3D reconstructed images. Subtraction techniques rely on the assumption that there is
no shift in position between the two acquisitions; this is
not always the case, particularly in patients who are not
consistent breath-holders.
Nevertheless, it is usually more than adequate for diagnostic purposes. The addition of fat saturation (usually
via chemical saturation pulses) is often helpful in reducing
background signal and improving venous contrast, albeit
at the cost of slightly longer acquisition times. Finally, the
requirement for breath-hold imaging places fundamental constraints on achievable spatial resolution and SNR:
increments in both spatial resolution and SNR generally
require increased acquisition times, and increased spatial
need for intravenous contrast: there is an association
between gadolinium contrast administration and nephro-
genic sclerosing brosis in patients with severe renal
insufciency,
contrast agents are not recommended in patients with
an estimated glomerular ltration rate of <30 mL/min-
ute/1.73m
reaction to gadolinium-based contrast agents, although
3D MRV data can be reconstructed using standard
Limitations of the CE MRV techniques include the
28
and as a general rule, gadolinium-based
2
. In addition, there is a small risk of allergic
16.3 Imaging technologies: MRI of venous disease 165
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16
16.27 Axillary and subclavian vein thrombosis. Source images
from 3D contrast-enhanced MR venography reveal occlusive
thrombus (arrows).
this is probably somewhat lower than the risk associated
with the iodinated contrast agents used in CT. Occasionally, the amount of contrast in the veins is not adequate
for optimal visualization; this is probably most common
in the lower extremities and pelvis in patients with very
slow venous return. In these cases, an increased contrast
dose or multiexcitation acquisitions may improve image
quality. An important advantage of MRV with respect to
CT is that the exact timing of the venous-phase acquisition is less important: there is no penalty in MRI for
acquiring multiple acquisitions until the venous contrast
is optimal, whereas the cumulative radiation dose is a signicant consideration in CT.
Direct MRV is a technique that is advocated by several
authors in which a dilute bolus of gadolinium contrast is
injected directly into the venous territory of interest while
simultaneous scanning is performed (Figure 16.30). This
avoids the problem of contrast dilution that occurs when
the contrast bolus rst passes through the arterial system.
16.28 Klippel–Trenaunay syndrome in the right lower extrem-
ity. Axial fat-suppressed 3D spoiled gradient recalled echo
(SPGR) image (a) obtained after contrast injection demonstrates massive enlargement of the central right popliteal vein
(arrow) in comparison with the normal left side, with multiple
additional enhancing intramuscular and subcutaneous varicosities. Coronal 3D SPGR image
extensive right calf varicosities, as well as an expanded thrombosed intramuscular vein (arrow). Volume-rendered image (c)
again demonstrates extensive deep and supercial varicosities in the right calf in comparison to the normal left-sided
arteries and veins.
(b) again demonstrates
166 Chapter 16 Computed tomography and MRI in venous disease
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16.29 (a) Arterial- and (b) venous-phase maximum intensity
projection images from contrast-enhanced MR angiography/
venography in a patient with severe IVC stenosis following radiation therapy to a lumbar vertebral metastasis. Note threadlike IVC (arrow) in
from the venous-phase image by subtracting the arterial-phase
source images from the venous-phase source images.
(b). Residual arterial contrast was removed
16.31 Pulmonary vein stenosis following radiofrequency abla-
tion of the left atrium. Posterior volume-rendered image from
3D gadolinium-enhanced pulmonary venogram demonstrates
severe stenosis of the left superior pulmonary vein (arrow) at its
junction with the left atrium.
16.3.3 Clinical applications
MRvenography generally plays a secondary role in venous
imaging. Duplex Doppler sonography is generally the rst
test performed in assessing lower or upper extremity veins
for thrombosis. Sonography is accurate, portable, and considerably less expensive than MRV, but is occasionally limited. Sonography is less effective at visualizing the central
veins of the thorax, the entire extent of the IVC, and the
iliac veins.
16.30 Direct venogram in patient with subclavian vein thrombo-
sis. Volume-rendered image from contrast-enhanced 3D spoiled
gradient echo sequence obtained while injecting dilute gadolinium contrast into a peripheral right-sided vein reveals patent
SVC (arrow), occluded distal right subclavian vein (arrowhead),
and extensive collateral formation (asterisks).
The two major limitations of this technique are that venous
access needs to be established in a peripheral vein of interest (typically the hand or foot) and that unless both arms or
legs are injected simultaneously, there will be only minimal
visualization of contralateral veins.
28–30
16.3.3.1 Upper extremity and central thoracic veins
Deep and supercial veins of the upper extremity are generally well seen with sonography; however, visualization of
more central thoracic veins is limited, and MRV can generally provide diagnostic images in patients with suspected
SVC, brachiocephalic, subclavian, or jugular vein stenosis
or occlusion (Figures 16.22, 16.27, and 16.30).
CE and noncontrast techniques
31,32
are effective, and MRV
25,30
Both
can be combined with anatomic imaging to characterize
obstructing lesions in the mediastinum.
16.3.3.2 Pulmonary veins
Assessment of pulmonary veins with MRV is useful both
before (to dene anatomy) and after (to detect complications, such as pulmonary vein stenosis or occlusion)
RF ablation of arrhythmogenic foci in the left atrium
(Figure 16.31).
with cardiac MRI; some authors have suggested that the
presence of atrial late gadolinium enhancement may be
helpful in planning therapeutic interventions.
tal anomalies of the pulmonary veins, such as anomalous
pulmonary venous return, are also well seen with MRV
(Figure 16.32)
assessment of the heart and quantication of shunt severity by measurement of the ratio of pulmonary artery to
aortic blood ow (Q
33
Pulmonary MRV can be combined
34
Congeni-
35
and can be combined with functional
).
p/Qs
16.3 Imaging technologies: MRI of venous disease 167
(b)
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16.32 Scimitar syndrome. Partial maximum intensity projection (MIP) image (a) and volume-rendered image (b) from 3D
gadolinium-enhanced pulmonary venogram reveal a large anomalous vein draining the right lung and entering the inferior vena cava
just above the diaphragm.
16
16.3.3.3 IVC and renal veins
The IVC can be accurately assessed with CE or noncontrast MRV. Venous extension is an important consideration in staging and treating renal cell carcinoma: the renal
vein is invaded in as many as 20% of cases and the IVC
in approximately 10%. MRI is an ideal technique for the
evaluation of renal cell carcinoma. It is highly accurate at
detecting and characterizing renal masses. Regional adenopathy, direct invasion of adjacent structures, and distant
metastases are easily visualized. Vascular staging including
MRV reveals the presence or absence of bland or tumor
thrombus in the renal veins and IVC, as well as the venous
anatomy, and this information plays a role in choosing the
most appropriate surgical approach and technique.
Tumor thrombus enhances after contrast administration
23,24,36–38
and is generally heterogeneous in appearance, whereas
bland thrombus is uniformly dark on all precontrast and
postcontrast sequences (Figures16.23 and 16.33). Several
recent studies have compared MRI with multidetector CT
for the vascular staging of renal cell carcinoma and have
generally found both techniques to be highly accurate.
37,38
Both MRI and CT are commonly used to screen potential
living renal transplant donors: the number and location of
renal arteries and veins are important in surgical planning.
MRV in conjunction with MRA can answer these questions effectively, without exposing patients to iodinated
contrast and ionizing radiation.
39
16.3.3.4 Portal, hepatic, and mesenteric veins
The portal, hepatic, and mesenteric veins are well visualized during standard abdominal MRI; thrombosis can
easily be detected, and often the underlying cause elucidated. MRI is an excellent technique for the detection and
characterization of hepatic masses, and invasion of hepatic
or portal veins is usually well seen (Figure16.34). Varices
in the setting of portal hypertension can be demonstrated
and the direction of portal venous ow determined using
phase-contrast techniques.
40
Sonography is the primary
technique used to assess for vascular complications following hepatic transplantation. MRI is a useful secondary examination technique when sonography is limited
or indeterminate. Portal vein and IVC anastomoses can
be directly visualized and stenosis or thrombosis detected.
Computed tomographic angiography (CTA) is probably
slightly more sensitive for the detection of arterial complications; however, MRI excels at the assessment of the biliary tree and hepatic parenchyma. Some authors have also
advocated the use of phase-contrast techniques in patients
with suspected chronic mesenteric ischemia, demonstrating
a lack of normal increased ow in the superior mesenteric
vein following a fatty meal.
16.3.3.5 Iliac and lower extremity veins
Deep vein thrombosis (DVT) is a fairly common problem,
with approximately 260,000 cases diagnosed in the United
States every year. The diagnosis is most often made with
duplex sonography, which is usually highly accurate for the
detection of femoral and popliteal DVT, but is somewhat
limited in the evaluation of pelvic and calf veins, obese
patients, and chronic asymptomatic thrombus.
Several studies have demonstrated the effectiveness
of MRV for detecting pelvic and lower extremity venous
168 Chapter 16 Computed tomography and MRI in venous disease
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16.33 Renal cell carcinoma (asterisk) with tumor thrombus and bland thrombus. (a) Coronal fat-saturated steady-state free preces-
sion image reveals a right renal mass with expansion of the renal vein and IVC and absence of the normal bright blood signal within
these vessels. Note the difference between the more heterogeneous and higher signal intensity tumor thrombus extending superiorly
(arrows) and the bland thrombus in the IVC below the level of the renal vein (arrowhead).
3D spoiled gradient echo images show similar ndings, with enhancing, heterogeneous tumor thrombus at the level of the left renal
vein (arrow in b) and uniform, nonenhancing bland thrombus more inferiorly (arrowhead).
thrombosis.
(b, c) Axial contrast-enhanced fat-saturated
19,20,27,41–43
Carpenter et al.19 reported a sensitivity of 100% and a specicity of 96% for the evaluation of
DVT from the IVC to the popliteal vein compared with 2D
time-of-ight MRV and conventional venography. Evans et
20
found MRV to be more sensitive than sonography, but
al.
of equivalent specicity for femoropopliteal DVT. More
recently, Fraser et al.
41
employed a CE subtraction technique to evaluate femoral and iliac veins for DVT, nding
sensitivity and specicity values of 100% in comparison to
conventional venography. Ruehm et al.
42
achieved excellent image quality in a CE direct MRV study of the lower
extremity veins.
Although noncontrast techniques have proved sensitive
and specic in several studies, their acquisition times can
16.34 Inltrative hepatocellular carcinoma (HCC) predomi-
nantly involving the portal vein. Axial venous phase post-gadolinium 3D spoiled gradient recalled echo image demonstrates
expansion of the main and peripheral portal veins with heterogeneously enhancing tumor (arrowheads).
be quite long, potentially reducing patient cooperation and
image quality—the major advantage of the CE methods is
probably the much shorter acquisition and reduced total
examination times (Figures 16.28 and 16.35). An additional advantage of MR and CT venography compared
16.3 Imaging technologies: MRI of venous disease 169
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16
16.35 Supercial venous thrombosis in the calf. (a, b) Coronal
and (c) axial contrast-enhanced fat-saturated 3D spoiled gradient echo images reveal lling defects in bilateral veins (arrowheads), surrounded by inammatory enhancement of the vessel
walls and adjacent muscle.
with conventional venography in the evaluation of iliac
and lower extremity veins is the excellent soft tissue detail
inherent in these techniques, which can provide insight into
the cause of venous thrombosis (Figure16.36).
16.3.3.6 Specific syndromes and special situations
May–Thurner syndrome represents symptomatic stenosis
or thrombosis of the left common iliac vein by the overlying right common iliac artery. MRA/MRV can show the
course of both the iliac arteries and veins (Figure16.37).
16.36 Ewing sarcoma with venous extension. (a, b) Axial con-
trast-enhanced fat-saturated spoiled gradient echo images
reveal a mass in the right iliac bone with extension into the
adjacent muscle. Note the enlarged right internal iliac vein lled
with tumor thrombus (arrowhead in a) and bland thrombus
in the external iliac vein at a lower level (arrowhead in b). (c)
Coronal 3D spoiled gradient echo image again demonstrates
tumor thrombus in the right common iliac vein (arrow) and bland
thrombus in the lower external iliac and common femoral vein
(arrowhead).
Nutcracker syndrome describes compression of the left
renal vein between the abdominal aorta and superior mesenteric artery, with resultant development of venous varicosities adjacent to the left kidney and ureter and dilatation
170 Chapter 16 Computed tomography and MRI in venous disease
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of the left gonadal vein (Figure16.38). Demonstration of
these ndings is most easily accomplished with coronal CE
MRA/MRV.
pain associated with pelvic venous congestion and incompetent, dilated ovarian veins. Standard CE or noncontrast
pulse sequences can demonstrate prominent parametrial
pelvic veins, which is a relatively nonspecic nding.
Time-resolved MRA has been proposed as an additional
technique, with demonstration of contrast reux from the
renal veins into the dilated, incompetent ovarian veins.
thrombotic (Paget–Schroetter syndrome) or nonthrombotic
(McCleery syndrome) compression of the subclavian veins.
Sonography is often adequate for diagnosis; however, MRV
is useful in equivocal cases. Images can be acquired with
provocative maneuvers (Figure16.39).
16.3.3.7 Venous and arteriovenous malformations
Arteriovenous malformations exhibit rapid lling from
feeding arteries with immediate visualization of draining
veins. Time-resolved CE MRV acquisitions are helpful in
16.37 May–Thurner syndrome. Coronal volume-rendered
image from 3D contrast-enhanced MRA/MRV demonstrates
focal thrombosis of the left common iliac vein (arrow) distal to
the overlying right common iliac artery.
order to fully depict the anatomy of these lesions. Venous
malformations may ll slowly, and delayed acquisitions
can be helpful for appreciating the extent of the lesions.
Pelvic congestion syndrome describes chronic pelvic
44
Venous thoracic outlet syndrome occurs with chronic
(c)
)
16.38 Nutcracker syndrome. Axial (a) and sagittal (b) reformatted images from 3D contrast-enhanced MRV demonstrate
marked compression and narrowing of the left renal vein by the overlying superior mesenteric artery (arrows). Coronal oblique
volume-rendered image
varicocele.
(c) again shows focal compression of the left renal vein, as well as a dilated left gonadal vein and small
16.3 Imaging technologies: MRI of venous disease 171
(a)
(b
(a)
(b
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16
)
)
16.39 Venous thoracic outlet syndrome. Volume-rendered image
from a contrast-enhanced thoracic venogram with the arms in
a neutral position (a) demonstrating normal appearance of the
thoracic veins. Volume-rendered image with the arms elevated
(b) reveals severe stenosis of the subclavian veins bilaterally
(arrows), as well as stenosis of the left subclavian artery (arrowhead).
16.3.3.8 Postoperative imaging
MRV can be very useful for assessing complications following venous surgery (Figure16.40), although visualization of
the vessel lumen may be limited following stent placement.
16.3.4 MRversus CT venography
The major advantages of CT with respect to MRare its
speed and spatial resolution. Large volumes can be covered
in only a few seconds with state-of-the-art multidetector
CT scanners, with an isotropic spatial resolution of less
than 1mm. Standard acquisition times for 3D SPGR MRV
sequences are generally between 10 and 20 seconds, which
is occasionally problematic for patients who are short of
breath. The in-plane spatial resolution for typical MRV
acquisitions is ≤1mm; however, slice thickness is generally
in the range of 2–4mm—signicantly increased compared
to CT, but generally adequate for most applications. CT is
also preferable in patients with claustrophobia, pacemakers, or other contraindications to MR.
16.40 Stenosis of a femoral–femoral venous bypass graft in a
patient with chronic left iliac vein thrombosis. Volume-rendered
image from contrast-enhanced MRV (a) demonstrates extensive venous collateral vessels near the left-sided anastomosis. Filling defect in the inferior vena cava (arrow) represents
an occluded left common iliac vein stent. Subvolume volume-rendered image (b) with the collateral veins removed
reveals multiple stenoses near the left-sided anastomosis and
within the graft (arrowheads). Asurgical arteriovenous stula
(arrow) has been placed to improve ow within the graft and the
stenoses were later repaired.
172 Chapter 16 Computed tomography and MRI in venous disease
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On the other hand, MRis a much more exible technique, with numerous noncontrast and CE methods relying on different contrast mechanisms, so that more choices
are available in difcult cases. In general, CNRs of venous
blood are signicantly higher with MRI, although SNRs
are occasionally lower. MRV is preferred in patients with
allergies to iodinated contrast or renal insufciency. MRV
is also the test of choice in patients without venous access,
since many noncontrast techniques are available with MRI
3D FSE pulse sequences.
background suppression and enable 3D reconstructions
that are very similar in appearance to those obtained from
3D CE MRA and have been shown to be as accurate or
nearly as accurate as standard 3D CE MRA in a variety of
situations, such as assessment of renal artery stenosis. The
same techniques can be applied to venography, and it is
likely that similar success will be achieved in noncontrast
venous imaging.
31,46,47
These methods have robust
and not with CT. Radiation dose is also a consideration,
particularly in pediatric or pregnant patients or other radiation-sensitive populations (Table16.1).
16.4 SUMMARY
16.3.5 Future prospects
The recognition that gadolinium-based contrast agents
could cause nephrogenic systemic brosis (NSF) when
administered to patients with severe renal insufciency has
led to the development of several robust noncontrast MRA
techniques, the most common of which employ 3D SSFP or
TABLE 16.1 Advantages and disadvantages of computed tomography and magnetic resonance imaging for the
evaluation of venous disease
Advantages Disadvantages
Computed tomography Speed
Superior spatial resolution
Calcications
Magnetic resonance imaging No radiation exposure Contraindications
No iodinated contrast Pacemaker
Multiple acquisitions possible Aneurysm clips
Superior contrast resolution Claustrophobia
CT and MRare both effective tools for answering a large
number of clinical questions regarding the venous system.
Each technique has unique advantages and disadvantages,
as outlined earlier. Advances in each technology will continue to provide optimal imaging evaluation for a wide
variety of venous disorders.
Iodinated contrast
Radiation
Consensus Statements 16.0 of the American Venous Forum on computed tomography (CT) and magnetic resonance
imaging (MRI) in venous disease
No. Consensus Statement
16.1 CT with intravenous contrast should be performed to evaluate obstruction of large veins in the chest, abdomen, and pelvis.
CT accurately depicts the underlying pathology and conrms extrinsic compression, tumor invasion, traumatic disruption,
anatomic variations, extent of thrombus, and position of a caval lter.
16.2 CT with intravenous contrast should be performed to diagnose pulmonary embolism. Sensitivity and specicity approach
100% for central emboli, whereas for small, subsegmental pulmonary emboli, sensitivity and specicity are 83% and 96%,
respectively.
16.3 Magnetic resonance venography (MRV) is helpful to conrm the diagnosis of acute iliofemoral and caval deep vein thrombosis. Asensitivity of 100% and specicity of 96% were reported. The study is useful for the diagnosis of portal, splenic, or
mesenteric venous thrombosis.
16.4 MRI and MRV are highly accurate for imaging inferior vena cava thrombus associated with renal, adrenal, retroperitoneal,
primary caval, or metastatic malignancies. MRV reveals the presence or absence of bland thrombus or tumor thrombus in
the renal veins and inferior vena cava.
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