IMAGING VIGNETTE Intraluminal Assessment of Coronary Arteries With Ferumoxytol-Enhanced Magnetic Resonance Angiography Matthew S. Chin, MD, a Michael Steigner, MD, b Wenqing Yin, MD, PHD, c Raymond Y. Kwong, MD, MPH, c Andrew M. Siedlecki, MD c DIAGNOSTIC ANGIOGRAPHY IS SOMETIMES INEVITABLE IN PATIENTS WITH ESTIMATED GLOMERULAR filtration rate (eGFR) of <30 ml/min/1.73 m 2 who are not yet on dialysis. However, iodine- or gadolinium-based contrast 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 but anaphylactic reactions have been described. We present a brief pictorial overview of our experience of its use in 5 patients (Figures 2 to 5, Online Videos) for assessing the coronary artery tree without complications. FIGURE 1 3-Dimensional Reconstruction of the Heart After Intravenous Ferumoxytol Injection and Image Acquisition Using cMRA and Cardiac/Respiratory Gating and Ventricular Wall Subtraction A B C (A) Four-chamber view, clockwise: main pulmonary artery, descending thoracic aorta, left ventricular chamber, right ventricular chamber, and ascending thoracic aorta. (B) Sagittal reconstruction with visualization of left coronary artery (arrow) and overlying main pulmonary artery. (C) Multiplanar reconstruction of the coronary tree viewed superior to inferior showing distribution of right coronary, left main continuous with left anterior descending artery, and left circumflex beginning at the level of the ascending aorta (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 a Department of Radiology, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, Pennsylvania; b Department of Radiology, Brigham and Women’s Hospital, Boston, Massachusetts; and the c Department 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. JACC: CARDIOVASCULAR IMAGING VOL. 11, NO. 3, 2018 ª 2018 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION PUBLISHED BY ELSEVIER
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FIGURE 1 3-Dimen
Cardiac/Respiratory
A
(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,c
Andrew 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.
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
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
508
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.