Endovascular interventional magnetic resonance imaging

Magnetic Resonance Techniques in Hemodialysis access Management

In this review we describe current applications and future perspectives of MR angiography, MR flow quantification, and interventional MRI in hemodialysis access management. Each section starts with a brief overview of the main techniques that are currently available or under development. This is followed by a survey of the pertinent literature. Each section concludes with a discussion of the reported findings and an indication of research opportunities.

Design of catheter radio frequency coils using coaxial transmission line resonators for interventional neurovascular MR imaging

BACKGROUND

It is technically challenging to design compact yet sensitive miniature catheter radio frequency (RF) coils for endovascular interventional MR imaging.

METHODS

In this work, a new design method for catheter RF coils is proposed based on the coaxial transmission line resonator (TLR) technique. Due to its distributed circuit, the TLR catheter coil does not need any lumped capacitors to support its resonance, which simplifies the practical design and construction and provides a straightforward technique for designing miniature catheter-mounted imaging coils that are appropriate for interventional neurovascular procedures. The outer conductor of the TLR serves as an RF shield, which prevents electromagnetic energy loss, and improves coil Q factors. It also minimizes interaction with surrounding tissues and signal losses along the catheter coil. To investigate the technique, a prototype catheter coil was built using the proposed coaxial TLR technique and evaluated with standard RF testing and measurement methods and MR imaging experiments. Numerical simulation was carried out to assess the RF electromagnetic field behavior of the proposed TLR catheter coil and the conventional lumped-element catheter coil.

RESULTS

The proposed TLR catheter coil was successfully tuned to 64 MHz for proton imaging at 1.5 T. B₁ fields were numerically calculated, showing improved magnetic field intensity of the TLR catheter coil over the conventional lumped-element catheter coil. MR images were acquired from a dedicated vascular phantom using the TLR catheter coil and also the system body coil. The TLR catheter coil is able to provide a significant signal-to-noise ratio (SNR) increase (a factor of 200 to 300) over its imaging volume relative to the body coil.

CONCLUSIONS

Catheter imaging RF coil design using the proposed coaxial TLR technique is feasible and advantageous in endovascular interventional MR imaging applications.

Real-Time MRI-Guided Catheter Tracking Using Hyperpolarized Silicon Particles

Visualizing the movement of angiocatheters during endovascular interventions is typically accomplished using x-ray fluoroscopy. There are many potential advantages to developing magnetic resonance imaging-based approaches that will allow three-dimensional imaging of the tissue/vasculature interface while monitoring other physiologically-relevant criteria, without exposing the patient or clinician team to ionizing radiation. Here we introduce a proof-of-concept development of a magnetic resonance imaging-guided catheter tracking method that utilizes hyperpolarized silicon particles. The increased signal of the silicon particles is generated via low-temperature, solid-state dynamic nuclear polarization, and the particles retain their enhanced signal for ≥ 40 minutes--allowing imaging experiments over extended time durations. The particles are affixed to the tip of standard medical-grade catheters and are used to track passage under set distal and temporal points in phantoms and live mouse models. With continued development, this method has the potential to supplement x-ray fluoroscopy and other MRI-guided catheter tracking methods as a zero-background, positive contrast agent that does not require ionizing radiation.

Comparing deflection measurements of a magnetically steerable catheter using optical imaging and MRI

PURPOSE

Magnetic resonance imaging (MRI) is an emerging modality for interventional radiology, giving clinicians another tool for minimally invasive image-guided interventional procedures. Difficulties associated with endovascular catheter navigation using MRI guidance led to the development of a magnetically steerable catheter. The focus of this study was to mechanically characterize deflections of two different prototypes of the magnetically steerable catheter in vitro to better understand their efficacy.

METHODS

A mathematical model for deflection of the magnetically steerable catheter is formulated based on the principle that at equilibrium the mechanical and magnetic torques are equal to each other. Furthermore, two different image based methods for empirically measuring the catheter deflection angle are presented. The first, referred to as the absolute tip method, measures the angle of the line that is tangential to the catheter tip. The second, referred to the base to tip method, is an approximation that is used when it is not possible to measure the angle of the tangent line. Optical images of the catheter deflection are analyzed using the absolute tip method to quantitatively validate the predicted deflections from the mathematical model. Optical images of the catheter deflection are also analyzed using the base to tip method to quantitatively determine the differences between the absolute tip and base to tip methods. Finally, the optical images are compared to MR images using the base to tip method to determine the accuracy of measuring the catheter deflection using MR.

RESULTS

The optical catheter deflection angles measured for both catheter prototypes using the absolute tip method fit very well to the mathematical model (R(2) = 0.91 and 0.86 for each prototype, respectively). It was found that the angles measured using the base to tip method were consistently smaller than those measured using the absolute tip method. The deflection angles measured using optical data did not demonstrate a significant difference from the angles measured using MR image data when compared using the base to tip method.

CONCLUSIONS

This study validates the theoretical description of the magnetically steerable catheter, while also giving insight into different methods and modalities for measuring the deflection angles of the prototype catheters. These results can be used to mechanically model future iterations of the design. Quantifying the difference between the different methods for measuring catheter deflection will be important when making deflection measurements in future studies. Finally, MR images can be used to reliably measure deflection angles since there is no significant difference between the MR and optical measurements.

Optimizing contrast agent concentration and spoiled gradient echo pulse sequence parameters for catheter visualization in MR-guided interventional procedures: an analytic solution

PURPOSE

A critical requirement of MR-guided interventions is the visualization of an instrument (e.g., catheter, needle) during the procedure. One approach is to fill the instrument with a contrast agent. Previously, the optimization of contrast agent visualization was performed only empirically. In the present study, an analytic optimization of contrast agent SNR efficiency was performed for a spoiled gradient echo pulse sequence.

METHODS

Optimal flip angle, repetition time, echo time, and contrast agent concentration were derived analytically. The solution is valid for any contrast agent, provided the relationship between T1 , T2 , and doping concentration is known.

RESULTS

Phantom experiments validated the analytic optimization for Gd- and MnCl2 -based contrast agents. Results showed excellent agreement between experimentally predicted and theoretically observed magnetization behavior. In vivo experiments demonstrated optimized contrast agent visualization in brain, heart, and prostate applications. The results demonstrated the large SNR that can be achieved with analytic optimization. As a practical guideline, an 11% dilution of 500 mMol/L Gd-DTPA solution, repetition time ≈ 4 ms, echo time ≈ 1 ms, and θ ≈ 65° was found to provide a large SNR.

CONCLUSION

This study derived and validated a method for analytically optimizing contrast agent SNR efficiency. This information may be useful for visualizing instruments during MR-guided interventions.

Toward true 3D visualization of active catheters using compressed sensing

A crucial requirement in MR-guided interventions is the visualization of catheter devices in real time. However, true 3D visualization of the full length of catheters has hitherto been impossible given scan time constraints. Compressed sensing (CS) has recently been proposed as a method to accelerate MR imaging of sparse objects. Images acquired with active interventional devices exhibit a high CNR and are inherently sparse, therefore rendering CS ideally suited for accelerating data acquisition. A framework for true visualization of active catheters in 3D is proposed employing CS to gain high undersampling factors making real-time applications feasible. Constraints are introduced taking into account prior knowledge of catheter geometry and catheter motion over time to improve and accelerate image reconstruction. The potential of the method is demonstrated using computer simulations and phantom experiments and in vivo feasibility is demonstrated in a pig experiment.

MR-guided intravascular interventions: techniques and applications

Magnetic resonance imaging (MRI) offers several advantages over other imaging modalities that make it an attractive imaging tool for diagnostic and therapeutic procedures. This tremendous potential of MRI has provided the rationale for increased attention toward MR-guided endovascular interventions. MR guidance has been used recently to navigate endovascular catheters and deliver stents, vena cava filters, embolization materials, and septum closure devices. However, its potential goes beyond just copying existing procedures toward the development of new minimally invasive techniques that cannot be performed with conventional guiding techniques. Because of technical limitations and safety issues associated with some of the currently available devices, a limited number of clinical studies have been performed so far. The overall success for this developing field requires considerable interdisciplinary research within both the interventional and the MR community. Only through a combined effort can this complex technology find its way into clinical practice. This review discusses the hardware and software improvements that have helped to advance endovascular interventions under MR imaging guidance from a pure research tool to become a clinical reality. In addition, technical and safety issues specific to endovascular MR image guidance will be described and practical applications will be shown that take advantage of the benefits of MR for endovascular interventions.

In vivo MR-tracking based on magnetic signature selective excitation

A novel magnetic resonance (MR)-tracking method specifically developed to locate the ferromagnetic core of an untethered microdevice, microrobot, or nanorobot for navigation or closed-loop control purpose is described. The tracking method relies on the application of radio-frequency (RF) excitation signals tuned to the equipotential magnetic curves generated by the magnetic signature of the object being tracked. Positive contrast projections are obtained with reference to the position of the magnetic source. A correlation function performed on only one k-space line for each of the three axes and corresponding to three projections, is necessary to obtain a 3-D location of the device. In this study, the effects of the sphere size and the RF frequency offset were investigated in order to find the best contrast noise ratio (CNR) for tracking. Resolution and precision were also investigated by proper measurement of the position of a ferromagnetic sphere by magnetic resonance imaging (MRI) acquisition and by comparing them with the real position. This method is also tested for a moving marker where the positions found by MRI projections were compared with the ones taken with a camera. In vitro and in vivo experiments show the operation of the technique in tortuous phantom and in animal models. Although the method was developed in the prospect of new interventional MR-guided endovascular operations based on miniature untethered devices, it could also be used as a passive tracking method using tools such as catheters or guide wires.

Magnetic resonance imaging of phase transitions in nitinol

Magnetic resonance images are prone to artifacts caused by metallic objects. Apart from being a source of image degradation, such artifacts can also provide information about the magnetic properties of the foreign object. In this work, we aim to explore the potential of magnetic resonance imaging to detect and characterize changes in magnetic properties of nitinol undergoing temperature- or strain-induced phase changes. A spin echo and a gradient echo method were used to measure the magnetization changes related to the phase transformations. Results of both methods were in agreement and in accordance with the independent measurements using a vibrating sample magnetometer. Magnetic resonance imaging turned out to be a suitable method to visualize and quantify magnetization and phase changes in situ. It is not restricted to a single imaging strategy and does not require any modification of the test object. The results indicate the potential of magnetic resonance imaging to provide direct feedback of the thermomechanical state of the alloy.

Preliminary Results of Nonfluoroscopy-based 3D Navigation for Neurointerventional Procedures

PURPOSE

To investigate the capabilities of a neurovascular navigation prototype in phantom experiments.

MATERIALS AND METHODS

The proposed navigation system integrates three-dimensional (3D) visualization of the anatomy and real-time electromagnetic localization of the endovascular tools. A 3D model of an endovascular phantom was reconstructed from thresholded preprocedural computed tomographic (CT) data. The vascular model was aligned with the reference frame of an electromagnetic tracker by using paired-point matching based on eight external fiducials. The robustness and accuracy of the registration were evaluated in 29 experiments. A magnetically tracked catheter was inserted into the carotid artery of the phantom, and the navigation system was used to reach five predefined vascular landmarks. The spatial accuracy of the prototype was evaluated during 50 endovascular targeting attempts.

RESULTS

The navigation system achieved accurate co-registration of the location of a catheter inside a 3D reconstruction of a phantom vasculature. The experiments demonstrated the robustness of the registration, with a standard deviation for the translation and rotation components of 0.7 mm and 0.3 degrees , respectively. The maximal average error on the fiducials was 3.2 mm. Endovascular navigation by using the 3D real-time display was successfully performed with a mean overall accuracy of 2.7 mm +/- 0.7 and no projection limitation.

CONCLUSION

The authors developed a navigation system that provides real-time 3D visualization of the position of endovascular components in a neurovascular phantom. The preliminary in vitro experiments showed clinically acceptable accuracy.

Image-guided and -monitored renal artery stenting using only MRI

PURPOSE

To demonstrate the ability of a unique interventional MR system to be used safely and effectively as the only imaging modality for all phases of MR-guided stent-supported angioplasty.

MATERIALS AND METHODS

An experimental disease model of renal stenosis was created in six pigs. An interventional MR system, which employed previously reported tools for real-time catheter tracking with automated scan-plane positioning, adaptive image parameters, and radial true-FISP imaging with steady-state precession (True-FISP) imaging coupled with a high-speed reconstruction technique, was then used to guide all phases of the intervention, including: guidewire and catheter insertion, stent deployment, and confirmation of therapeutic success. Pre- and postprocedural X-ray imaging was used as a gold standard to validate the experimental results.

RESULTS

All of the stent-supported angioplasty interventions were a technical success and were performed without complications. The average postoperative residual stenosis was 14.9%. The image guidance enabled the stents to be deployed with an accuracy of 0.98 +/- 0.69 mm. Additionally, using this interventional MRI system to guide renal artery stenting significantly reduces the procedure time, as compared to using X-ray fluoroscopy.

CONCLUSION

This study has clearly demonstrated the first successful treatment of renal artery stenting in an experimental animal model solely under MRI guidance and monitoring.

MR coronary angiography in pigs with intraarterial injections of a hyperpolarized 13C substance

A new diagnostic application of a water-soluble contrast medium (CM) based on the hyperpolarization of a 13C substance is introduced. The degree of polarization achieved is >30%, which is about a factor of 10(5) higher than the thermal equilibrium polarization level at 1.5 T. Imaging of hyperpolarized (HP) CM during a cardiac interventional MRI procedure was studied. Catheters were positioned in the left and right coronary arteries of pigs. A coil tuned to 13C was used for nonproton imaging. The HP-13C CM ( approximately 5 ml, 0.5 M, approximately 30% polarization) was injected during projection imaging using a fully balanced steady-state free precession (SSFP) pulse sequence with and without cardiac gating. The contrast agent-filled catheter was clearly visible during the procedure. The coronary arteries were well depicted and the signal-to-noise ratios (SNRs) were in the range of 10-40. The use of HP-13C CM may provide a new diagnostic procedure for interventional MRI.

Magnetic resonance imaging of microstructure transition in stainless steel

Magnetic resonance images are prone to artifacts caused by metallic objects. Such artifacts may not only hamper image interpretation, but also have been shown to provide information about the magnetic properties of the substances involved. In this work, we aim to explore the potential of MRI to detect, localize and characterize changes in magnetic properties that may occur when certain alloys have been exposed to a thermomechanical stress. For this purpose, stainless steel 304 L wires were drawn to induce a change from paramagnetic austenitic into ferromagnetic martensitic microstructure. The changes in magnetic behavior were quantified by analyzing the geometric distortion in spin echo and the geometric distortion and intravoxel dephasing in gradient echo images at 0.5, 1.5 and 3 T. The results of both imaging strategies were in agreement and in accordance with independent measurements with a vibrating sample magnetometer. Drawing wire to 2% of its cross-sectional area was found to increase the volume fraction of the ferromagnetic martensite from 0.3% to 80% and to enhance the magnetization up to two or three orders of magnitude. The results demonstrate the potential of MRI to locate and quantify stress-induced changes in the magnetic properties of alloys in a completely noninvasive and nondestructive way.

Development and testing of passive tracking markers for different field strengths and tracking speeds

Susceptibility markers for passive tracking need to be small in order to maintain the shape and mechanical properties of the endovascular device. Nevertheless, they also must have a high magnetic moment to induce an adequate artefact at a variety of scan techniques, tracking speeds and, preferably, field strengths. Paramagnetic markers do not satisfy all of these requirements. Ferro- and ferrimagnetic materials were therefore investigated with a vibrating sample magnetometer and compared with the strongly paramagnetic dysprosium oxide. Results indicated that the magnetic behaviour of stainless steel type AISI 410 corresponds the best with ideal marker properties. Markers with different magnetic moments were constructed and tested in in vitro and in vivo experiments. The appearance of the corresponding artefacts was field strength independent above magnetic saturation of 1.5 T. Generally, the contrast-to-noise ratio decreased at increasing tracking speed and decreasing magnetic moment. Device depiction was most consistent at a frame rate of 20 frames per second.

Fully MR-guided hepatic artery catheterization for selective drug delivery: A feasibility study in pigs

PURPOSE

To demonstrate the feasibility of hepatic catheterization for selective delivery of therapeutic agents using a clinical MRI scanner for real-time image guidance.

MATERIALS AND METHODS

Experiments were performed in three domestic pigs (70-80 kg) using a clinical 1.5-T MR scanner. After abdominal three-dimensional contrast-enhanced MR angiography (3D-CE-MRA) was performed, endovascular devices with susceptibility markers were tracked with passive tracking techniques. Catheters were maneuvered into the primary and secondary hepatic arteries. Selective catheterization was verified using selective time-resolved CE angiography. Paramagnetic microspheres were administered to a different region for each liver. The resulting biodistributions were investigated using MR images.

RESULTS

Successful selective hepatic catheterization was repeatedly demonstrated using passive tracking techniques. 3D-CE-MRA significantly aided the interventional procedure by showing the vascular anatomy, and maximum-intensity projections (MIPs) were used as roadmaps during the interventions. In all cases, microspheres were successfully delivered to the selected regions. The catheters were visualized at a maximum frame rate of five frames per second, allowing a good depiction of the devices and a reliable catheterization of the hepatic arteries.

CONCLUSION

Fully MR-guided real-time navigation of endovascular devices permits complex procedures such as selective intra-arterial delivery of therapeutic agents to parts of the liver.

A Faraday effect position sensor for interventional magnetic resonance imaging

An optical sensor is presented which determines the position and one degree of orientation within a magnetic resonance tomograph. The sensor utilizes the Faraday effect to measure the local magnetic field, which is modulated by switching additional linear magnetic fields, the gradients. Existing methods for instrument localization during an interventional MR procedure often use electrically conducting structures at the instruments that can heat up excessively during MRI and are thus a significant danger for the patient. The proposed optical Faraday effect position sensor consists of non-magnetic and electrically non-conducting components only so that heating is avoided and the sensor could be applied safely even within the human body. With a non-magnetic prototype set-up, experiments were performed to demonstrate the possibility of measuring both the localization and the orientation in a magnetic resonance tomograph. In a 30 mT m(-1) gradient field, a localization uncertainty of 1.5 cm could be achieved.

Magnetic resonance imaging-guided vascular interventions

Magnetic resonance imaging (MRI), which provides superior soft-tissue imaging and no known harmful effects, has the potential as an alternative modality to guide various medical interventions. This review will focus on MR-guided endovascular interventions and present its current state and future outlook. In the first technical part, enabling technologies such as developments in fast imaging, catheter devices, and visualization techniques are examined. This is followed by a clinical survey that includes proof-of-concept procedures in animals and initial experience in human subjects. In preclinical experiments, MRI has already proven to be valuable. For example, MRI has been used to guide and track targeted cell delivery into or around myocardial infarctions, to guide atrial septal puncture, and to guide the connection of portal and systemic venous circulations. Several investigational MR-guided procedures have already been reported in patients, such as MR-guided cardiac catheterization, invasive imaging of peripheral artery atheromata, selective intraarterial MR angiography, and preliminary angioplasty and stent placement. In addition, MR-assisted transjugular intrahepatic portosystemic shunt procedures in patients have been shown in a novel hybrid double-doughnut x-ray/MRI system. Numerous additional investigational human MR-guided endovascular procedures are now underway in several medical centers around the world. There are also significant hurdles: availability of clinical-grade devices, device-related safety issues, challenges to patient monitoring, and acoustic noise during imaging. The potential of endovascular interventional MRI is great because as a single modality, it combines 3-dimensional anatomic imaging, device localization, hemodynamics, tissue composition, and function.

A safe transmission line for MRI

Magnetic resonance imaging (MRI) has been established as a reliable and safe imaging method for the human body. However, electric conductors, such as cables situated near or in the human body, should be avoided because induced currents in the cables can cause hazardous heating in the surrounding tissue. In this paper, a new principle for the design of a transmission line is introduced and demonstrated, which is capable of avoiding dangerous heating of cables. The principle is based on transformers placed along the line, splitting the long line into several short not resonant and thus safe sections. A transformer design is introduced along with the theoretical aspects for both the avoidance of the undesired induced currents and the reduction of signal attenuation. Furthermore, the design fulfills the geometrical requirements of the side lumen of a standard catheter. Matching networks, whose elements are determined by power matching, are used to reduce signal attenuation by the transformers. A prototype was built to validate both theory and the simulations. As demonstrated in this work, it is possible to build safe transmission lines for MRI, making applications such as active catheter tracking possible. We expect that even new applications, such as safe intravascular imaging will be possible in a safe manner in the future.

Invasive human magnetic resonance imaging: feasibility during revascularization in a combined XMR suite

We tested the feasibility and safety of invasive magnetic resonance imaging (MRI) during peripheral angioplasty. Real-time MRI can image soft tissue and may potentially guide therapeutic procedures without ionizing radiation or nephrotoxic contrast. MRI-guided diagnostic catheterization has been described recently, but safe and conspicuous catheter devices are not widely available. An active guidewire, which serves as an MRI receiver antenna, might be useful to guide catheterization or even to image atheroma. We describe a combined interventional suite offering both X-ray fluoroscopy and real-time MRI. We used a 0.030'' active guidewire receiver coil for invasive MRI after X-ray lesion traversal in patients undergoing percutaneous iliofemoral artery revascularization. Intravascular MRI was compared with noninvasive MRI, X-ray angiography, and intravascular ultrasound (IVUS). Seven eligible patients consented to participate, but three were excluded because of lengthy revascularization procedures. Four remaining patients safely underwent combined X-ray fluoroscopy and real-time magnetic resonance imaging (XMR) transport, continuous monitoring, and all imaging modalities. There was no device dislodgment, contamination or evidence of heating. The intravascular MRI coil was well visualized except at the tip, but did not provide superior mural imaging compared with IVUS. Therefore, because an adequate safety and workflow experience was obtained, enrollment was terminated after only four subjects. Invasive MRI is feasible and apparently safe during peripheral angioplasty. Patients can safely be transported and monitored in an XMR interventional suite. An active quarter-wavelength guidewire coil does not provide superior imaging compared with IVUS, but provides satisfactory guidewire visualization. These tools may prove useful for advanced therapeutic procedures in the future.

Interventional and intraoperative MR: review and update of techniques and clinical experience

The concept of interventional magnetic resonance imaging (MRI) is based on the integration of diagnostic and therapeutic procedures, favored by the combination of the excellent morphological and functional imaging characteristics of MRI. The spectrum of MRI-assisted interventions ranges from biopsies and intraoperative guidance to thermal ablation modalities and vascular interventions. The most relevant recently published experimental and clinical results are discussed. In the future, interventional MRI is expected to play an important role in interventional radiology, minimal invasive therapy and guidance of surgical procedures. However, the associated high costs require a careful evaluation of its potentials in order to ensure cost-effective medical care.

Verbal communication in MR environments: effect of MR system acoustic noise on speech understanding

PURPOSE

To assess the masking effect of magnetic resonance (MR)-related acoustic noise and the effect of passive hearing protection on speech understanding.

MATERIALS AND METHODS

Acoustic recordings were made at 1.5 T at patient and operator (interventionalist in the MR suite) locations for relevant pulse sequences. In an audiologic laboratory, speech-to-noise ratios (STNRs) were determined, defined as the difference between the absolute sound pressure levels of MR noise and speech. The recorded noise of the MR sequences was played simultaneously with the recorded sentences at various intensities, and 15 healthy volunteers (seven women, eight men; median age, 27 years) repeated these sentences as accurately as possible. The STNR that corresponded with a 50% correct repetition was used as the measure for speech intelligibility. In addition, the effect of passive hearing protection on speech intelligibility was tested by using an earplug model.

RESULTS

Overall, speech understanding was reduced more at operator than at patient location. Most problematic were fast gradient-recalled-echo train and spiral k-space sequences. As the absolute sound pressure level of these sequences was approximately 100 dB at patient location, the vocal effort needed to attain 50% intelligibility was shouting (>77 dB). At operator location, less effort was required because of the lower sound pressure levels of the MR noise. Fast spoiled gradient-recalled-echo and echo-planar imaging sequences showed relatively favorable results with raised voice at operator location and loud speaking at patient location. The use of hearing protection slightly improved STNR.

CONCLUSION

At 1.5 T, the level of MR noise requires that large vocal effort is used, at the operator and especially at the patient location. Depending on the specific MR sequence used, loud speaking or shouting is needed to achieve adequate bidirectional communication with the patient. The wearing of earplugs improves speech intelligibility.