1. MRA of Abdominal Aortic Aneurysms Martin R. Prince, MD, PhD www.Mrprotocols.com

2. AAA Definition Normal Abdominal Aorta = 1.4-2.1 cm* Aneurysmal Abdominal Aorta > 3 cm* *measure outer wall to outer wall 6.9 cm www.Mrprotocols.com

3. AAA Natural History Expansion rate = 2-4 mm/year –Larger aneurysms expand faster than small diameter aneurysms –> 5mm in 6 months  risk of rupture Risk of Rupture (over 5 years) < 4 cm2%follow 4-5 cm3-12% +/- repair > 5 cm25-41%repair 9.2 cm www.Mrprotocols.com

4. Imaging AAA Ultrasound- screening and following CT- suspected rupture - following with precision MRA- pre-operative planning - following with precision Angio- contraindication to MR - resolving issues - stent graft placement Ultrasound www.Mrprotocols.com

5. AAA Surgical Mortality Elective:4% 6% w/ late complications Ruptured:49% (23%-69%) CT shows aortic rupture www.Mrprotocols.com

6. AAA MRA Technique Sag T1 or SSFSE7 min Coronal 3D Gd MRA 30s x 3 Axial 2D TOF post Gd7 min Axial 3D PC (Venc = 30 cm/sec)8min Total imaging time~24 minutes Sequences Time Sag T1 www.Mrprotocols.com

7. 3D Gd MRA Gd dose = 40 ml Gd bolus timing is critical SmartPrep  8 sec image acquisition delay 3 mm slices: Zip  1.5mm Include iliac arteries Exclude anterior part of AAA www.Mrprotocols.com

8. Check iliac Artery Position www.Mrprotocols.com

9. Axial 2D Time of Flight Post Gd Thick slices 4 NEX Respiratory compersation No saturation pulse Cover from celiac to femoral head Use large Gap (10-20 cm) www.Mrprotocols.com

10. Axial 3D PC Post Gd 2.5 mm slice thickness encode in all 3 directions Venc = 30 cm/sec reconstruct overlapping axial MIPs www.Mrprotocols.com

11. AAA Surgical Planning Issues Proximal extent: classification Distal Extent Size Character –inflammatory –shaggy Associated Aneurysms Occlusive Disease Anatomic Variants www.Mrprotocols.com

12. AAA Classification Thoraco abdominal suprarenal pararenal juxtarenal infrarenal Thick MIPThinner MIP www.Mrprotocols.com

13. Suprarenal AAA Aneurysm ends above celiac Sag Oblique MIP www.Mrprotocols.com

14. AAA Classification Thoraco abdominal suprarenal pararenal juxtarenal infrarenal Coronal MIP Sagittal MIP www.Mrprotocols.com

15. Pararenal Coronal MIP Sagittal MIP Axial MIP Renal artery arises from aneurysm www.Mrprotocols.com

16. AAA Classification Thoraco abdominal suprarenal pararenal juxtarenal infrarenal Coronal MIP www.Mrprotocols.com

17. Juxtarenal 9mm Aneurysm begins within 1 cm of renal artery origins: Clamp above renals www.Mrprotocols.com

18. AAA Classification Thoraco abdominal suprarenal pararenal juxtarenal infrarenal Thick MIP Thinner MIP www.Mrprotocols.com

19. Infrarenal AAA > 1cm between AAA & renal artery 3.2 cm www.Mrprotocols.com

20. AAA Surgical Planning Issues Proximal extent: classification Distal Extent Size Character –inflammatory –shaggy Associated Aneurysms Occlusive Disease Anatomic Variants www.Mrprotocols.com

21. AAA Surgical Planning Issues Proximal extent: classification Distal Extent Size Character –inflammatory –shaggy Associated Aneurysms Occlusive Disease Anatomic Variants www.Mrprotocols.com

22. AAA Surgical Planning Issues Proximal extent: classification Distal Extent Size Character –inflammatory –shaggy Associated Aneurysms Occlusive Disease Anatomic Variants Retroperitoneal enhancement www.Mrprotocols.com

23. AAA Surgical Planning Issues Proximal extent: classification Distal Extent Size Character –inflammatory –shaggy Associated Aneurysms Occlusive Disease Anatomic Variants www.Mrprotocols.com

24. AAA Surgical Planning Issues Proximal extent: classification Distal Extent Size Character –inflammatory –shaggy –dissecting Associated Aneurysms Occlusive Disease Anatomic Variants www.Mrprotocols.com

25. AAA Surgical Planning Issues Proximal extent: classification Distal Extent Size Character –inflammatory –shaggy Associated Aneurysms Occlusive Disease Anatomic Variants www.Mrprotocols.com

26. Aneurysms associated with AAA thoracic aorta iliac common femoral popliteal renal visceral Coronal MIPSag MIP www.Mrprotocols.com

27. Renal Artery Aneurysms www.Mrprotocols.com

28. AAA Surgical Planning Issues Proximal extent: classification Distal Extent Size Character –inflammatory –shaggy Associated Aneurysms Occlusive Disease Anatomic Variants Coronal MIP www.Mrprotocols.com

29. Post tube graft: iliac aneurysms left renal artery stenosis Coronal MIPMag Coronal thin MIP www.Mrprotocols.com

30. AAA Surgical Planning Issues Proximal extent: classification Distal Extent Size Character –inflammatory –shaggy Associated Aneurysms Occlusive Disease Anatomic Variants www.Mrprotocols.com

31. AAA w/accessory renal arteries www.Mrprotocols.com

32. Retroaortic left renal vein www.Mrprotocols.com

33. Summary MRA for pre-op AAA evaluation Gd is essential No nephrotoxicity Analyze data systematically www.Mrprotocols.com