基于多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列在评估移植肾血管解剖和并发症方面的研究.doc

分 类 号学校代码学号 D20117835010487密级博士学位论文基于多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列在评估移植肾血管解剖和并发症方面的研究学 位 申 请 人 ： 汤浩学 科 专 业 ： 影像医学与核医学指 导 教 师 ： 胡道予 教授答 辩 日 期 ：2014年 3月 A dissertation submitted to Huazhong University of Science and Technology for the Degree of Doctor of Medicine Depiction of Transplant Renal Vascular Anatomy and Complications: Non-contrast Enhanced MR angiography Using Spatial Labeling with Multiple Inversion Pulses Ph.D.Candidate : Tang HaoMajor: Radiology and Nuclear Medicine: Prof. Hu Dao-yuSupervisorHuazhong University of Science & Technology Wuhan 430074, P. R. China March, 2014 独创性声明本人郑重声明，本学位论文是本人在导师指导下进行的研究工作及取得的研究成果的总结。尽我所知，除文中已经标明引用的内容外，本论文不包含任何其他个人或集体已经发表或撰写过的研究成果。对本文的研究做出贡献的个人和集体，均已在文中以明确方式标明。本人完全意识到本人将承担本声明引起的一切法律后果。学位论文作者签名：日期：年月日学位论文版权使用授权书本学位论文作者完全了解学校有关保留、使用学位论文的规定，即：学校有权保留并向国家有关部门或机构送交论文的复印件和电子版，允许论文被查阅和借阅。本人授权华中科技大学可以将本学位论文的全部或部分内容编入有关数据库进行检索，可以采用影印、缩印或扫描等复制手段保存和汇编本学位论文。保密，在_年解密后适用本授权书。本论文属于不保密。（请在以上方框内打“”）学位论文作者签名：指导教师签名：日期：年月日日期：年月日 目录主要缩略词表 1中文摘要 3英文摘要 8正文前言 13第一部分基于多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列（SLEEK）在评估移植肾血管解剖方面的研究 18第二部分基于多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列（SLEEK）在评估移植肾血管并发症方面的研究 31第三部分基于多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列（SLEEK）对移植肾动脉狭窄的评估：与 DSA相对照 48第四部分移植肾动脉 SLEEK扫描中 BSP TI的参数优化 61全文小结 72综述 73附录 99致谢 101 华中科技大学博士学位论文缩略词中英文对照表英文缩略词NCE英文全称non-contrast enhanced中文全称非对比剂增强磁共振血管成像比剂增强MRACEmagnetic resonance angiographycontrast enhancedSLEEKFIESTACTAspatial labeling with multiple inversion pulsesfast imaging employing steady state acquisitioncomputed tomography angiographydigital subtraction angiographytransplant renal artery多翻转脉冲空间标记稳态采集快速成像CT血管成像DSA数字剪影血管造影移植肾动脉TRATRASAVFtransplant renal artery stenosisarteriovenous fistulas移植肾动脉狭窄动静脉瘘PSApseudoaneurysms假性动脉瘤TRVSFMDPPVtransplant renal venous stenosisfibromuscular dysplasia移植肾静脉狭窄肌纤维发育不良阳性预测值positive predictive valueNPVnegative predictive value阴性预测值MRImagnetic resonance imagingnephrogenic systemic fibrosishasContrast-Induced Nephropathy磁共振成像NSF肾源性系统性纤维化对比剂肾病CIN1 华中科技大学博士学位论文BSP TIMIPVRblood suppression inversion timemaximum intensity projectionvolume rendering血液抑制翻转时间最大密度投影容积再现SSFPASLQISSFSDsteady-state free precessionarterial spin labeling稳态自由进动序列动脉自旋标记静态间隔单次激发流动敏感去相位心电门控的快速自旋回波心率quiescent interval single-shotflow-sensitive dephasingelectrocardiograph-gated fast spin echocardiac rateECG-FSECRRRrespiratory rate呼吸频率IRBinstitutional review boardEnd to end机构审查委员会端-端E-EE-SEnd to Side端-侧2 华中科技大学博士学位论文基于多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列在评估移植肾血管解剖和并发症方面的研究博士研究生:汤浩指导教师:胡道予教授华中科技大学同济医学院同济医院放射科中文摘要第一部分 :基于多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列（SLEEK）在评估移植肾血管解剖方面的研究目的：评估基于多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列（SLEEK）在显示移植肾血管解剖方面的价值，并和彩色多普勒超声（CDUS）及术中记录结果进行对照。材料和方法：应用 GE公司 1.5T HD MR扫描仪对 75名行肾移植手术后临床需要排除血管并发症的患者进行彩色多普勒超声扫描及非对比剂增强磁共振血管成像扫描，所有患者检查前均签署知情同意书。由两名放射科专家对 SLEEK显示移植肾血管解剖结构进行评估，并将 SLEEK结果与彩色多普勒超声及术中记录结果进行对照。结果：总共 75名肾移植患者，所有患者均成功进行了 SLEEK扫描及彩色多普勒超声扫描。有三名患者移植了两个肾脏，总共有 78例移植肾进行了图像评估，所有患者的图像质量都是可以接受的。图像质量评分为优秀的占 85%（66/78），良好的占 10%（8/78），一般的占 5%（4/78）。在检查移植肾血管吻合方式方面，SLEEK检查结果与术中记录完全吻合，发现 72个肾脏被移植在右侧髂窝，6个肾脏被移植在左侧髂窝。移植肾动脉与髂外动脉端侧吻合的有 43例，移植肾动脉与髂内动脉端端吻合的有 353 华中科技大学博士学位论文例，所有 78例移植肾静脉均与髂外静脉端侧吻合。这一结果与彩色多普勒超声对比没有明显统计学意义（P0.05）。SLEEK在检出副肾动脉方面明显优于彩色多普勒超声（P0.05），根据手术记录 75名患者的 78个移植肾中有 9个移植肾有副肾动脉，SLEEK发现了其中的 8例，超声只发现了 2例。结论：基于多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列（SLEEK）无创、无辐射在显示移植肾血管解剖方面显示出了很好的应用价值，在显示移植肾的位置和血管吻合方法方面与彩色多普勒超声没有显著统计学差异，在显示副肾动脉方面优于彩色多普勒超声。对临床医生评估移植肾的术后状态提供了新的客观依据。关键词：移植肾，血管解剖，SLEEK，非对比剂，磁共振血管成像第二部分 :基于多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列（SLEEK）在评估移植肾血管并发症方面的研究目的：评估基于多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列（SLEEK）在显示移植肾血管并发症方面的价值，并和彩色多普勒超声（ CDUS）、DSA及手术结果进行对照。材料和方法：应用 GE公司 1.5T HD MR扫描仪对 23名行肾移植手术后经超声检查后临床高度怀疑血管并发症的患者行非对比剂增强磁共振血管成像扫描扫描，所有患者检查前均签署知情同意书。随后其中有 15名患者行 DSA检查（6人行球囊扩张及支架植入术，7人行球囊扩张术，2人仅行血管造影），8名患者进行了手术。由两名放射科专家对 SLEEK显示移植肾血管并发症进行评估，并将 SLEEK结果与彩色多普勒超声、DSA及手术结果进行对照。4 华中科技大学博士学位论文结果：23名行肾移植手术后经超声检查后临床高度怀疑血管并发症的患者，所有患者均成功进行了 SLEEK扫描。经 DSA及手术确定的 23名并发症患者中移植肾动脉狭窄有 11例，移植肾动脉闭塞有 3例，移植肾动脉扭曲有 3例，移植肾静脉狭窄有 2例，动静脉瘘有 2例，假性动脉瘤有 1例，肌纤维发育不良有 1例。SLEEK检查出了其中所有的 23例并发症，彩色多普勒超声检查出了其中 19例，两者没有明显的统计学差异（P0.05）。结论：基于多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列（SLEEK）无创、无辐射在显示移植肾血管并发症方面显示出了很好的应用价值，其结果与彩色多普勒超声并无明显统计学差异。关键词：移植肾，血管并发症，SLEEK，非对比剂，磁共振血管成像第三部分 :基于多翻转脉冲空间标记技术的非对比剂增强 磁共振血管成像序列（SLEEK）对移植肾动脉狭窄的评估：与 DSA相对照目的：以数字减影血管造影（DSA）为金标准，评估基于多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列（SLEEK）在显示移植肾狭窄方面的价值。材料和方法：本研究收集行 SLEEK扫描并行 DSA进一步确诊的肾移植患者 11例，所有患者检查前均签署知情同意书。应用 GE公司 1.5T HD MR扫描仪对 11名肾移植患者行非对比剂增强磁共振血管成像扫描扫描，随后 11名患者行 DSA检查。由两名放射科医生对 SLEEK显示移植肾动脉狭窄程度进行评估，并将 SLEEK结果与 DSA5 华中科技大学博士学位论文结果进行对照。结果：11名经 DSA验证的的肾移植患者均成功进行了 SLEEK扫描。经 DSA确定的1度狭窄患者有 4例，2度狭窄有 6例，3度狭窄有 1例。除了 1例轻度狭窄患者被SLEEK过高估计狭窄程度外，其余均与 DSA显示的一致，SLEEK对临床上显著狭窄（狭窄程度50%）的阳性预测值为 87.5%，阴性预测值为 100%，灵敏度为 100%，特异度为 75%，准确度为：90.9%。SLEEK与 DSA在评估移植肾动脉狭窄程度方面的有着很好的相关性（r=0.96; P0.05）。相对于 DSA，SLEEK会稍微过高估计移植肾动脉狭窄的程度，但是这个差异没有显著统计学意义（ Wilcoxon符号秩检验，P=0.57）。Bland-Altman plot显示以 DSA为金标准 SLEEK产生的误差很低（平均误差, 3.2%7.3%）。结论：基于多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列（SLEEK）无创、无辐射，在评估移植肾动脉狭窄方面与 DSA有着很好的一致性。SLEEK可以成为一种临床上评估移植肾动脉狭窄的方法。关键词：移植肾，动脉狭窄，DSA，SLEEK，非对比剂，磁共振血管成像第四部分:肾移植患者肾动脉 SLEEK扫描中 BSP TI的参数优化目的：评估基于多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列（SLEEK）应用在移植肾动脉方面时 BSP TI的参数优化。材料和方法：对 20名行肾移植的健康志愿者，应用 GE公司 1.5T HD MR扫描仪分6 华中科技大学博士学位论文别进行血液抑制反转时间（BSP TI）为 500、800、1100、1400ms扫描，比较不同 BSPTI下移植肾动脉主干、分支与肾实质的相对信号强度。结果：20名志愿者均成功实现了非对比剂移植肾动脉血管成像。BSP TI由 5001400ms，移植肾动脉远端分支的信号强度逐渐增强。在 BSP TI=800 ms或 1100ms时，移植肾动脉与移植肾实质之间的相对信号强度最高。结论：在血流正常情况下 BSP TI为 800ms或 1100ms时成像效果较好。关键词：移植肾，SLEEK，BSP TI，非对比剂，磁共振血管成像7 华中科技大学博士学位论文Abstract Part 1 Depiction of Transplant Renal Vascular Anatomy: Non-contrastEnhanced MR angiography Using Spatial Labeling with MultipleInversion PulsesPurpose: To prospectively evaluate the performance of a non-contrast enhanced MRangiography using spatial labeling with multiple inversion pulses, to depict transplant renalvascular anatomy in comparison to color Doppler ultrasonography (CDUS).Materials and Methods: This study was approved by the institutional review board (IRB),and all patients gave written informed consent before examination. 75 patients with renaltransplant were examined with non-contrast enhanced MRA using SLEEK and CDUS. Theability to present transplant renal vascular anatomy with SLEEK was evaluated inconsensus by two experienced radiologists, and to compare the results with operative notes.The ability of SLEEK detected accessory artery was analyzed using the Chi-square test.Results: A total of 75 patients underwent renal transplantation were examined with CDUSand SLEEK. There were 3 patients with two renal transplant and 9 patients with nineaccessory renal arteries. Image quality of all patients was acceptable. The image qualitywas categorized as excellent in 85% (66 of 78), good in 10% (8 of 78) and moderate in 5%(4 of 78) of the patients. Significantly more of accessory renal arteries were detected withSLEEK than with CDUS (P0.05).Conclusions: Non-contrast enhanced MRA using SLEEK was preliminarily proven to be areliable diagnostic method for depicting the anatomy of transplant renal vascular. Its likelyto serve as a choice for imaging evaluation of the patients with renal transplantation, inparticular with renal insufficiency.8 华中科技大学博士学位论文Key Words: Renal transplantation; Vascular anatomy; SLEEK; Non-contrast enhancedMRAPart 2 Depiction of Transplant Renal Vascular Complications:Non-contrast Enhanced MR angiography Using Spatial Labeling withMultiple Inversion PulsesPurpose: To prospectively evaluate the performance of a non-contrast enhanced MRangiography using spatial labeling with multiple inversion pulses, to depict transplant renalvascular complications in comparison to color Doppler ultrasonography (CDUS) , digitalsubtraction angiography (DSA) and intraoperative findings.Materials and Methods: This study was approved by the institutional review board (IRB),and all patients gave written informed consent before examination. 23 patients with renaltransplant were examined with non-contrast enhanced MRA using SLEEK and CDUS. Theability to present transplant renal vascular complications with SLEEK was evaluated inconsensus by two experienced radiologists, and to compare the results with CDUS, DSAand intraoperative findings.Results: 23 patients were diagnosed with transplant renal vascular complications,including 14 with arterial stenosis（3 with arterial occlusion), 3 with arterial kinking, 2 witharteriovenous fistulas, 2with venous stenosis, 1with pseudoaneurysms and 1 withfibromuscular dysplasia. The ability of SLEEK found vascular complications is superior toCDUS, but there were no statistically significant differences between them (P0.05).Conclusions: Non-contrast enhanced MRA using SLEEK was preliminarily proven to be a9 华中科技大学博士学位论文reliable diagnostic method for depicting the complications of transplant renal vascular. Itslikely to serve as a choice for imaging evaluation of the patients with renal transplantation,in particular with renal insufficiency.Key Words: Renal transplantation; Vascular complications; SLEEK; Non-contrastenhanced MRAPart 3 Depiction of Transplant Renal Arterial Stenosis: Non-contrastEnhanced MR angiography Using Spatial Labeling with MultipleInversion Pulses versus DSAPurpose: To prospectively evaluate the performance of a non-contrast enhanced MRangiography using spatial labeling with multiple inversion pulses, to depict transplant renalarterial stenosis in comparison to digital subtraction angiography (DSA).Materials and Methods: This study was approved by the institutional review board (IRB),and all patients gave written informed consent before examination. 11 patients with renaltransplant arterial stenosis were examined with non-contrast enhanced MRA using SLEEKand DSA. The ability to present transplant renal arterial stenosis with SLEEK wasevaluated in consensus by two experienced radiologists, and to compare the results withDSA.Results: 11 patients were diagnosed with transplant renal arterial stenosis. With SLEEK,only one grade 1 stenosis on DSA was evaluated as grades 3 stenosis. The correlationbetween SLEEK and DSA was found in presenting the degree of TRAS (r= 0.96; p 0.05).10 华中科技大学博士学位论文With SLEEK, a slight overestimation of the degree of stenosis was observed (median,57.5%; range, 3576%; mean, 56.3%13.6%), compared with the degree of stenosisestimated with DSA (median, 56.5%; range, 3075%; mean, 53.1%13.8%), but there wasno significant difference between them (Wilcoxon signed-rank test, P=0.57). TheBland-Altman plot showed very low bias in assessment of the degree of stenosis by usingSLEEK (mean bias, 3.2%7.3%). The sensitivity of SLEEK for identifying a signicantstenosis (50% narrowing) was 100%, and the specicity was 75%. The positivepredictive value was 87.5%, the negative predictive value was 100%, and the accuracy was90.9%.Conclusions: Non-contrast enhanced MRA using SLEEK was preliminarily proven to be areliable diagnostic method for depicting the transplant renal arterial stenosis. Its likely toserve as a choice for imaging evaluation of the patients with renal transplantation, inparticular with renal insufficiency.Key Words: Renal transplantation; Arterial stenosis; SLEEK; Non-contrast enhancedMRAPart 4 Parameter Optimization for Blood Suppression Inversion Time(BSP TI): Non-Contrast Enhanced MR Angiography using SpatialLabeling with Multiple Inversion Pulses of Transplant Renal ArteryPurpose: To evaluate non-contrast enhanced MR angiography using spatial labeling withmultiple inversion pulses visualization of the transplant renal artery，and explore theoptimization of BSP TI11 华中科技大学博士学位论文Materials and Methods: 20 volunteers with renal transplantation were examined underdifferent BSP TI (500,800,1100, 1400 ms), and the vessel-to- renal parenchyma contrastratio of the transplant renal arteries were measured.Results: Non-contrast-enhanced MRA images of transplant renal arteries were obtainedsuccessfully in all 20 volunteers. The signal intensity of transplant renal arterial branchesgradually increased when BSP TI increased from 500 ms to 1400 ms, and the highestvessel-to- renal parenchyma contrast ratio occurred when TI was 800ms and 1100ms.Conclusion: Non-contrast enhanced MR angiography of the transplant renal artery can besuccessfully achieved at 1.5T high field MRI. Fixed BSP TI of 800ms and 1100ms arepreferable.Key Words: Renal transplantation; BSP TI; SLEEK; Non-contrast enhanced MRA12 华中科技大学博士学位论文前言自美国哈佛大学 Merril和 Murray博士的器官移植小组于 1954年成功的完成首例同卵双生子之间的活体肾脏移植以来，肾脏移植经历了探索、发展和逐渐成熟的过程。如今肾移植被认为是当前治疗各种终末期肾病的最佳方法(1)。与透析治疗相比，肾移植具有更高的性价比，患者的长期生存率和生活质量也更高(1-4)。然而，肾移植术后的并发症仍然比较常见，这严重的影响着移植肾的存活。尽管肾移植术后并发症在尿路系统和免疫系统有着更高的发生率，但是这类并发症导致移植肾功能丧失几率比较小。正相反，肾移植术后血管并发症的发生率相对较低，但是这类并发症却是导致移植肾功能丧失的主要原因(5-7)。据报道肾移植后血管并发症的发生率为5%-15%(8-10)，临床上常见到的血管并发症包括：移植肾动脉狭窄、移植肾动脉闭塞、移植肾动脉扭曲、移植肾动静脉瘘、假性动脉瘤、移植肾静脉狭窄和移植肾动脉肌纤维发育不良等(11-14)。临床医生和放射科医生为了进一步了解和处理这些血管并发症，清晰地显示肾移植术后血管的解剖结构是非常重要的。因此，用一种安全、准确、无创的成像方法来评估肾移植术后患者的血管解剖和并发症是非常有必要的。临床上常用的检查移植肾血管的影像方法有数字减影血管造影（DSA）、彩色多普勒超声（CDUS）、CT血管成像（CTA）及对比剂增强磁共振血管成像（CE-MRA）。数字减影血管造影（DSA）DSA被认为是诊断移植肾血管并发症的金标准，而且可以进行介入治疗。然而，DSA是一种有创的检查方法，价格昂贵，而且有产生造影剂肾病等各种并发症的风险(15)。因此，考虑到上述不足，DSA一般不作为首选检查方法。彩色多普勒超声（CDUS）CDUS是检查移植肾血管并发症的一个可靠的方法，具有很高的敏感性(6, 7, 14,16, 17)。由于 CDUS的无创性、准确性，临床上 CDUS往往作为检查移植肾血管并发症的首选检查方法。但是，超声检查过分依赖于操作者的经验及技术，尤其在评估扭曲的血管和副肾动脉方面(18, 19)。除此之外，CDUS评估动脉狭窄往往是通过流速的高低，而难以具体直观的显示狭窄程度。13 华中科技大学博士学位论文CT血管成像（CTA）和对比剂增强 MR血管成像（CE-MRA）近来，CTA和 CE-MRA两种影像诊断方法在评估移植肾血管方面都展现出很好的结果(20-22)。但是 CTA扫描的时候需要使用含碘的对比剂，并且患者需要接受电离辐射。最近的研究表明，基于碘的对比剂对肾功能不良的病人可能产生对比剂肾病等不良反应(23)。而对于 CE-MRA，最近的报道指出基于钆的对比剂可能导致肾功能不良的病人出现肾源性系统性纤维化(24-27)。肾移植后，由于患者终生服用免疫抑制剂等药物，这就需要更加注重对患者肾功能的保护，因此这两种方法在肾移植患者中的应用也有一定局限性。近年来随着磁共振硬件及软件的进步，非对比剂增强磁共振血管成像再次焕发生机。最近，有学者应用基于多翻转脉冲空间标记技术的非对比剂增强磁共振血管成像序列（SLEEK）在评估高血压病人的肾动脉狭窄方面取得了初步的结果(28)。在本次研究中将 SLEEK技术应用在移植肾方面，不但对动脉进行评估而且还对静脉进行了评估。本次研究旨在探讨 SLEEK技术在评估移植肾血管解剖及并发症方面的价值，并与彩色多普勒超声，DSA及手术结果相对比。参考文献1. de Wit GA, Ramsteijn PG, de Charro FT. 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Colour-coded duplex sonography in the diagnosticassessment of vascular complications after kidney transplantation in children. PediatrRadiol1997 Dec;27(12):898-902.7. Tarzamni MK, Argani H, Nurifar M, Nezami N. Vascular complication and Dopplerultrasonographicfindingafterrenaltransplantation.TransplantProc2007May;39(4):1098-102.8. Hohnke C, Abendroth D, Schleibner S, Land W. Vascular complications in 1,200kidney transplantations. Transplant Proc1987 Oct;19(5):3691-2.9. Dimitroulis D, Bokos J, Zavos G, Nikiteas N, Karidis NP, Katsaronis P, Kostakis A.Vascular complications in renal transplantation: a single-center experience in 1367 renaltransplantations and review of the literature. Transplant Proc