1、 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
2、 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 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（ Wilc
3、oxon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 BS
4、P 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
5、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 us
6、ing 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 examinati
7、on. 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 d
8、etected 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 accept
9、able. 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
10、 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; S
11、LEEK; 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 m
12、ultiple 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
13、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
14、 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
15、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
16、 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 Depic
17、tion 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
18、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 e
19、xamined 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. W
20、ith 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,
21、 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 usingSLE
22、EK (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
23、 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; S
24、LEEK; 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 labeli
25、ng 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 contrastra
26、tio 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 th
27、e 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 transplantatio
28、n; 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
29、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
30、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
31、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
32、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, Rams
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