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.

ISSN 1936-878X/$36.00 https://doi.org/10.1016/j.jcmg.2017.10.017

From the aDepartment of Radiology, Geisinger Wyoming Valley Medical Center, Wilkes-Barre, Pennsylvania; bDepartment of

Radiology, Brigham and Women’s Hospital, Boston, Massachusetts; and the cDepartment 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.

Ai i ii

ii

iii

A

*

B

A

B

B FIGURE 2 cMRA After Intravenous Ferumoxytol

Injection Correlated With Cardiac Catheterization

Performed 154 Days Previously in Patient #1

(Ai) Left heart cardiac catheterization with

demarcated section of left coronary artery (blue

arrow [ proximal; red arrow ¼ distal) corresponds

to MRA demarcation and Online Video 11. (Aii)

Three-dimensional reconstruction (with ventric-

ular wall subtraction) showing the path of vessel

descent and the axial cross section showing the left

lateral direction of vessel. Aortic root (asterisk).

(Bi)Multiplanar straight-line and (Bii) curvilinear

reconstruction shows ferumoxytol-containing left

main origin and left anterior descending (green

line) vessels. (Biii) Luminal cross section at the

proximal (left) and distal (right) segment,

respectively. Abbreviation as in Figure 1.

Ai

ii

i ii

iii

B

A

A

*

B

B FIGURE 3 Ferumoxytol cMRA Correlation With

Cardiac Catheterization in Patient #1

(Ai) Right heart cardiac catheterization with

demarcated section of right coronary artery (blue

arrow ¼ proximal; red arrow ¼ distal) corresponds

to MRA demarcation and Online Video 12. (Aii)

Three-dimensional reconstruction (with ven-

tricular wall subtraction) showing path of vessel

descent and axial cross section showing right

lateral direction of vessel. Aortic root (asterisk).

(Bi) Multiplanar straight line and (Bii) curvilinear

reconstruction shows patent, continuous,

ferumoxytol-containing proximal-to-mid right

coronary artery (green line). (Biii) Luminal cross

section at the proximal (left) and distal (right)

segment, respectively. Scale bar ¼ 5 mm.

Abbreviation as in Figure 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

506

A

A B

i

ii

i ii

A

*

B

iii

B FIGURE 4 cMRA After Intravenous Ferumoxytol

Injection Performed 185 Days After Patient #2

Received a 3.75 � 23 mm Xience Drug-Eluting Stent to

the Mid-Left Anterior Descending Artery

(Ai) Post-deployment coronary angiography with

iodinated contrast identifies the stent (yellow arrow)

in the left anterior descending artery proximal to the

second diagonal branch and corresponding to MRA

demarcation and Online Video 13. (Aii) Three-

dimensional reconstruction (with ventricular wall

subtraction) and axial cross section showing left lateral

direction of vessel. Aortic root (asterisk). (Bi)

Multiplanar straight line and (Bii) curvilinear recon-

struction shows ferumoxytol-containing left anterior

ascending artery (stent, yellow bar). (Biii) Luminal cross

section at the proximal (left) and distal (right)

segments, respectively. Xience Drug-Eluting Stent

(Abbott Laboratories, Chicago, Illinois). Abbreviation as

in Figure 1.

Ai

*

i

ii

B

A

A B

ii

iii

B FIGURE 5 cMRA After Intravenous Ferumoxytol

Injection Performed 185 Days After Patient #2

Received a 3.75 � 23 mm Xience Drug-Eluting Stent to

the Mid-Left Anterior Descending Artery and

Correlation With RCA Cardiac Catheterization

Showing Stenosis

(Ai) Seventy percent mid-right coronary artery lesion

(RCA) (red arrow) is visualized by right coronary artery

catheterization and corresponds to MRA demarcation

and Online Video 14. (Aii) Three-dimensional recon-

struction (with ventricular wall subtraction) and axial

cross section showing left lateral direction of vessel.

Aortic root (asterisk). (Bi) Multiplanar straight-line and

(Bii) curvilinear reconstruction shows RCA luminal

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

507

Right Coronary Origin

Patient 1

Patient 2

Patient 3

Patient 4

Patient 5

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: asiedlecki@bwh.harvard.edu.

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.