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МРТ- И КТ-венография в диагностике гемодинамических нарушений у пациентов с хроническими заболеваниями вен нижних конечностей. Часть II. Возможности МРТ- исслелований в диагностике тромбоза глубоких вен

Шайдаков Е. В., Санников А. Б., Емельяненко В. М., Крюкова Л. Н., Баранова А. Е., Рачков М. А.
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Шайдаков Евгений Владимирович - доктор мед. наук, профессор ФГБУН “Институт мозга человека имени Н.П. Бехтеревой” РАН, президент Санкт-Петербургской ассоциации флебологов (SPSP), ФГБУН “Институт мозга человека имени Н.П. Бехтеревой” РАН, evgeny-shaydakov@gmail.com, 197376 Санкт-Петербург, ул. Академика Павлова, д. 9, Российская Федерация
Санников Александр Борисович - канд. мед. наук, заместитель главного врача, сосудистый хирург Клиники инновационной диагностики “Медика”, Владимир; доцент кафедры дополнительного профессионального образования специалистов здравоохранения РНИМУ имени Н.И. Пирогова Минздрава России, Клиника инновационной диагностики “Медика”; ФГАОУ ВО “РНИМУ имени Н.И. Пирогова” Минздрава России, aliplast@mail.ru, 600031 Владимир, ул. Вокзальная, д. 24, Российская Федерация
Емельяненко Владимир Михайлович - доктор мед. наук, профессор, заведующий кафедрой дополнительного профессионального образования специалистов здравоохранения РНИМУ имени Н.И. Пирогова Минздрава России, ФГАОУ ВО “РНИМУ имени Н.И. Пирогова” Минздрава России, vla05@yandex.ru, 117997 Москва, ул. Островитянова, д. 1, Российская Федерация
Крюкова Людмила Николаевна - врач-рентгенолог кабинета МРТ Клиники инновационной диагностики “Медика”, Клиника инновационной диагностики “Медика”, mashа1ivanova@yandex.ru, 600031 Владимир, ул. Вокзальная, д. 24, Российская Федерация
Баранова Анна Евгеньевна - врач-рентгенолог кабинета МРТ Клиники инновационной диагностики “Медика”, Клиника инновационной диагностики “Медика”, annashik.baranova@mail.ru, 600031 Владимир, ул. Вокзальная, д. 24, Российская Федерация
Рачков Михаил Александрович - врач-рентгенолог кабинета КТ Клиники инновационной диагностики “Медика”, Клиника инновационной диагностики “Медика”, rachkoff@gmail.com, 600031 Владимир, ул. Вокзальная, д. 24, Российская Федерация

В данном обзоре литературы проводится анализ исследований патологии венозного кровотока в системе нижней полой вены с помощью магнитно-резонансной томографии (Magnetic Resonance Imaging - MRI). Особое внимание уделяется предпринятым попыткам использования этого метода в диагностике хронических заболеваний вен нижних конечностей (Chronic Venous Disorders - CVD) посредством проведения магнитно-резонансной венографии (MRV). Исторически и методически показано поэтапное внедрение методов MRV в диагностику тромбоза вен нижних конечностей (LEDVT) и венозного тромбоэмболизма (VTE). Методы бесконтрастной MRV, основанные на эффекте потока крови, как и в случае применения MR-Angiography, подразделяются на две принципиальные группы: методы, основанные на амплитудных эффектах время-пролета (Time-of-Flight - TOF), и методы, основанные на фазовых эффектах (Phase Contrast - PC). Техники проведения бесконтрастной MRV подробно описаны. Уделено внимание импульсным последовательностям, используемым в мире для визуализации вен при бесконтрастной MRV в режиме TOF и РС (FR-FBI, SPADE, SSFP), и методам постобработки изображения: 2D-TOF MRV FLASH, 2D-TOF MRV CRASS, FIPS, VED, VENS. В основе выполнения контрастно-усиленной MRV (Contrast-Enhanced MRV - CE MRV) лежит использование контрастных препаратов “пула крови”, особенностью которых является способность образовывать устойчивые соединения с белками плазы крови. В мире в качестве контрастных препаратов для CE MRV используются вещества, обладающие магнитными и супермагнитными свойствами на основе гадолиния или оксида железа. Результатом использования данных контрастных препаратов является повышение качества визуализации за счет лучшего соотношения сигнал/шум (Signal to Noise Ratio - SNR) с использованием обработки изображения в режиме 3D (3D-CE MRV) с использованием быстрых последовательностей: GRE, TFLAS, VESPA, CAT в условиях проведения прямой и непрямой СE MRV. Отмечено, что в последнее время в отношении некоторых линейных контрастных препаратов, содержащих гадолиний, в их дальнейшем использовании предприняты определенные ограничения. В связи с этим с целью проведения СE MRV рационально применять только циклические контрастные вещества, чтобы избежать неоправданных рисков. Бесконтрастная MRV вновь получила интенсивное развитие в последние годы в связи с введенными ограничениями. Одним из таких методов стал прямая визуализация тромба (Direct Thrombus Imaging - DTI или Magnetic Resonance Direct Thrombus Imaging - MRDTI) с использование быстрых импульсных последовательностей: bSSFP, BBTI, DANTE. Последние исследования в отношении этого метода диагностики LEDVT были опубликованы в 2019 г. и показали высокую диагностическую ценность. В отношении всех наиболее часто используемых методов проведения MRV показана специфичность и чувствительность. Дальнейшее проведение MRV у пациентов с CVD и DVT является перспективной диагностической задачей в современной флебологии. MRV должна внедряться в клиническую практику более активно, чем это происходит сегодня.

Ключевые слова:
магнитно-резонансная томография, магнитно-резонансная флебография, компьютерная томография, компьютерно-томографическая флебография, хронические заболевания вен, диагностика тромбоза вен нижних конечностей, варикозное расширение вен, анатомическое строение вен нижних конечностей, magnetic resonance imaging, magnetic resonance venography, computed tomography, computed tomography venography, chronic

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MRI- and CT-venography in the diagnosis of hemodynamic disorders in patients suffering from lower extremities chronic venous disorders. Part II. Possibilities of MRI in diagnostics of the deep vein thrombosis

Shajdakov E. V., Sannikov A. B., Emelyanenko V. M., Kryukova L. N., Baranova A. E., Rachkov M. A.

In this literature review, the analysis of the studies of venous blood flow pathology in the inferior Vena cava system using magnetic resonance imaging (MRI) is carried out. Special attention is paid to the attempts made to use this method in the diagnosis of chronic lower limb vein disorders (CVD) through magnetic resonance venography (MRV). Historically and methodically, the gradual introduction of MRV methods in the diagnosis of lower limb vein thrombosis (LEDVT) and venous thromboembolism (VTE) has been shown. Methods of non-contrast MRV based on the effect of blood flow, as in the case of MR-Angiography, are divided into two principal groups: methods based on the amplitude effects of Time-of-Flight (TOF) and methods based on Phase Contrast effects (PC). Techniques for conducting contrast-free MRV are described in detail. Attention is paid to pulse sequences used in the world for visualization of veins in contrast-free MRV in TOF and PC mode (FR-FBI, SPADE, SSFP) and post-processing methods: 2D-TOF MRV FLASH, 2D-TOF MRV CRASS, FIPS, VED, VENS. Contrast-enhanced MRV (CE MRV) is based on the use of “blood pool” contrast agents, which feature the ability to form stable compounds with blood plasma proteins. Worldwidesubstances with magnetic and supermagnetic properties based on gadolinium or iron oxide are used as contrast agents for CE MRV. The result of using these contrast agents is an increase in the quality of visualization due to a better signal to noise ratio (SNR) using 3D image processing (3D CE MRV) using fast sequences: GRE, TFLAS, VESPA, CAT, in conditions of direct and indirect CE MRV. It is noted that in recent years, certain restrictions have been imposed on certain linear contrast agents containing gadolinium in their further use. Therefore, for the purpose of CE MRV, it is efficientl to use only cyclic contrast agents to avoid unnecessary risks. Contrast-free MRV has again received intensive development in recent years, due to the restrictions imposed, one of these methods is direct thrombus imaging (Direct Thrombus Imaging - DTI or Magnetic Resonance Direct Thrombus Imaging - MRDTI) using fast pulse sequences: bSSFP, BBTI, DANTE. The latest research on this LEDVT diagnostic method was published in 2019 and has shown high diagnostic value. For all the most commonly used methods of MRV, specificity and sensitivity are shown. Further MRV in patients with CVD and DVT is a promising diagnostic task in modern phlebology. MRV should be introduced into clinical practice more actively than it is today.

Keywords:
магнитно-резонансная томография, магнитно-резонансная флебография, компьютерная томография, компьютерно-томографическая флебография, хронические заболевания вен, диагностика тромбоза вен нижних конечностей, варикозное расширение вен, анатомическое строение вен нижних конечностей, magnetic resonance imaging, magnetic resonance venography, computed tomography, computed tomography venography, chronic

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