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• Clinical Article •
Phosphorus-31 magnetic resonance spectroscopy assessment of calf skeletal muscle energy metabolism in patients with lower extremity peripheral artery disease
ZHONG Siyi  ZHANG Qinhe  WANG Shigeng  LIN Liangjie  PENG Jing  XU Xiaofang  SONG Qingwei  WANG Jiazheng  JI Donghua  LIU Ailian 

Cite this article as: ZHONG S Y, ZHANG Q H, WANG S G, et al. Phosphorus-31 magnetic resonance spectroscopy assessment of calf skeletal muscle energy metabolism in patients with lower extremity peripheral artery disease[J]. Chin J Magn Reson Imaging, 2026, 17(9): 144-151. DOI:10.12015/issn.1674-8034.2026.09.019.


[Abstract] Objective To evaluate energy metabolism impairment in the gastrocnemius (GM) and soleus (SOL) muscles of the calf in patients with lower-extremity peripheral artery disease (PAD) and healthy volunteers using phosphorus-31 magnetic resonance spectroscopy (31P-MRS).Materials and Methods This prospective study enrolled 15 PAD patients (patient group) and 16 age-, sex-, and BMI-matched healthy volunteers (control group) who met the inclusion and exclusion criteria. All subjects underwent resting-state 31P-MRS multi-voxel scanning of the posterior calf muscles on the left side using a 3.0 T MR scanner with a 31P surface coil. Two observers independently selected GM and SOL voxels for post-processing analysis using JMRUI software, obtaining the peak area under the curve for metabolites including phosphocreatine (PCr), adenosine triphosphate (ATP) (with the total area under the three ATP peaks recorded as tATP), phosphodiesters (PDE), and inorganic phosphate (Pi). Metabolite ratios were subsequently calculated, including Pi/tATP, PCr/tATP, Pi/PCr, and PDE/PCr. Statistical analyses were performed using GraphPad Prism 10.1.2 and MedCalc 15.2.2. Inter-observer agreement was assessed using the intra-class correlation coefficient (ICC). Within-group differences in metabolic parameters between GM and SOL were compared using paired t-tests for normally distributed data and the Wilcoxon signed-rank test for non-normally distributed data. Between-group differences in GM and SOL metabolic parameters were assessed using independent t-tests or Mann-Whitney U tests, as appropriate, with Cohen's d effect sizes calculated to evaluate the sensitivity of each metabolic indicator in discriminating PAD. Receiver operating characteristic (ROC) curves and the corresponding area under the curve (AUC) were computed to further quantify diagnostic performance, with sensitivity and specificity derived via the Youden index. Differences between AUCs were compared using the DeLong test, and McNemar test was used to compare sensitivity and specificity across metabolic indicators.Results Inter-observer agreement was good for all metabolic parameters in both groups (all ICC > 0.80). No significant within-group differences in metabolic parameters between GM and SOL were observed in either group (all P > 0.05). Compared with the control group, the patient group demonstrated significantly elevated GM Pi/tATP (0.223 ± 0.050 vs. 0.170 ± 0.066, P = 0.007), Pi/PCr (0.154 ± 0.036 vs. 0.105 ± 0.036, P = 0.002), and PDE/PCr (0.158 ± 0.056 vs. 0.076 ± 0.028, P < 0.001). Similarly, SOL Pi/tATP (0.223 ± 0.051 vs. 0.161 ± 0.045, P = 0.004), Pi/PCr (0.147 ± 0.037 vs. 0.105 ± 0.026, P = 0.005), and PDE/PCr (0.143 ± 0.040 vs. 0.073 ± 0.025, P < 0.001) were all significantly elevated, with SOL PDE/PCr showing the largest Cohen's d effect size among all between-group comparisons (d = 2.1). ROC curve analysis showed that PDE/PCr in both GM and SOL (AUC = 0.896 and 0.942, respectively) achieved better diagnostic performance than the other metabolic indices. DeLong test showed that the AUC difference between SOL Pi/PCr and PDE/PCr was statistically significant (P = 0.044), while differences among all other pairs of metabolic indices were not significant (all P > 0.05). McNemar test showed that, for sensitivity, SOL PDE/PCr (93.3%) was significantly higher than SOL Pi/PCr (53.3%, P = 0.031) but did not differ significantly from SOL Pi/tATP (86.7%, P > 0.05). No significant differences in sensitivity were found between GM PDE/PCr (80.0%) and GM Pi/tATP (100.0%) or Pi/PCr (86.7%, all P > 0.05). For specificity, GM PDE/PCr (87.5%) was significantly higher than GM Pi/tATP (50.0%, P = 0.031) but did not differ significantly from GM Pi/PCr (68.8%, P > 0.05); no significant differences in specificity were found among the SOL metabolic indices (all P > 0.05).Conclusions This study preliminarily demonstrates that 31P-MRS has the potential to assess changes in skeletal muscle energy metabolism in patients with PAD, and the increase in PDE/PCr ratio in SOL can serve as a potentially sensitive indicator for evaluating energy metabolism disorders in PAD.
[Keywords] lower extremity peripheral artery disease；multi-nuclear magnetic resonance imaging；energy metabolism；31P magnetic resonance spectroscopy

ZHONG Siyi1, 2, 3   ZHANG Qinhe1, 2   WANG Shigeng1, 2   LIN Liangjie4   PENG Jing4   XU Xiaofang4   SONG Qingwei1, 2   WANG Jiazheng2   JI Donghua3   LIU Ailian1, 2*  

1 Department of Radiology, the First Affiliated Hospital of Dalian Medical University, Dalian 116011, China

2 Technology Innovation Center of Hyperpolarized MRI, Liaoning Province, Dalian 116011, China

3 Department of Interventional Radiology, the First Affiliated Hospital of Dalian Medical University, Dalian 116011, China

4 Philips (China) Investment Co., Ltd, Beijing 100016, China

Corresponding author: LIU A L, E-mail: cjr.liuailian@vip.163.com

Conflicts of interest   None.

Received  2026-04-29
Accepted  2026-08-17
DOI: 10.12015/issn.1674-8034.2026.09.019
Cite this article as: ZHONG S Y, ZHANG Q H, WANG S G, et al. Phosphorus-31 magnetic resonance spectroscopy assessment of calf skeletal muscle energy metabolism in patients with lower extremity peripheral artery disease[J]. Chin J Magn Reson Imaging, 2026, 17(9): 144-151. DOI:10.12015/issn.1674-8034.2026.09.019.

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