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20 CT Angiography of the Thoracic Aorta

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20 CT Angiography of the Thoracic Aorta CT Angiography of the Thoracic Aorta 287 20 CT Angiography of the Thoracic Aorta G. D. Rubin CONTENTS with the aortic lumen, and slow perigraft fl ow around thoracic aortic stent grafts. Finally, the aortic wall Introduction 287 and non-communicating intramural collections are 20.1 Imaging Techniques 287 20.2 Contrast Medium 288 directly visualized. These advantages together with 20.3 CTA Acquisition 288 the rapid, non-invasive means with which CT angi- 20.4 Reconstruction 289 ography (CTA) is acquired has resulted in CTA chal- 20.5 SDCT vs MDCT 289 lenging conventional arteriography for the assessment 20.6 Technical Considerations for Interpretation 289 of many thoracic aortic abnormalities. The purpose 20.6.1 Common Artifacts in Thoracic CTA 289 20.7 Alternative Visualization: of this chapter is to review the technical factors that Reformation and Rendering 292 must be considered when acquiring and interpreting 20.8 Clinical Applications 293 thoracic aortic CT angiograms as well as the range of 20.8.1 Thoracic Aortic Aneurysm 293 disease states for which CTA can be valuable. 20.8.2 Thoracic Aortic Dissection 293 20.8.3 Intramural Hematoma 296 20.8.4 Thoracic Aortic Trauma 298 20.8.5 Congenital Anomalies 300 20.8.6 Assessment of Open and Endovascular 20.1 Interventions 301 Imaging Techniques 20.9 Conclusion 302 References 305 The fi rst step in performing thoracic aortic CTA is to determine the anatomic coverage required to assess the clinical question. At a minimum, the initiation point of the CT scan should be at the base of the neck Introduction so that the proximal aspect of the common carotid and vertebral arteries are included within the CT Although aortography has long been considered the scan. Inferiorly, coverage should extend to include the standard for aortic imaging, there are several reasons origin of the celiac axis. The inclusion of the supra- why spiral or helical CT may be superior to conven- aortic branches is important when lesions involving tional arteriography for assessing the thoracic aorta. the aortic arch extend into these brachiocephalic Firstly, the volumetric acquisition of spiral CT enables branches, which commonly occurs in the setting of clear delineation of the aortic arch, tortuous brachio- both aneurysmal disease and aortic dissection. The cephalic arterial branches, and adjacent aneurysms purpose of including the celiac origin is that lesions and pseudoaneurysms. Because aortography is a pro- of the distal thoracic aorta can be accurately local- jectional technique, the commonly occurring overlap ized relative to this anatomic landmark, which can of these structures can confound their visualization greatly facilitate planning of endovascular and open and delineation of anatomic relationships. Secondly, repair. There may be some instances when additional blood-pool imaging provided by the intravenous anatomic coverage is necessary. For example, in the administration of iodinated contrast media allows setting of acute aortic dissection, frequently imaging simultaneous visualization of true and false luminal through the abdomen and pelvis is necessary due to fl ow channels, intramural hematomas communicating signs and symptoms of diminished blood fl ow to the abdominal viscera or lower extremity. Similarly, G. D. Rubin, MD some disease processes may warrant inclusion of Department of Radiology, S-072, Stanford University School of portions of the upper extremities particularly when Medicine, Stanford, California 94305-5105, USA assessing for sources of embolization to the hands. scho_20-Rubin.ind 287 11.10.2003, 13:03:57 Uhr 288 G. D. Rubin Finally, occasionally, a greater degree of anatomic contrast required is determined by multiplying the coverage to include the entirety of the carotid arte- CT scan duration by the fl ow rate. We have found rial circulation may be warranted, particularly in that a volume of at least 80 ml of iodinated contrast the setting of assessment of large vessel arteritis medium (350 mg of iodine/ml) is necessary for reli- and aortic dissection associated with symptoms of able opacifi cation. This volume of contrast medium cerebral ischemia. at the recommended fl ow rate is readily delivered To ensure that all relevant anatomy is included in through a 20- or 22-G antecubital intravenous cath- the CT angiograms, thoracic aortic CT angiography eter. Because highly attenuative undiluted contrast begins with a relatively thick section unenhanced medium within the in-fl owing veins can obscure localizing scan prescribed from a frontal scout view of adjacent structures, we always perform thoracic the chest and upper abdomen. Usually, 5-mm nominal aortic CT angiography through a right antecubital section thickness associated with a high pitch (2.0 for venous source to avoid opacifi cation of the left bra- SDCT and 1.3–1.7 for MDCT) is suffi cient to localize chiocephalic vein which can substantially obscure the the relevant landmarks; however, there are several origins of the brachiocephalic, left, common carotid, clinical scenarios where thinner sections should be and left subclavian arteries. Because of the high fl ow acquired for these unenhanced views. Specifi cally, rates employed in CTA, iodinated contrast medium when the assessment is for acute chest pain and should always be non-ionic. intramural hematoma is a diagnostic consideration, The fi nal and critical step for optimizing con- unenhanced views can be very valuable for identifying trast medium delivery is the determination of the a hyperattenuative mural crescent corresponding to scan delay time following initiation of the contrast the intramural hematoma. Because 10-mm-thick sec- medium bolus. In the past we relied upon a prelimi- tions can result in substantial volume averaging, 5-mm nary injection of 15 ml of iodinated contrast medium nominal thick sections are advised for the unenhanced coupled with serial CT sections acquired within the portion of the scan in this setting. Additionally, when proximal descending aorta to obtain a time-attenua- assessing stent grafts, 5-mm-thick unenhanced sec- tion curve. We selected the time from the initiation tions can be useful for mapping the location of calcifi - of the injection to the peak of this curve as the scan cations around the stent graft, which can subsequently delay for the CT angiogram. The availability of auto- mimic an endoleak following contrast administration. mated scan-triggering capabilities on the CT scanner Because these initial unenhanced scans are thick, a has led us to abandon this approach. On our CT scan- relatively low tube current and potential is satisfac- ners equipped with this feature, approximately 8 s is tory for this acquisition. We typically use 120 kV and required from the time that contrast medium arrives 100 mA. Not only does this dose save radiation expo- in the descending aorta until the enhancement is sure to the patient, it also minimizes tube heating that recognized and the CTA acquisition is initiated; can subsequently limit the current at which the X-ray therefore, we determine the injection duration to be tube is operated for single-detector-row CT when equal to the scan duration plus 8 s. We have found acquiring the CTA. this direct method of visualizing aortic enhancement Based on these localizing sections, the initiation to be the most reliable method for achieving consis- point and terminus of the CT angiograms, as well as tently high-quality CT angiograms. the fi eld of view for reconstruction, is determined. 20.3 20.2 CTA Acquisition Contrast Medium Thoracic aortic CT angiography should be per- Prior to performing the CT angiogram, the iodin- formed with a nominal section thickness of 3 mm ated contrast administration protocol must be or less coupled with a relatively high pitch value determined. As a general rule, we do not perform of 2.0 for SDCT and 1.3–1.7 for MDCT. A 1.25-mm CT angiography at a fl ow rate less than 4 ml/s and section thickness is not required for the majority for thoracic aortic CT angiograms with durations of thoracic aortic applications; however, it can be less than 20 s we prefer at least 5 ml/s injection rate. of particular value when a detailed assessment of The duration of the bolus should be equivalent to the the supra-aortic branches is indicated. The gantry duration of the CT scan, and therefore the volume of rotation period should be minimized to the lowest scho_20-Rubin.ind 288 11.10.2003, 13:04:00 Uhr CT Angiography of the Thoracic Aorta 289 value available in order to minimize the duration of 20.5 the acquisition and the dosage of contrast medium. SDCT vs MDCT Occasionally, larger patients may benefi t from the use of a slower gantry rotation period to overcome For imaging of the thoracic aorta, single-detector-row excessive image noise, thus enabling a higher mA•S CT (SDCT) scanners are adequate for the majority product. Recently introduced techniques for cardiac of applications; however, MDCT typically results in gating of CT data may prove valuable in the assess- superior image quality. This is because MDCT scans ment of the ascending aorta and in particular the are usually acquired with narrower effective section coronary arteries; however, these techniques are not thickness, and a shorter period of time, and with widespread and therefore are not discussed further less contrast medium. In particular, the shorter scan in this chapter. duration allows for substantially shorter breath-hold The CT angiogram should be performed within periods and more consistent enhancement across a single breath hold. If breath holding is not pos- the scan acquisition. Furthermore, diminished pul- sible due to mechanical ventilation of the patient sation-related artifacts through the heart and great or extreme dyspnea, attempts should be made to vessels have been observed with MDCT (Fig.
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