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MR Angiography of the Thoracic Aorta with an Electrocardiographically Triggered Breath-Hold Contrast-enhanced Sequence¹

¹ From the Department of Radiology, William Beaumont Hospital, 3601 W 13 Mile Rd, Royal Oak, MI 48073 (P.J.A., K.G.B., A.N.S.); the Department of Radiology, Cleveland Clinic, Cleveland, Ohio (R.D.W.); and Siemens Medical Systems, Iselin, NJ (O.P.S.). Presented as a scientific exhibit at the 1997 RSNA scientific assembly. Received February 16, 1999; revision requested April 5; final revision received June 10; accepted June 14. Address reprint requests to K.G.B.

View larger version (13K): [in a new window]   Figure 1.   ECG-triggered contrast-enhanced 3D fast low-angle shot sequence. During each R-R interval, the phase-encoding steps for a given partition are all collected during a 500-msec acquisition window after a predetermined trigger delay, which is used to drive acquisition of the partitions during the diastolic phase of the cardiac cycle. Therefore, every heartbeat yields a single 3D partition.

View larger version (124K): [in a new window]   Figure 2.   Nontriggered acquisition limited by artifact. Oblique sagittal maximum-intensity projection (MIP) image obtained without ECG triggering shows a moderate amount of artifact in the phase-encoding direction (arrows). This artifact obscures the ascending aorta and a moderate portion of the descending thoracic aorta. Images obtained with ECG-triggered acquisition do not demonstrate this degree of artifact.

View larger version (121K): [in a new window]   Figure 3a.   Normal thoracic aorta. Coronal (a) and oblique sagittal (b) MIP images show the thoracic aorta in a healthy subject. The coronal image (a) shows overlap between the aorta and the pulmonary vasculature. However, the ascending aorta is not obscured by the pulmonary vasculature on the oblique sagittal image (b). Note the small ductus bump (arrow). The arch vessels are well demonstrated on both images.

View larger version (152K): [in a new window]   Figure 3b.   Normal thoracic aorta. Coronal (a) and oblique sagittal (b) MIP images show the thoracic aorta in a healthy subject. The coronal image (a) shows overlap between the aorta and the pulmonary vasculature. However, the ascending aorta is not obscured by the pulmonary vasculature on the oblique sagittal image (b). Note the small ductus bump (arrow). The arch vessels are well demonstrated on both images.

View larger version (121K): [in a new window]   Figure 4a.   Aberrant right subclavian artery. Oblique (a) and coronal (b) MIP images show an aberrant right subclavian artery (straight arrows). This finding is seen as the terminal tributary from the arch. Loss of signal near the pulmonary apex (curved arrow) is due to the vessel passing out of the plane of acquisition.

View larger version (129K): [in a new window]   Figure 4b.   Aberrant right subclavian artery. Oblique (a) and coronal (b) MIP images show an aberrant right subclavian artery (straight arrows). This finding is seen as the terminal tributary from the arch. Loss of signal near the pulmonary apex (curved arrow) is due to the vessel passing out of the plane of acquisition.

View larger version (148K): [in a new window]   Figure 5a.   Aberrant right subclavian artery. (a) Sagittal 3D partition obtained in another patient shows an aberrant right subclavian artery (arrow) passing posterior to the trachea and esophagus. (b) Oblique sagittal MIP image shows the aberrant right subclavian artery (straight arrow), which is associated with a diverticulum of Kommerell. In addition, there is a small ductus bump (curved arrow).

View larger version (133K): [in a new window]   Figure 5b.   Aberrant right subclavian artery. (a) Sagittal 3D partition obtained in another patient shows an aberrant right subclavian artery (arrow) passing posterior to the trachea and esophagus. (b) Oblique sagittal MIP image shows the aberrant right subclavian artery (straight arrow), which is associated with a diverticulum of Kommerell. In addition, there is a small ductus bump (curved arrow).

View larger version (153K): [in a new window]   Figure 6a.   Aortic coarctation. (a) Oblique sagittal MIP image shows a discrete postductal coarctation (straight arrow), which is associated with dilatation of the left subclavian artery (curved arrow). (b) Left anterior oblique digital subtraction angiogram shows similar findings.

View larger version (148K): [in a new window]   Figure 6b.   Aortic coarctation. (a) Oblique sagittal MIP image shows a discrete postductal coarctation (straight arrow), which is associated with dilatation of the left subclavian artery (curved arrow). (b) Left anterior oblique digital subtraction angiogram shows similar findings.

View larger version (143K): [in a new window]   Figure 7a.   Aortic sinus aneurysm. (a) Sagittal contrast-enhanced 3D partition shows dilatation of the right coronary cusp (arrow). (b-d) Angled vertical long-axis turbo spin-echo breath-hold MR image (b), oblique axial turbo spin-echo breath-hold MR image (c), and oblique axial breath-hold cine MR image (d) show the dilatation more clearly (arrow).

View larger version (143K): [in a new window]   Figure 7b.   Aortic sinus aneurysm. (a) Sagittal contrast-enhanced 3D partition shows dilatation of the right coronary cusp (arrow). (b-d) Angled vertical long-axis turbo spin-echo breath-hold MR image (b), oblique axial turbo spin-echo breath-hold MR image (c), and oblique axial breath-hold cine MR image (d) show the dilatation more clearly (arrow).

View larger version (185K): [in a new window]   Figure 7c.   Aortic sinus aneurysm. (a) Sagittal contrast-enhanced 3D partition shows dilatation of the right coronary cusp (arrow). (b-d) Angled vertical long-axis turbo spin-echo breath-hold MR image (b), oblique axial turbo spin-echo breath-hold MR image (c), and oblique axial breath-hold cine MR image (d) show the dilatation more clearly (arrow).

View larger version (125K): [in a new window]   Figure 7d.   Aortic sinus aneurysm. (a) Sagittal contrast-enhanced 3D partition shows dilatation of the right coronary cusp (arrow). (b-d) Angled vertical long-axis turbo spin-echo breath-hold MR image (b), oblique axial turbo spin-echo breath-hold MR image (c), and oblique axial breath-hold cine MR image (d) show the dilatation more clearly (arrow).

View larger version (145K): [in a new window]   Figure 8a.   Aortoannular ectasia in a patient with Marfan disease. (a) Oblique MIP image clearly shows aortoannular ectasia (arrow). The entire thoracic aorta was imaged in a single breath hold, thus eliminating the need for acquisition of multiple breath-hold cine or spin-echo sections. (b) Coronal 3D partition shows a focal area of signal void due to aortic insufficiency (arrow).

View larger version (138K): [in a new window]   Figure 8b.   Aortoannular ectasia in a patient with Marfan disease. (a) Oblique MIP image clearly shows aortoannular ectasia (arrow). The entire thoracic aorta was imaged in a single breath hold, thus eliminating the need for acquisition of multiple breath-hold cine or spin-echo sections. (b) Coronal 3D partition shows a focal area of signal void due to aortic insufficiency (arrow).

View larger version (142K): [in a new window]   Figure 9a.   Aortic aneurysm with aortic insufficiency. Coronal (a) and oblique sagittal (b) MIP images show a 10-cm-wide ascending aortic aneurysm (arrow). (c) Coronal 3D partition shows signal void due to aortic insufficiency (arrow). The image provides a 3D perspective on the relationship of the aneurysm to the aortic arch.

View larger version (133K): [in a new window]   Figure 9b.   Aortic aneurysm with aortic insufficiency. Coronal (a) and oblique sagittal (b) MIP images show a 10-cm-wide ascending aortic aneurysm (arrow). (c) Coronal 3D partition shows signal void due to aortic insufficiency (arrow). The image provides a 3D perspective on the relationship of the aneurysm to the aortic arch.

View larger version (169K): [in a new window]   Figure 9c.   Aortic aneurysm with aortic insufficiency. Coronal (a) and oblique sagittal (b) MIP images show a 10-cm-wide ascending aortic aneurysm (arrow). (c) Coronal 3D partition shows signal void due to aortic insufficiency (arrow). The image provides a 3D perspective on the relationship of the aneurysm to the aortic arch.

View larger version (167K): [in a new window]   Figure 10a.   Aortic aneurysm. (a) Coronal MIP image shows a large thoracoabdominal aortic aneurysm. However, only the lumen of the aneurysm is shown. (b) Coronal 3D partition shows enhancement of the lumen. The wall of the aneurysm, which is lined with subintimal thrombus, is better seen on this image (arrows). Therefore, the size and extent of aneurysms are best determined by reviewing the source images.

View larger version (186K): [in a new window]   Figure 10b.   Aortic aneurysm. (a) Coronal MIP image shows a large thoracoabdominal aortic aneurysm. However, only the lumen of the aneurysm is shown. (b) Coronal 3D partition shows enhancement of the lumen. The wall of the aneurysm, which is lined with subintimal thrombus, is better seen on this image (arrows). Therefore, the size and extent of aneurysms are best determined by reviewing the source images.

View larger version (133K): [in a new window]   Figure 11a.   Atherosclerotic stenosis. Oblique sagittal (a) and coronal (b) MIP images show a focal area of atherosclerotic narrowing (arrow).

View larger version (133K): [in a new window]   Figure 11b.   Atherosclerotic stenosis. Oblique sagittal (a) and coronal (b) MIP images show a focal area of atherosclerotic narrowing (arrow).

View larger version (158K): [in a new window]   Figure 12a.   Penetrating ulcer. (a) Lateral digital subtraction angiogram obtained with a pigtail catheter in the proximal descending aorta shows a large penetrating ulcer involving the ventral aspect of the descending aorta (arrow). (b, c) Sagittal contrast-enhanced 3D partition (b) and sagittal MIP image (c) also show this finding (arrow). The subintimal penetration is best seen on the 3D partition (b). The diagnosis of penetrating ulcer was confirmed at surgery.

View larger version (159K): [in a new window]   Figure 12b.   Penetrating ulcer. (a) Lateral digital subtraction angiogram obtained with a pigtail catheter in the proximal descending aorta shows a large penetrating ulcer involving the ventral aspect of the descending aorta (arrow). (b, c) Sagittal contrast-enhanced 3D partition (b) and sagittal MIP image (c) also show this finding (arrow). The subintimal penetration is best seen on the 3D partition (b). The diagnosis of penetrating ulcer was confirmed at surgery.

View larger version (154K): [in a new window]   Figure 12c.   Penetrating ulcer. (a) Lateral digital subtraction angiogram obtained with a pigtail catheter in the proximal descending aorta shows a large penetrating ulcer involving the ventral aspect of the descending aorta (arrow). (b, c) Sagittal contrast-enhanced 3D partition (b) and sagittal MIP image (c) also show this finding (arrow). The subintimal penetration is best seen on the 3D partition (b). The diagnosis of penetrating ulcer was confirmed at surgery.

View larger version (127K): [in a new window]   Figure 13a.   Type A thoracic aortic dissection. (a, b) Immediate (a) and delayed (b) oblique sagittal 3D partitions show a dissection flap in the ascending aorta (arrow). On the immediate image (obtained 10 seconds after the start of contrast material injection) (a), low signal intensity within the false channel produces a false impression of thrombosis. On the delayed image (b), the false channel demonstrates enhancement, with delayed washout manifesting as higher signal intensity than in the true channel. (c, d) Coronal (c) and axial (d) 3D partitions show the morphology of the dissection flap.

View larger version (137K): [in a new window]   Figure 13b.   Type A thoracic aortic dissection. (a, b) Immediate (a) and delayed (b) oblique sagittal 3D partitions show a dissection flap in the ascending aorta (arrow). On the immediate image (obtained 10 seconds after the start of contrast material injection) (a), low signal intensity within the false channel produces a false impression of thrombosis. On the delayed image (b), the false channel demonstrates enhancement, with delayed washout manifesting as higher signal intensity than in the true channel. (c, d) Coronal (c) and axial (d) 3D partitions show the morphology of the dissection flap.

View larger version (126K): [in a new window]   Figure 13c.   Type A thoracic aortic dissection. (a, b) Immediate (a) and delayed (b) oblique sagittal 3D partitions show a dissection flap in the ascending aorta (arrow). On the immediate image (obtained 10 seconds after the start of contrast material injection) (a), low signal intensity within the false channel produces a false impression of thrombosis. On the delayed image (b), the false channel demonstrates enhancement, with delayed washout manifesting as higher signal intensity than in the true channel. (c, d) Coronal (c) and axial (d) 3D partitions show the morphology of the dissection flap.

View larger version (47K): [in a new window]   Figure 13d.   Type A thoracic aortic dissection. (a, b) Immediate (a) and delayed (b) oblique sagittal 3D partitions show a dissection flap in the ascending aorta (arrow). On the immediate image (obtained 10 seconds after the start of contrast material injection) (a), low signal intensity within the false channel produces a false impression of thrombosis. On the delayed image (b), the false channel demonstrates enhancement, with delayed washout manifesting as higher signal intensity than in the true channel. (c, d) Coronal (c) and axial (d) 3D partitions show the morphology of the dissection flap.

View larger version (166K): [in a new window]   Figure 14a.   Thrombosed type A thoracic aortic dissection. (a) Coronal 3D partition shows a dissection flap in the ascending aorta (arrow). The false channel enhances proximally; however, there is evidence of thrombosis distally, which manifests as a lack of enhancement. (b) Oblique sagittal 3D partition shows the extent of the dissection, which extends to the diaphragm. The false channel does not enhance (arrows). (c, d) Oblique sagittal MIP images show components of the dissection.

View larger version (111K): [in a new window]   Figure 14b.   Thrombosed type A thoracic aortic dissection. (a) Coronal 3D partition shows a dissection flap in the ascending aorta (arrow). The false channel enhances proximally; however, there is evidence of thrombosis distally, which manifests as a lack of enhancement. (b) Oblique sagittal 3D partition shows the extent of the dissection, which extends to the diaphragm. The false channel does not enhance (arrows). (c, d) Oblique sagittal MIP images show components of the dissection.

View larger version (119K): [in a new window]   Figure 14c.   Thrombosed type A thoracic aortic dissection. (a) Coronal 3D partition shows a dissection flap in the ascending aorta (arrow). The false channel enhances proximally; however, there is evidence of thrombosis distally, which manifests as a lack of enhancement. (b) Oblique sagittal 3D partition shows the extent of the dissection, which extends to the diaphragm. The false channel does not enhance (arrows). (c, d) Oblique sagittal MIP images show components of the dissection.

View larger version (124K): [in a new window]   Figure 14d.   Thrombosed type A thoracic aortic dissection. (a) Coronal 3D partition shows a dissection flap in the ascending aorta (arrow). The false channel enhances proximally; however, there is evidence of thrombosis distally, which manifests as a lack of enhancement. (b) Oblique sagittal 3D partition shows the extent of the dissection, which extends to the diaphragm. The false channel does not enhance (arrows). (c, d) Oblique sagittal MIP images show components of the dissection.

View larger version (167K): [in a new window]   Figure 15a.   Type B thoracic aortic dissection. (a, b) Oblique sagittal (a) and coronal (b) 3D partitions show a dissection flap with entry (arrow in b) and reentry (arrow in a) points. (c-e) Targeted coronal (c, d) and targeted oblique sagittal (e) MIP images show the proximal and distal aspects of the dissection and its relationship to the abdominal aortic tributaries. The flap extends to the celiac artery (arrow).

View larger version (166K): [in a new window]   Figure 15b.   Type B thoracic aortic dissection. (a, b) Oblique sagittal (a) and coronal (b) 3D partitions show a dissection flap with entry (arrow in b) and reentry (arrow in a) points. (c-e) Targeted coronal (c, d) and targeted oblique sagittal (e) MIP images show the proximal and distal aspects of the dissection and its relationship to the abdominal aortic tributaries. The flap extends to the celiac artery (arrow).

View larger version (103K): [in a new window]   Figure 15c.   Type B thoracic aortic dissection. (a, b) Oblique sagittal (a) and coronal (b) 3D partitions show a dissection flap with entry (arrow in b) and reentry (arrow in a) points. (c-e) Targeted coronal (c, d) and targeted oblique sagittal (e) MIP images show the proximal and distal aspects of the dissection and its relationship to the abdominal aortic tributaries. The flap extends to the celiac artery (arrow).

View larger version (100K): [in a new window]   Figure 15d.   Type B thoracic aortic dissection. (a, b) Oblique sagittal (a) and coronal (b) 3D partitions show a dissection flap with entry (arrow in b) and reentry (arrow in a) points. (c-e) Targeted coronal (c, d) and targeted oblique sagittal (e) MIP images show the proximal and distal aspects of the dissection and its relationship to the abdominal aortic tributaries. The flap extends to the celiac artery (arrow).

View larger version (61K): [in a new window]   Figure 15e.   Type B thoracic aortic dissection. (a, b) Oblique sagittal (a) and coronal (b) 3D partitions show a dissection flap with entry (arrow in b) and reentry (arrow in a) points. (c-e) Targeted coronal (c, d) and targeted oblique sagittal (e) MIP images show the proximal and distal aspects of the dissection and its relationship to the abdominal aortic tributaries. The flap extends to the celiac artery (arrow).

View larger version (168K): [in a new window]   Figure 16a.   Bicuspid aortic valve stenosis with poststenotic dilatation. (a) Early-phase oblique sagittal MIP image shows an aneurysm of the ascending aorta. The presence of underlying valvular disease cannot be determined with contrast-enhanced MR angiography. (b) Oblique coronal cine MR image shows the bicuspid nature of the aortic valve in this patient (arrowhead). (c) Coronal systolic cine MR image shows an area of signal void due to underlying aortic stenosis (arrow). (d, e) In-plane (d) and through-plane (e) velocity-encoded cine MR images allow calculation of the gradient through the valve. Gadolinium-enhanced MR angiography should be used in conjunction with traditional spin-echo and cine MR angiography to optimize evaluation of the thoracic aorta.

View larger version (173K): [in a new window]   Figure 16b.   Bicuspid aortic valve stenosis with poststenotic dilatation. (a) Early-phase oblique sagittal MIP image shows an aneurysm of the ascending aorta. The presence of underlying valvular disease cannot be determined with contrast-enhanced MR angiography. (b) Oblique coronal cine MR image shows the bicuspid nature of the aortic valve in this patient (arrowhead). (c) Coronal systolic cine MR image shows an area of signal void due to underlying aortic stenosis (arrow). (d, e) In-plane (d) and through-plane (e) velocity-encoded cine MR images allow calculation of the gradient through the valve. Gadolinium-enhanced MR angiography should be used in conjunction with traditional spin-echo and cine MR angiography to optimize evaluation of the thoracic aorta.

View larger version (172K): [in a new window]   Figure 16c.   Bicuspid aortic valve stenosis with poststenotic dilatation. (a) Early-phase oblique sagittal MIP image shows an aneurysm of the ascending aorta. The presence of underlying valvular disease cannot be determined with contrast-enhanced MR angiography. (b) Oblique coronal cine MR image shows the bicuspid nature of the aortic valve in this patient (arrowhead). (c) Coronal systolic cine MR image shows an area of signal void due to underlying aortic stenosis (arrow). (d, e) In-plane (d) and through-plane (e) velocity-encoded cine MR images allow calculation of the gradient through the valve. Gadolinium-enhanced MR angiography should be used in conjunction with traditional spin-echo and cine MR angiography to optimize evaluation of the thoracic aorta.

View larger version (172K): [in a new window]   Figure 16d.   Bicuspid aortic valve stenosis with poststenotic dilatation. (a) Early-phase oblique sagittal MIP image shows an aneurysm of the ascending aorta. The presence of underlying valvular disease cannot be determined with contrast-enhanced MR angiography. (b) Oblique coronal cine MR image shows the bicuspid nature of the aortic valve in this patient (arrowhead). (c) Coronal systolic cine MR image shows an area of signal void due to underlying aortic stenosis (arrow). (d, e) In-plane (d) and through-plane (e) velocity-encoded cine MR images allow calculation of the gradient through the valve. Gadolinium-enhanced MR angiography should be used in conjunction with traditional spin-echo and cine MR angiography to optimize evaluation of the thoracic aorta.

View larger version (181K): [in a new window]   Figure 16e.   Bicuspid aortic valve stenosis with poststenotic dilatation. (a) Early-phase oblique sagittal MIP image shows an aneurysm of the ascending aorta. The presence of underlying valvular disease cannot be determined with contrast-enhanced MR angiography. (b) Oblique coronal cine MR image shows the bicuspid nature of the aortic valve in this patient (arrowhead). (c) Coronal systolic cine MR image shows an area of signal void due to underlying aortic stenosis (arrow). (d, e) In-plane (d) and through-plane (e) velocity-encoded cine MR images allow calculation of the gradient through the valve. Gadolinium-enhanced MR angiography should be used in conjunction with traditional spin-echo and cine MR angiography to optimize evaluation of the thoracic aorta.

View larger version (169K): [in a new window]   Figure 17a.   Aortic graft. (a) Sagittal contrast-enhanced 3D partition shows atheromatous changes with postoperative deformity of the distal ascending aorta and portions of a graft that extends from the aortic arch to the mid-descending thoracic aorta (arrows). (b) Sagittal MIP image shows the graft more clearly (arrows).

View larger version (113K): [in a new window]   Figure 17b.   Aortic graft. (a) Sagittal contrast-enhanced 3D partition shows atheromatous changes with postoperative deformity of the distal ascending aorta and portions of a graft that extends from the aortic arch to the mid-descending thoracic aorta (arrows). (b) Sagittal MIP image shows the graft more clearly (arrows).

View larger version (98K): [in a new window]   Figure 18a.   Aortic graft in a patient who underwent resection of a large thoracoabdominal aortic aneurysm with graft placement and reimplementation of abdominal aortic visceral tributaries. Sagittal targeted MIP image (a) and sagittal contrast-enhanced 3D partition (b) show a large graft that extends from the proximal descending thoracic aorta to include the entire abdominal aorta (arrows).

View larger version (116K): [in a new window]   Figure 18b.   Aortic graft in a patient who underwent resection of a large thoracoabdominal aortic aneurysm with graft placement and reimplementation of abdominal aortic visceral tributaries. Sagittal targeted MIP image (a) and sagittal contrast-enhanced 3D partition (b) show a large graft that extends from the proximal descending thoracic aorta to include the entire abdominal aorta (arrows).

View larger version (185K): [in a new window]   Figure 19a.   Dissection flap missed on an MIP image. (a) Sagittal contrast-enhanced 3D partition shows a dissection flap in the ascending aorta (arrow). (b) MIP image from sagittal 3D partitions shows the aorta; however, the underlying dissection flap is obscured by the surrounding enhancing blood pool. Thus, it is imperative to review the source images in patients with dissection.

View larger version (175K): [in a new window]   Figure 19b.   Dissection flap missed on an MIP image. (a) Sagittal contrast-enhanced 3D partition shows a dissection flap in the ascending aorta (arrow). (b) MIP image from sagittal 3D partitions shows the aorta; however, the underlying dissection flap is obscured by the surrounding enhancing blood pool. Thus, it is imperative to review the source images in patients with dissection.

View larger version (107K): [in a new window]   Figure 20.   Pseudodissection from subjacent enhancing atelectasis. Sagittal contrast-enhanced 3D partitions show areas of enhancement subjacent to the descending aorta, which represent areas of enhancing atelectasis (arrows). This finding should not be confused with the false channel in a patient with dissection; careful evaluation of all images including multiplanar reformations is required to avoid this pitfall.

View larger version (189K): [in a new window]   Figure 21.   Pseudodissection due to passage of the azygos vein along a right-sided aortic descent. Sagittal MIP image shows a subjacent enhancing azygos vein (arrows). This finding should not be confused with a dissection; review of the source images and multiplanar reformations is required to avoid this pitfall.