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Multisection CT Evaluation of the Reoperative Cardiac Surgery Patient¹

¹ From the Departments of Radiology (R.C.G., L.C.) and Cardiothoracic Surgery (A.H.M.), University Hospitals of Cleveland, 11100 Euclid Ave, Cleveland, OH 44106. Presented as an education exhibit at the 2002 RSNA scientific assembly. Received February 3, 2003; revision requested March 11 and received April 2; accepted April 8. Address correspondence to R.C.G. (e-mail: gilkeson@uhrad.com).

View larger version (118K): [in a new window]   Figure 1.  Preoperative assessment before aortic valve replacement in a 55-year-old man with a history of congenital bicuspid aortic valve and aortic stenosis. Coronal volume-rendered image shows a small amount of calcium at the level of the aortic valve (lower arrow). The ascending aorta is free of atherosclerotic disease (upper arrow). Direct aortic cannulation can be performed safely.

View larger version (110K): [in a new window]   Figure 2a.  Imaging evaluation before reoperative CABG in an 83-year-old woman with a history of severe peripheral vascular disease and prior CABG. (a) Axial CT image shows dense calcification in the aortic arch and origin of the great vessels (arrow). The calcium is similar in attenuation to the contrast material within the superior vena cava (arrowhead). (b) Sagittal MIP image shows extensive calcium in the ascending aorta (curved arrow) and arch vessels (straight arrow). (c) Virtual endoscopic image of the ascending aorta shows extensive calcified plaque within the vessel (arrows). Because of the extensive degree of ascending aortic atherosclerotic disease in this patient, axillary cannulation for cardiopulmonary bypass was performed. The patient suffered no neurologic sequelae.

View larger version (106K): [in a new window]   Figure 2b.  Imaging evaluation before reoperative CABG in an 83-year-old woman with a history of severe peripheral vascular disease and prior CABG. (a) Axial CT image shows dense calcification in the aortic arch and origin of the great vessels (arrow). The calcium is similar in attenuation to the contrast material within the superior vena cava (arrowhead). (b) Sagittal MIP image shows extensive calcium in the ascending aorta (curved arrow) and arch vessels (straight arrow). (c) Virtual endoscopic image of the ascending aorta shows extensive calcified plaque within the vessel (arrows). Because of the extensive degree of ascending aortic atherosclerotic disease in this patient, axillary cannulation for cardiopulmonary bypass was performed. The patient suffered no neurologic sequelae.

View larger version (162K): [in a new window]   Figure 2c.  Imaging evaluation before reoperative CABG in an 83-year-old woman with a history of severe peripheral vascular disease and prior CABG. (a) Axial CT image shows dense calcification in the aortic arch and origin of the great vessels (arrow). The calcium is similar in attenuation to the contrast material within the superior vena cava (arrowhead). (b) Sagittal MIP image shows extensive calcium in the ascending aorta (curved arrow) and arch vessels (straight arrow). (c) Virtual endoscopic image of the ascending aorta shows extensive calcified plaque within the vessel (arrows). Because of the extensive degree of ascending aortic atherosclerotic disease in this patient, axillary cannulation for cardiopulmonary bypass was performed. The patient suffered no neurologic sequelae.

View larger version (147K): [in a new window]   Figure 3a.  Preoperative assessment of aortic aneurysm in a 63-year-old man. (a) Oblique axial MPR view shows delineation of the patient’s tricuspid aortic valve, with clear definition of the three aortic sinuses and normal-appearing valve leaflets (arrow). (b) Virtual endoscopic image of the valve shows a normal-appearing tricuspid aortic valve.

View larger version (196K): [in a new window]   Figure 3b.  Preoperative assessment of aortic aneurysm in a 63-year-old man. (a) Oblique axial MPR view shows delineation of the patient’s tricuspid aortic valve, with clear definition of the three aortic sinuses and normal-appearing valve leaflets (arrow). (b) Virtual endoscopic image of the valve shows a normal-appearing tricuspid aortic valve.

View larger version (106K): [in a new window]   Figure 4a.  Preoperative assessment of the thoracic aorta in a 57-year-old man with a history of aortic stenosis. (a) Oblique axial MPR view of the aortic valve shows a bicuspid aortic valve (arrow), with mild thickening of the aortic leaflets and calcification within the aortic sinuses. (b) Virtual endoscopic image of the thoracic aorta shows the bicuspid aortic valve (arrow) and valvular calcification. Note the origin of the left coronary artery within the sinus of Valsalva (L), whereas the origin of the right coronary artery (R) is above the sinotubular junction. Because the ostia of the coronary arteries are less than 180o apart, a stentless aortic valve can be safely placed within the aortic valve position.

View larger version (182K): [in a new window]   Figure 4b.  Preoperative assessment of the thoracic aorta in a 57-year-old man with a history of aortic stenosis. (a) Oblique axial MPR view of the aortic valve shows a bicuspid aortic valve (arrow), with mild thickening of the aortic leaflets and calcification within the aortic sinuses. (b) Virtual endoscopic image of the thoracic aorta shows the bicuspid aortic valve (arrow) and valvular calcification. Note the origin of the left coronary artery within the sinus of Valsalva (L), whereas the origin of the right coronary artery (R) is above the sinotubular junction. Because the ostia of the coronary arteries are less than 180o apart, a stentless aortic valve can be safely placed within the aortic valve position.

View larger version (141K): [in a new window]   Figure 5a.  Postoperative evaluation of LIMA graft patency in a 73-year-old man. (a) Coronal volume-rendered image of the thoracic aorta shows normal appearance of the LIMA graft (arrow). A = aorta, RVOT = right ventricular outflow tract. Note the normal appearance of the right coronary artery (arrowhead). (b) Sagittal image shows the relationship of the LIMA graft (arrow) to the sternum. Note the distance between the graft and the sternum. This LIMA graft is at low risk for injury during sternal reentry.

View larger version (187K): [in a new window]   Figure 5b.  Postoperative evaluation of LIMA graft patency in a 73-year-old man. (a) Coronal volume-rendered image of the thoracic aorta shows normal appearance of the LIMA graft (arrow). A = aorta, RVOT = right ventricular outflow tract. Note the normal appearance of the right coronary artery (arrowhead). (b) Sagittal image shows the relationship of the LIMA graft (arrow) to the sternum. Note the distance between the graft and the sternum. This LIMA graft is at low risk for injury during sternal reentry.

View larger version (108K): [in a new window]   Figure 6a.  Preoperative assessment for aortic valve replacement in a 72-year-old man who had undergone CABG. Sequential coronal volume-rendered images show relationship of the sternum to the LIMA (arrow) and saphenous vein (arrowhead in b) grafts. The position of the LIMA graft lateral to the sternum makes sternal reentry uncomplicated.

View larger version (101K): [in a new window]   Figure 6b.  Preoperative assessment for aortic valve replacement in a 72-year-old man who had undergone CABG. Sequential coronal volume-rendered images show relationship of the sternum to the LIMA (arrow) and saphenous vein (arrowhead in b) grafts. The position of the LIMA graft lateral to the sternum makes sternal reentry uncomplicated.

View larger version (116K): [in a new window]   Figure 7a.  Preoperative assessment for aortic valve replacement in a 67-year-old man who had undergone CABG. Axial CT image (a) and sagittal volume-rendered image (b) show adherence of the LIMA graft (arrow) to the inner table of the sternum. Given these findings, the surgeon did not attempt the usual operative dissection of the LIMA graft during the surgical procedure.

View larger version (170K): [in a new window]   Figure 7b.  Preoperative assessment for aortic valve replacement in a 67-year-old man who had undergone CABG. Axial CT image (a) and sagittal volume-rendered image (b) show adherence of the LIMA graft (arrow) to the inner table of the sternum. Given these findings, the surgeon did not attempt the usual operative dissection of the LIMA graft during the surgical procedure.

View larger version (82K): [in a new window]   Figure 8a.  Preoperative assessment for mitral valve replacement and CABG in a 43-year-old woman who had undergone placement of an automatic implantable cardioverter/defibrillator. Physical examination revealed a continuous murmur over the left side of the chest. (a) Axial CT scan shows enlargement of the left internal mammary artery and vein. Note enhancement of both dilated internal mammary artery and vein (arrow). (b) Coronal MIP image shows the dilated, fistulous internal mammary artery and vein (arrow).

View larger version (155K): [in a new window]   Figure 8b.  Preoperative assessment for mitral valve replacement and CABG in a 43-year-old woman who had undergone placement of an automatic implantable cardioverter/defibrillator. Physical examination revealed a continuous murmur over the left side of the chest. (a) Axial CT scan shows enlargement of the left internal mammary artery and vein. Note enhancement of both dilated internal mammary artery and vein (arrow). (b) Coronal MIP image shows the dilated, fistulous internal mammary artery and vein (arrow).

View larger version (120K): [in a new window]   Figure 9a.  Preoperative assessment of the existing RIMA graft in a 67-year-old man scheduled for CABG surgery. (a) Axial image shows the portion of the RIMA graft as it crosses near the sternum (arrow). (b) Curved axial MPR image shows the full course of the RIMA graft (arrow) as it crosses the midline to pass directly behind the sternum (S) and anastomose to the circumflex artery (arrowhead). A = transverse aortic arch.

View larger version (142K): [in a new window]   Figure 9b.  Preoperative assessment of the existing RIMA graft in a 67-year-old man scheduled for CABG surgery. (a) Axial image shows the portion of the RIMA graft as it crosses near the sternum (arrow). (b) Curved axial MPR image shows the full course of the RIMA graft (arrow) as it crosses the midline to pass directly behind the sternum (S) and anastomose to the circumflex artery (arrowhead). A = transverse aortic arch.

View larger version (127K): [in a new window]   Figure 10a.  Postoperative evaluation of graft patency in a 67-year-old man. (a) Coronal volume-rendered image shows normal postoperative position of the right (R) sided and left (L) sided saphenous vein grafts. (b) Axial volume-rendered image in a cephalocaudal orientation shows relationship of the left-sided saphenous vein (long arrow) to the sternum (short arrow). (c) Sagittal volume-rendered image shows position of the right-sided saphenous vein graft (arrow) to the sternum.

View larger version (119K): [in a new window]   Figure 10b.  Postoperative evaluation of graft patency in a 67-year-old man. (a) Coronal volume-rendered image shows normal postoperative position of the right (R) sided and left (L) sided saphenous vein grafts. (b) Axial volume-rendered image in a cephalocaudal orientation shows relationship of the left-sided saphenous vein (long arrow) to the sternum (short arrow). (c) Sagittal volume-rendered image shows position of the right-sided saphenous vein graft (arrow) to the sternum.

View larger version (179K): [in a new window]   Figure 10c.  Postoperative evaluation of graft patency in a 67-year-old man. (a) Coronal volume-rendered image shows normal postoperative position of the right (R) sided and left (L) sided saphenous vein grafts. (b) Axial volume-rendered image in a cephalocaudal orientation shows relationship of the left-sided saphenous vein (long arrow) to the sternum (short arrow). (c) Sagittal volume-rendered image shows position of the right-sided saphenous vein graft (arrow) to the sternum.

View larger version (83K): [in a new window]   Figure 11a.  Preoperative evaluation for aortic valve repair in a 77-year-old woman with a history of prior CABG. (a) Nonenhanced axial CT image obtained for aortic atherosclerosis assessment shows a subtle, rounded area of soft-tissue attenuation posterior to the sternum (arrow), a finding that suggests an adherent saphenous vein graft. (b) Sagittal curved MPR image shows adherence of the saphenous vein graft to the inner table of the sternum (arrows). The extent of adhesions in the patient resulted in an extensive dissection of the saphenous vein graft from the sternum before sternotomy was attempted.

View larger version (104K): [in a new window]   Figure 11b.  Preoperative evaluation for aortic valve repair in a 77-year-old woman with a history of prior CABG. (a) Nonenhanced axial CT image obtained for aortic atherosclerosis assessment shows a subtle, rounded area of soft-tissue attenuation posterior to the sternum (arrow), a finding that suggests an adherent saphenous vein graft. (b) Sagittal curved MPR image shows adherence of the saphenous vein graft to the inner table of the sternum (arrows). The extent of adhesions in the patient resulted in an extensive dissection of the saphenous vein graft from the sternum before sternotomy was attempted.

View larger version (79K): [in a new window]   Figure 12a.  Preoperative evaluation for epicardial placement of an automatic implantable cardioverter/defibrillator in an 82-year-old man. (a) Axial CT image shows a central filling defect within the proximal left saphenous vein graft (arrow). (b) MPR image of the left coronary graft shows extensive filling defects within the saphenous vein graft (arrow). (c) Virtual endoscopic image of the left-sided saphenous vein graft reveals extensive mural thrombus (arrow) within the graft. This finding places the patient at risk for peripheral embolization with surgical manipulation of the graft.

View larger version (102K): [in a new window]   Figure 12b.  Preoperative evaluation for epicardial placement of an automatic implantable cardioverter/defibrillator in an 82-year-old man. (a) Axial CT image shows a central filling defect within the proximal left saphenous vein graft (arrow). (b) MPR image of the left coronary graft shows extensive filling defects within the saphenous vein graft (arrow). (c) Virtual endoscopic image of the left-sided saphenous vein graft reveals extensive mural thrombus (arrow) within the graft. This finding places the patient at risk for peripheral embolization with surgical manipulation of the graft.

View larger version (115K): [in a new window]   Figure 12c.  Preoperative evaluation for epicardial placement of an automatic implantable cardioverter/defibrillator in an 82-year-old man. (a) Axial CT image shows a central filling defect within the proximal left saphenous vein graft (arrow). (b) MPR image of the left coronary graft shows extensive filling defects within the saphenous vein graft (arrow). (c) Virtual endoscopic image of the left-sided saphenous vein graft reveals extensive mural thrombus (arrow) within the graft. This finding places the patient at risk for peripheral embolization with surgical manipulation of the graft.

View larger version (64K): [in a new window]   Figure 13a.  Evaluation of a thoracic aortic aneurysm in an 82-year-old man with a history of prior CABG. (a) Axial MIP image shows aneurysmal dilatation of the ascending aorta (arrow). This dilatation results in a 2-mm separation between the origin of the saphenous vein graft and the inner table of the sternum (arrowhead). (b) Craniocaudal volume-rendered image shows the proximity of the saphenous vein graft (arrow) to the sternum.

View larger version (128K): [in a new window]   Figure 13b.  Evaluation of a thoracic aortic aneurysm in an 82-year-old man with a history of prior CABG. (a) Axial MIP image shows aneurysmal dilatation of the ascending aorta (arrow). This dilatation results in a 2-mm separation between the origin of the saphenous vein graft and the inner table of the sternum (arrowhead). (b) Craniocaudal volume-rendered image shows the proximity of the saphenous vein graft (arrow) to the sternum.

View larger version (81K): [in a new window]   Figure 14.  Assessment of thoracic aortic aneurysm repair in an 82-year-old man with a history of prior CABG. Axial MIP image shows a saphenous vein graft (arrow) in close apposition to the patient’s thoracic aneurysm

View larger version (151K): [in a new window]   Figure 15.  Evaluation of a saphenous vein graft in a 70-year-old man with multiple prior revascularizations for coronary artery disease. The previous reoperative surgery had used an end-to-side descending aorta-saphenous vein graft to anastomose to a proximally occluded saphenous vein graft. Because of possible risk of embolization from cardiac catheterization, a CT evaluation was requested. Sagittal reformatted image shows the patent end-to-side saphenous vein graft from the descending aorta to the existing saphenous vein-circumflex graft (arrows). No catheterization was performed and no surgical intervention was necessary.

View larger version (111K): [in a new window]   Figure 16a.  Preoperative evaluation for aortic valve replacement in an 87-year-old woman with a history of prior CABG. (a) Axial CT image shows a partially enhancing aneurysm of the saphenous vein graft to the left circumflex artery (arrow). (b) Axial CT scan obtained inferior to a shows a larger saphenous vein graft aneurysm to the right coronary artery (arrow). (c) Sagittal volume-rendered image shows the relationship of the superior saphenous vein graft aneurysm to the sternum (arrow).

View larger version (130K): [in a new window]   Figure 16b.  Preoperative evaluation for aortic valve replacement in an 87-year-old woman with a history of prior CABG. (a) Axial CT image shows a partially enhancing aneurysm of the saphenous vein graft to the left circumflex artery (arrow). (b) Axial CT scan obtained inferior to a shows a larger saphenous vein graft aneurysm to the right coronary artery (arrow). (c) Sagittal volume-rendered image shows the relationship of the superior saphenous vein graft aneurysm to the sternum (arrow).

View larger version (174K): [in a new window]   Figure 16c.  Preoperative evaluation for aortic valve replacement in an 87-year-old woman with a history of prior CABG. (a) Axial CT image shows a partially enhancing aneurysm of the saphenous vein graft to the left circumflex artery (arrow). (b) Axial CT scan obtained inferior to a shows a larger saphenous vein graft aneurysm to the right coronary artery (arrow). (c) Sagittal volume-rendered image shows the relationship of the superior saphenous vein graft aneurysm to the sternum (arrow).

View larger version (86K): [in a new window]   Figure 17a.  Preoperative assessment for aortic aneurysm repair in a 52-year-old man who had previously undergone repair of a type A aortic dissection. (a) Axial ECG-gated CT image obtained during diastole shows the relationship of the right coronary artery to the sternum (arrow.) Note the distance from the native right coronary artery to the sternum. (b) Axial ECG-gated CT image obtained during systole shows close approximation of the right coronary artery to the sternum (arrow). Because of this close anatomic relationship, a "keyhole" sternal incision was performed to avoid injury to the native coronary artery.

View larger version (90K): [in a new window]   Figure 17b.  Preoperative assessment for aortic aneurysm repair in a 52-year-old man who had previously undergone repair of a type A aortic dissection. (a) Axial ECG-gated CT image obtained during diastole shows the relationship of the right coronary artery to the sternum (arrow.) Note the distance from the native right coronary artery to the sternum. (b) Axial ECG-gated CT image obtained during systole shows close approximation of the right coronary artery to the sternum (arrow). Because of this close anatomic relationship, a "keyhole" sternal incision was performed to avoid injury to the native coronary artery.

View larger version (85K): [in a new window]   Figure 18a.  Assessment of a 43-year-old man with a history of aortic dissection who presented to the emergency department with recurrent chest pain. Original nongated CT study was inconclusive for aortic dissection. (a) Axial ECG-gated image of the aortic root shows aortic dissection, with the posterior dissection flap involving the origin of the left coronary artery (arrow). (b) Axial CT scan obtained superior to a shows involvement of the origin of the right coronary artery (arrow). Because of these findings, the patient’s LIMA and saphenous vein grafts were dissected before coronary bypass in anticipation of coronary revascularization. Dissection involving the native coronary arteries was confirmed at surgery, and coronary artery bypass was performed.

View larger version (85K): [in a new window]   Figure 18b.  Assessment of a 43-year-old man with a history of aortic dissection who presented to the emergency department with recurrent chest pain. Original nongated CT study was inconclusive for aortic dissection. (a) Axial ECG-gated image of the aortic root shows aortic dissection, with the posterior dissection flap involving the origin of the left coronary artery (arrow). (b) Axial CT scan obtained superior to a shows involvement of the origin of the right coronary artery (arrow). Because of these findings, the patient’s LIMA and saphenous vein grafts were dissected before coronary bypass in anticipation of coronary revascularization. Dissection involving the native coronary arteries was confirmed at surgery, and coronary artery bypass was performed.

View larger version (90K): [in a new window]   Figure 19a.  Preoperative evaluation of a 53-year-man with chest pain. Coronary catheterization showed stenosis of the right coronary artery and findings consistent with an aberrant left coronary artery, which originated from the right coronary cusp. CT was requested to evaluate the anatomic course of the left coronary artery. (a) Axial curved MPR image shows the left coronary artery originating from the right coronary artery orifice (arrow), with passage of the left coronary artery between the pulmonary artery and aorta. (b) Sagittal volume-rendered image shows the relationship of the left coronary artery as it passes between the aortic root and pulmonary artery. Given this anomalous course, the cardiac surgeon used a LIMA graft to the distal left main coronary artery to bypass the anatomic site of narrowing.

View larger version (109K): [in a new window]   Figure 19b.  Preoperative evaluation of a 53-year-man with chest pain. Coronary catheterization showed stenosis of the right coronary artery and findings consistent with an aberrant left coronary artery, which originated from the right coronary cusp. CT was requested to evaluate the anatomic course of the left coronary artery. (a) Axial curved MPR image shows the left coronary artery originating from the right coronary artery orifice (arrow), with passage of the left coronary artery between the pulmonary artery and aorta. (b) Sagittal volume-rendered image shows the relationship of the left coronary artery as it passes between the aortic root and pulmonary artery. Given this anomalous course, the cardiac surgeon used a LIMA graft to the distal left main coronary artery to bypass the anatomic site of narrowing.