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Multi–Detector Row CT Angiography in Patients with Abdominal Angina¹

¹ From the Department of Radiology, Erasmus Medical Center-Rotterdam, Dr Molenwaterplein 40, 3015 GD-Rotterdam, The Netherlands. Presented as an education exhibit at the 2002 RSNA scientific assembly. Received July 15, 2003; revision requested August 19 and received December 8; accepted December 11. All authors have no financial relationships to disclose. Address correspondence to F.C. (e-mail: filippocademartiri@hotmail.com).

	Abstract

Top Abstract LEARNING OBJECTIVES Introduction Abdominal Angina Multi-Detector Row CT Protocol... Discussion Conclusions References

 
Abdominal angina (AA) is an infrequently occurring syndrome characterized by postprandial abdominal pain due to reduced blood flow to organs in the territory of the celiac trunk, superior mesenteric artery (SMA), and inferior mesenteric artery. Multi–detector row computed tomographic (CT) angiography with four- or 16-row scanners has become a primary tool for the evaluation of patients with suspected steno-occlusive diseases of the abdominal vessels. In patients with suspected AA, multi–detector row CT angiography can help evaluate the presence and degree of stenosis in the celiac trunk and SMA, demonstrate the collateral circulation, and help exclude other causes of vascular obstruction. It also allows visualization of small vessels and of vessel wall abnormalities in the absence of significant stenosis. Vessels with a complex anatomic configuration can easily be visualized with proper postprocessing techniques. This modality can also be used to follow up patients who have undergone percutaneous interventional treatment. Limitations include the lack of dynamic representation of flow abnormalities and difficulty in evaluating heavily calcified vessels. Nevertheless, multi–detector row CT angiography with appropriate postprocessing techniques is highly effective for the diagnosis, evaluation, and treatment of suspected AA. Additional studies will help further evaluate the performance and applications of this modality.

© RSNA, 2004

Index Terms: Abdomen, CT, 95.12916 • Abdomen, diseases, 95.761 • Computed tomography (CT), angiography, 95.12916 • Computed tomography (CT), multi–detector row, 95.12916 • Computed tomography (CT), technology, 95.12916 • Mesentery, ischemia, 792.769

	LEARNING OBJECTIVES

Top Abstract LEARNING OBJECTIVES Introduction Abdominal Angina Multi-Detector Row CT Protocol... Discussion Conclusions References

 
After reading this article and taking the test, the reader will be able to:

• Describe the epidemiology, pathogenesis, natural history, diagnosis, and treatment of abdominal angina.
  
• Discuss the optimal protocol for multi–detector row CT of the splanchnic vessels with appropriate postprocessing techniques.
  

	Introduction

Top Abstract LEARNING OBJECTIVES Introduction Abdominal Angina Multi-Detector Row CT Protocol... Discussion Conclusions References

 
When arterial blood flow to the intestines is compromised, a complicated disorder known as mesenteric ischemia occurs. This disorder is classified as either acute or chronic, depending on its clinical manifestation. The chronic form of mesenteric ischemia is the pathophysiologic cause of the symptom of abdominal angina (AA), based on the fact that patients experience abdominal pain with increased demand for blood at the level of the splanchnic organs. This increased demand normally occurs after meals. AA is mostly due to atherosclerotic obstruction of the superior mesenteric artery (SMA) and celiac trunk. Advanced disease can result in fatal intestinal necrosis.

Angiography is the standard of reference in work-up of patients with suspected mesenteric ischemia, but it is invasive and time-consuming.

Computed tomography (CT) was introduced in the late 1970s, but its performance in the detection of mesenteric ischemia before the introduction of spiral technology was relatively poor (1,2). Spiral single–detector row CT allowed narrower collimations and faster scans, thereby improving the depiction of the mesenteric vessels and bowel wall, but did not have sufficient sensitivity for the early detection of reversible small bowel ischemia; thus, in most cases, angiography was still necessary (3,4).

Spiral four–detector row CT was introduced in 1998 and improved on the performance of previous spiral CT systems by a factor of eight, combining multiple rows of detectors and faster gantry rotation with narrow collimation (5). In 2002, a generation of 16–detector row CT scanners was introduced, with a further reduction in section collimation and scan time (6–9).

CT is useful in patients with suspected ischemia because it can (a) help detect ischemic changes in the affected small bowel loops and mesentery (bowel wall thickening and edema, submucosal hemorrhage, changes in bowel wall enhancement, mesenteric stranding or fluid, pneumatosis) and (b) help determine the cause of the ischemia by allowing evaluation of the mesenteric vasculature for obstructive disease resulting from atherosclerosis, thrombus, occlusion, compression or invasion by tumor, or trauma.

With earlier CT (sequential and early spiral CT), the detection of bowel ischemic changes was limited in that only secondary signs were revealed. This limitation is especially problematic in chronic disease (eg, AA), in which secondary signs are mild or even absent. In contrast, the latest generations of four- and 16-row CT scanners can help determine the cause of bowel ischemia at the level of the splanchnic vessels.

In this article, we suggest an optimized protocol for multi–detector row CT angiography with appropriate postprocessing techniques. We also discuss and illustrate the epidemiology, pathogenesis, natural history, diagnosis, and treatment of AA.

	Abdominal Angina

Top Abstract LEARNING OBJECTIVES Introduction Abdominal Angina Multi-Detector Row CT Protocol... Discussion Conclusions References

 
AA, also known as chronic mesenteric ischemia, is the syndrome of chronic arterial insufficiency of the intestine. AA is characterized by abdominal epigastric pain, which typically occurs with increased demand for splanchnic blood flow after a meal.

Epidemiologic Characteristics
The true prevalence of AA is unknown. Females are more frequently affected than males by a 3:1 ratio, and the mean age of affected patients is 60 years. Ancillary reports state that 18% of patients over 65 years old have mesenteric arterial stenosis of 50% or more, even though very few of these patients are symptomatic (10,11).

Pathogenesis
AA is caused by the stenosis or obstruction of the celiac trunk, SMA, and inferior mesenteric artery (IMA). It often appears in the context of diffuse atherosclerotic disease. The degree of stenosis or obstruction capable of determining clinical symptoms of each single tributary axis is variable and probably depends on anatomic configuration, the speed of progression of the stenotic or obstructional process, and the presence of collateral vessels. Generally, all three main supplying vessels are variably occluded or narrowed, with at least two being significantly compromised. In fact, because of extensive collateral vessels between the vascular territories of the three main splanchnic arteries, AA most commonly occurs whenever at least two of the three vessels are obstructed. There is usually atherosclerotic obstruction at the origins of the celiac trunk and SMA.

In some cases, the assessment of flow reduction based solely on morphology is not sufficient, and magnetic resonance (MR) imaging can play a significant role (12).

Other less frequent causes of vessel obstruction include fibromuscular dysplasia, Takayasu arteritis, and, rarely, extrinsic obstruction or vessel encasement by a tumor.

Natural History
Like atherosclerotic disease in other vascular territories, AA is slowly progressive. On average, complaints exist for 1 year before treatment is sought. Complications such as frank bowel infarction or malnutrition are the sources of high morbidity and mortality and help determine the need for treatment (Fig 1).

View larger version (97K): [in this window] [in a new window] [Download PPT slide]   Figure 1a.  Natural history of AA. The patient was a 64-year-old woman who had lost 12 kg and was experiencing characteristic cramping abdominal pain after meals. (a, b) Panoramic three-dimensional (3D) volume-rendered (VR) (a) and maximum-intensity-projection (MIP) (b) images show high-grade stenoses at the origins of the celiac trunk and SMA. Collateral intestinal perfusion is supplied by the IMA via a hypertrophic Riolan arc (arrow). (c-f) Magnified views show the high-grade stenoses more clearly. Several days after undergoing multi-detector row CT angiography, the patient developed rapidly progressing abdominal pain and a rising serum lactate level. (g) Abdominal CT scans show signs of bowel ischemia, with distended small bowel loops and wall thickening. Results of surgery performed the following day confirmed necrosis of the entire small bowel. The patient died the day after surgery.

View larger version (139K): [in this window] [in a new window] [Download PPT slide]   Figure 1b.  Natural history of AA. The patient was a 64-year-old woman who had lost 12 kg and was experiencing characteristic cramping abdominal pain after meals. (a, b) Panoramic three-dimensional (3D) volume-rendered (VR) (a) and maximum-intensity-projection (MIP) (b) images show high-grade stenoses at the origins of the celiac trunk and SMA. Collateral intestinal perfusion is supplied by the IMA via a hypertrophic Riolan arc (arrow). (c-f) Magnified views show the high-grade stenoses more clearly. Several days after undergoing multi-detector row CT angiography, the patient developed rapidly progressing abdominal pain and a rising serum lactate level. (g) Abdominal CT scans show signs of bowel ischemia, with distended small bowel loops and wall thickening. Results of surgery performed the following day confirmed necrosis of the entire small bowel. The patient died the day after surgery.

View larger version (59K): [in this window] [in a new window] [Download PPT slide]   Figure 1c.  Natural history of AA. The patient was a 64-year-old woman who had lost 12 kg and was experiencing characteristic cramping abdominal pain after meals. (a, b) Panoramic three-dimensional (3D) volume-rendered (VR) (a) and maximum-intensity-projection (MIP) (b) images show high-grade stenoses at the origins of the celiac trunk and SMA. Collateral intestinal perfusion is supplied by the IMA via a hypertrophic Riolan arc (arrow). (c-f) Magnified views show the high-grade stenoses more clearly. Several days after undergoing multi-detector row CT angiography, the patient developed rapidly progressing abdominal pain and a rising serum lactate level. (g) Abdominal CT scans show signs of bowel ischemia, with distended small bowel loops and wall thickening. Results of surgery performed the following day confirmed necrosis of the entire small bowel. The patient died the day after surgery.

View larger version (58K): [in this window] [in a new window] [Download PPT slide]   Figure 1d.  Natural history of AA. The patient was a 64-year-old woman who had lost 12 kg and was experiencing characteristic cramping abdominal pain after meals. (a, b) Panoramic three-dimensional (3D) volume-rendered (VR) (a) and maximum-intensity-projection (MIP) (b) images show high-grade stenoses at the origins of the celiac trunk and SMA. Collateral intestinal perfusion is supplied by the IMA via a hypertrophic Riolan arc (arrow). (c-f) Magnified views show the high-grade stenoses more clearly. Several days after undergoing multi-detector row CT angiography, the patient developed rapidly progressing abdominal pain and a rising serum lactate level. (g) Abdominal CT scans show signs of bowel ischemia, with distended small bowel loops and wall thickening. Results of surgery performed the following day confirmed necrosis of the entire small bowel. The patient died the day after surgery.

View larger version (83K): [in this window] [in a new window] [Download PPT slide]   Figure 1e.  Natural history of AA. The patient was a 64-year-old woman who had lost 12 kg and was experiencing characteristic cramping abdominal pain after meals. (a, b) Panoramic three-dimensional (3D) volume-rendered (VR) (a) and maximum-intensity-projection (MIP) (b) images show high-grade stenoses at the origins of the celiac trunk and SMA. Collateral intestinal perfusion is supplied by the IMA via a hypertrophic Riolan arc (arrow). (c-f) Magnified views show the high-grade stenoses more clearly. Several days after undergoing multi-detector row CT angiography, the patient developed rapidly progressing abdominal pain and a rising serum lactate level. (g) Abdominal CT scans show signs of bowel ischemia, with distended small bowel loops and wall thickening. Results of surgery performed the following day confirmed necrosis of the entire small bowel. The patient died the day after surgery.

View larger version (81K): [in this window] [in a new window] [Download PPT slide]   Figure 1f.  Natural history of AA. The patient was a 64-year-old woman who had lost 12 kg and was experiencing characteristic cramping abdominal pain after meals. (a, b) Panoramic three-dimensional (3D) volume-rendered (VR) (a) and maximum-intensity-projection (MIP) (b) images show high-grade stenoses at the origins of the celiac trunk and SMA. Collateral intestinal perfusion is supplied by the IMA via a hypertrophic Riolan arc (arrow). (c-f) Magnified views show the high-grade stenoses more clearly. Several days after undergoing multi-detector row CT angiography, the patient developed rapidly progressing abdominal pain and a rising serum lactate level. (g) Abdominal CT scans show signs of bowel ischemia, with distended small bowel loops and wall thickening. Results of surgery performed the following day confirmed necrosis of the entire small bowel. The patient died the day after surgery.

View larger version (48K): [in this window] [in a new window] [Download PPT slide]   Figure 1g.  Natural history of AA. The patient was a 64-year-old woman who had lost 12 kg and was experiencing characteristic cramping abdominal pain after meals. (a, b) Panoramic three-dimensional (3D) volume-rendered (VR) (a) and maximum-intensity-projection (MIP) (b) images show high-grade stenoses at the origins of the celiac trunk and SMA. Collateral intestinal perfusion is supplied by the IMA via a hypertrophic Riolan arc (arrow). (c-f) Magnified views show the high-grade stenoses more clearly. Several days after undergoing multi-detector row CT angiography, the patient developed rapidly progressing abdominal pain and a rising serum lactate level. (g) Abdominal CT scans show signs of bowel ischemia, with distended small bowel loops and wall thickening. Results of surgery performed the following day confirmed necrosis of the entire small bowel. The patient died the day after surgery.

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 2a.  Typical CT angiographic appearance of AA: phase 1—diagnosis. The patient was a 49-year-old man who was experiencing characteristic cramping abdominal pain after meals. (a) Multi-detector row CT angiogram shows a mildly stenotic celiac trunk and a high-grade atherosclerotic obstruction of the SMA. The IMA is not seen. (b) Digital subtraction angiogram (DSA) helps confirm the findings at multi-detector row CT. (c-f) Curved multiplanar reformatted (MPR) images obtained along the celiac trunk (c, d) and SMA (e, f) clearly demonstrate the extent of stenotic disease.

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 2b.  Typical CT angiographic appearance of AA: phase 1—diagnosis. The patient was a 49-year-old man who was experiencing characteristic cramping abdominal pain after meals. (a) Multi-detector row CT angiogram shows a mildly stenotic celiac trunk and a high-grade atherosclerotic obstruction of the SMA. The IMA is not seen. (b) Digital subtraction angiogram (DSA) helps confirm the findings at multi-detector row CT. (c-f) Curved multiplanar reformatted (MPR) images obtained along the celiac trunk (c, d) and SMA (e, f) clearly demonstrate the extent of stenotic disease.

View larger version (160K): [in this window] [in a new window] [Download PPT slide]   Figure 2c.  Typical CT angiographic appearance of AA: phase 1—diagnosis. The patient was a 49-year-old man who was experiencing characteristic cramping abdominal pain after meals. (a) Multi-detector row CT angiogram shows a mildly stenotic celiac trunk and a high-grade atherosclerotic obstruction of the SMA. The IMA is not seen. (b) Digital subtraction angiogram (DSA) helps confirm the findings at multi-detector row CT. (c-f) Curved multiplanar reformatted (MPR) images obtained along the celiac trunk (c, d) and SMA (e, f) clearly demonstrate the extent of stenotic disease.

View larger version (155K): [in this window] [in a new window] [Download PPT slide]   Figure 2d.  Typical CT angiographic appearance of AA: phase 1—diagnosis. The patient was a 49-year-old man who was experiencing characteristic cramping abdominal pain after meals. (a) Multi-detector row CT angiogram shows a mildly stenotic celiac trunk and a high-grade atherosclerotic obstruction of the SMA. The IMA is not seen. (b) Digital subtraction angiogram (DSA) helps confirm the findings at multi-detector row CT. (c-f) Curved multiplanar reformatted (MPR) images obtained along the celiac trunk (c, d) and SMA (e, f) clearly demonstrate the extent of stenotic disease.

View larger version (166K): [in this window] [in a new window] [Download PPT slide]   Figure 2e.  Typical CT angiographic appearance of AA: phase 1—diagnosis. The patient was a 49-year-old man who was experiencing characteristic cramping abdominal pain after meals. (a) Multi-detector row CT angiogram shows a mildly stenotic celiac trunk and a high-grade atherosclerotic obstruction of the SMA. The IMA is not seen. (b) Digital subtraction angiogram (DSA) helps confirm the findings at multi-detector row CT. (c-f) Curved multiplanar reformatted (MPR) images obtained along the celiac trunk (c, d) and SMA (e, f) clearly demonstrate the extent of stenotic disease.

View larger version (141K): [in this window] [in a new window] [Download PPT slide]   Figure 2f.  Typical CT angiographic appearance of AA: phase 1—diagnosis. The patient was a 49-year-old man who was experiencing characteristic cramping abdominal pain after meals. (a) Multi-detector row CT angiogram shows a mildly stenotic celiac trunk and a high-grade atherosclerotic obstruction of the SMA. The IMA is not seen. (b) Digital subtraction angiogram (DSA) helps confirm the findings at multi-detector row CT. (c-f) Curved multiplanar reformatted (MPR) images obtained along the celiac trunk (c, d) and SMA (e, f) clearly demonstrate the extent of stenotic disease.

View larger version (89K): [in this window] [in a new window] [Download PPT slide]   Figure 3a.  Typical CT angiographic appearance of AA: phase 2—treatment planning (same patient as in Fig 2). (a, b) Paraaxial (a) and parasagittal (b) curved MPR images allow evaluation of vessel diameter at the stenosis (line 1) and in the distal segment (line 2) of the SMA (7 mm). (c-e) Locations of the resulting orthogonal cuts are shown in c and d; e displays the length of the segment requiring percutaneous treatment (18 mm). The ostial diameter is not well assessed because of the proximity of the stenosis. The patient experienced relief from symptoms after placement of a balloon-expandable, 31-gauge stainless-steel 7 x 22-mm stent.

View larger version (126K): [in this window] [in a new window] [Download PPT slide]   Figure 3b.  Typical CT angiographic appearance of AA: phase 2—treatment planning (same patient as in Fig 2). (a, b) Paraaxial (a) and parasagittal (b) curved MPR images allow evaluation of vessel diameter at the stenosis (line 1) and in the distal segment (line 2) of the SMA (7 mm). (c-e) Locations of the resulting orthogonal cuts are shown in c and d; e displays the length of the segment requiring percutaneous treatment (18 mm). The ostial diameter is not well assessed because of the proximity of the stenosis. The patient experienced relief from symptoms after placement of a balloon-expandable, 31-gauge stainless-steel 7 x 22-mm stent.

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 3c.  Typical CT angiographic appearance of AA: phase 2—treatment planning (same patient as in Fig 2). (a, b) Paraaxial (a) and parasagittal (b) curved MPR images allow evaluation of vessel diameter at the stenosis (line 1) and in the distal segment (line 2) of the SMA (7 mm). (c-e) Locations of the resulting orthogonal cuts are shown in c and d; e displays the length of the segment requiring percutaneous treatment (18 mm). The ostial diameter is not well assessed because of the proximity of the stenosis. The patient experienced relief from symptoms after placement of a balloon-expandable, 31-gauge stainless-steel 7 x 22-mm stent.

View larger version (141K): [in this window] [in a new window] [Download PPT slide]   Figure 3d.  Typical CT angiographic appearance of AA: phase 2—treatment planning (same patient as in Fig 2). (a, b) Paraaxial (a) and parasagittal (b) curved MPR images allow evaluation of vessel diameter at the stenosis (line 1) and in the distal segment (line 2) of the SMA (7 mm). (c-e) Locations of the resulting orthogonal cuts are shown in c and d; e displays the length of the segment requiring percutaneous treatment (18 mm). The ostial diameter is not well assessed because of the proximity of the stenosis. The patient experienced relief from symptoms after placement of a balloon-expandable, 31-gauge stainless-steel 7 x 22-mm stent.

View larger version (143K): [in this window] [in a new window] [Download PPT slide]   Figure 3e.  Typical CT angiographic appearance of AA: phase 2—treatment planning (same patient as in Fig 2). (a, b) Paraaxial (a) and parasagittal (b) curved MPR images allow evaluation of vessel diameter at the stenosis (line 1) and in the distal segment (line 2) of the SMA (7 mm). (c-e) Locations of the resulting orthogonal cuts are shown in c and d; e displays the length of the segment requiring percutaneous treatment (18 mm). The ostial diameter is not well assessed because of the proximity of the stenosis. The patient experienced relief from symptoms after placement of a balloon-expandable, 31-gauge stainless-steel 7 x 22-mm stent.

Four–detector row CT angiography is well suited for noninvasive imaging of the abdominal arteries (14,15) and clearly depicts branches of the SMA and celiac trunk (14). This technique is accurate and is less expensive and more tolerable than conventional DSA (16). Moreover, multi–detector row CT angiography provides additional information about the surrounding anatomic structures, which can be critical in developing the differential diagnosis and planning patient treatment (Figs 3, 4).

View larger version (130K): [in this window] [in a new window] [Download PPT slide]   Figure 4a.  Typical CT angiographic appearance of AA: phase 3—follow-up (same patient as in Fig 2). Follow-up multi-detector row CT angiogram (a), MIP images (b, c), and MPR images (d, e) obtained 6 months after stent placement to assess patency show that the stent is correctly positioned, protruding a few millimeters into the aortic lumen. No signs of in-stent restenosis are visualized.

View larger version (125K): [in this window] [in a new window] [Download PPT slide]   Figure 4b.  Typical CT angiographic appearance of AA: phase 3—follow-up (same patient as in Fig 2). Follow-up multi-detector row CT angiogram (a), MIP images (b, c), and MPR images (d, e) obtained 6 months after stent placement to assess patency show that the stent is correctly positioned, protruding a few millimeters into the aortic lumen. No signs of in-stent restenosis are visualized.

View larger version (115K): [in this window] [in a new window] [Download PPT slide]   Figure 4c.  Typical CT angiographic appearance of AA: phase 3—follow-up (same patient as in Fig 2). Follow-up multi-detector row CT angiogram (a), MIP images (b, c), and MPR images (d, e) obtained 6 months after stent placement to assess patency show that the stent is correctly positioned, protruding a few millimeters into the aortic lumen. No signs of in-stent restenosis are visualized.

View larger version (134K): [in this window] [in a new window] [Download PPT slide]   Figure 4d.  Typical CT angiographic appearance of AA: phase 3—follow-up (same patient as in Fig 2). Follow-up multi-detector row CT angiogram (a), MIP images (b, c), and MPR images (d, e) obtained 6 months after stent placement to assess patency show that the stent is correctly positioned, protruding a few millimeters into the aortic lumen. No signs of in-stent restenosis are visualized.

View larger version (138K): [in this window] [in a new window] [Download PPT slide]   Figure 4e.  Typical CT angiographic appearance of AA: phase 3—follow-up (same patient as in Fig 2). Follow-up multi-detector row CT angiogram (a), MIP images (b, c), and MPR images (d, e) obtained 6 months after stent placement to assess patency show that the stent is correctly positioned, protruding a few millimeters into the aortic lumen. No signs of in-stent restenosis are visualized.

On the basis of recent technical improvements and previously reported optimal results, we developed a multi–detector CT angiography protocol for the evaluation of patients with suspected chronic mesenteric ischemia.

Treatment
Once the need for treatment has been established, there are two main options: surgical treatment and percutaneous treatment.

Surgical Treatment.— Surgical treatment may consist of transaortic endarterectomy of the celiac trunk or SMA or creation of a retrograde or anterograde bypass from the external iliac artery, the latter providing a more optimal orientation of the graft to the aorta. In a study by Park et al (18), recurrence was seen at 3-year follow-up in 11% of patients who had undergone surgical endarterectomy or creation of a retrograde bypass.

Percutaneous Treatment.— Percutaneous treatment is currently the therapy of choice and can also be used in critically ill patients. This method usually involves stent placement (Figs 5–7), and anecdotal reports suggest that it provides good and lasting clinical benefits. However, firm data on long-term benefits are limited (19–22).

View larger version (185K): [in this window] [in a new window] [Download PPT slide]   Figure 5a.  Treatment of AA with percutaneous transluminal angioplasty and stent placement in a heavily calcified SMA. The 73-year-old male patient had lost 25 kg and was experiencing postprandial abdominal pain. (a) Panoramic 3D VR image shows a hypertrophic collateral circulation between the IMA and SMA via the Riolan arcade (arrow). (b-d) Three-dimensional VR (b), sagittal MIP (c), and curved MPR (d) images show stenoses of the celiac trunk and SMA. Heavy calcifications do not allow accurate grading of the stenoses. (e) Pretreatment angiograms helped confirm the high-grade stenosis of the SMA. Placement of a balloon-expandable, 31-gauge stainless-steel stent (6 x 15 mm) in the SMA resulted in complete relief of symptoms. (f-i) A comparison of pretreatment (f, g) and posttreatment (h, i) multi-detector row CT angiograms shows improved vessel patency.

View larger version (86K): [in this window] [in a new window] [Download PPT slide]   Figure 5b.  Treatment of AA with percutaneous transluminal angioplasty and stent placement in a heavily calcified SMA. The 73-year-old male patient had lost 25 kg and was experiencing postprandial abdominal pain. (a) Panoramic 3D VR image shows a hypertrophic collateral circulation between the IMA and SMA via the Riolan arcade (arrow). (b-d) Three-dimensional VR (b), sagittal MIP (c), and curved MPR (d) images show stenoses of the celiac trunk and SMA. Heavy calcifications do not allow accurate grading of the stenoses. (e) Pretreatment angiograms helped confirm the high-grade stenosis of the SMA. Placement of a balloon-expandable, 31-gauge stainless-steel stent (6 x 15 mm) in the SMA resulted in complete relief of symptoms. (f-i) A comparison of pretreatment (f, g) and posttreatment (h, i) multi-detector row CT angiograms shows improved vessel patency.

View larger version (108K): [in this window] [in a new window] [Download PPT slide]   Figure 5c.  Treatment of AA with percutaneous transluminal angioplasty and stent placement in a heavily calcified SMA. The 73-year-old male patient had lost 25 kg and was experiencing postprandial abdominal pain. (a) Panoramic 3D VR image shows a hypertrophic collateral circulation between the IMA and SMA via the Riolan arcade (arrow). (b-d) Three-dimensional VR (b), sagittal MIP (c), and curved MPR (d) images show stenoses of the celiac trunk and SMA. Heavy calcifications do not allow accurate grading of the stenoses. (e) Pretreatment angiograms helped confirm the high-grade stenosis of the SMA. Placement of a balloon-expandable, 31-gauge stainless-steel stent (6 x 15 mm) in the SMA resulted in complete relief of symptoms. (f-i) A comparison of pretreatment (f, g) and posttreatment (h, i) multi-detector row CT angiograms shows improved vessel patency.

View larger version (95K): [in this window] [in a new window] [Download PPT slide]   Figure 5d.  Treatment of AA with percutaneous transluminal angioplasty and stent placement in a heavily calcified SMA. The 73-year-old male patient had lost 25 kg and was experiencing postprandial abdominal pain. (a) Panoramic 3D VR image shows a hypertrophic collateral circulation between the IMA and SMA via the Riolan arcade (arrow). (b-d) Three-dimensional VR (b), sagittal MIP (c), and curved MPR (d) images show stenoses of the celiac trunk and SMA. Heavy calcifications do not allow accurate grading of the stenoses. (e) Pretreatment angiograms helped confirm the high-grade stenosis of the SMA. Placement of a balloon-expandable, 31-gauge stainless-steel stent (6 x 15 mm) in the SMA resulted in complete relief of symptoms. (f-i) A comparison of pretreatment (f, g) and posttreatment (h, i) multi-detector row CT angiograms shows improved vessel patency.

View larger version (178K): [in this window] [in a new window] [Download PPT slide]   Figure 5e.  Treatment of AA with percutaneous transluminal angioplasty and stent placement in a heavily calcified SMA. The 73-year-old male patient had lost 25 kg and was experiencing postprandial abdominal pain. (a) Panoramic 3D VR image shows a hypertrophic collateral circulation between the IMA and SMA via the Riolan arcade (arrow). (b-d) Three-dimensional VR (b), sagittal MIP (c), and curved MPR (d) images show stenoses of the celiac trunk and SMA. Heavy calcifications do not allow accurate grading of the stenoses. (e) Pretreatment angiograms helped confirm the high-grade stenosis of the SMA. Placement of a balloon-expandable, 31-gauge stainless-steel stent (6 x 15 mm) in the SMA resulted in complete relief of symptoms. (f-i) A comparison of pretreatment (f, g) and posttreatment (h, i) multi-detector row CT angiograms shows improved vessel patency.

View larger version (102K): [in this window] [in a new window] [Download PPT slide]   Figure 5f.  Treatment of AA with percutaneous transluminal angioplasty and stent placement in a heavily calcified SMA. The 73-year-old male patient had lost 25 kg and was experiencing postprandial abdominal pain. (a) Panoramic 3D VR image shows a hypertrophic collateral circulation between the IMA and SMA via the Riolan arcade (arrow). (b-d) Three-dimensional VR (b), sagittal MIP (c), and curved MPR (d) images show stenoses of the celiac trunk and SMA. Heavy calcifications do not allow accurate grading of the stenoses. (e) Pretreatment angiograms helped confirm the high-grade stenosis of the SMA. Placement of a balloon-expandable, 31-gauge stainless-steel stent (6 x 15 mm) in the SMA resulted in complete relief of symptoms. (f-i) A comparison of pretreatment (f, g) and posttreatment (h, i) multi-detector row CT angiograms shows improved vessel patency.

View larger version (56K): [in this window] [in a new window] [Download PPT slide]   Figure 5g.  Treatment of AA with percutaneous transluminal angioplasty and stent placement in a heavily calcified SMA. The 73-year-old male patient had lost 25 kg and was experiencing postprandial abdominal pain. (a) Panoramic 3D VR image shows a hypertrophic collateral circulation between the IMA and SMA via the Riolan arcade (arrow). (b-d) Three-dimensional VR (b), sagittal MIP (c), and curved MPR (d) images show stenoses of the celiac trunk and SMA. Heavy calcifications do not allow accurate grading of the stenoses. (e) Pretreatment angiograms helped confirm the high-grade stenosis of the SMA. Placement of a balloon-expandable, 31-gauge stainless-steel stent (6 x 15 mm) in the SMA resulted in complete relief of symptoms. (f-i) A comparison of pretreatment (f, g) and posttreatment (h, i) multi-detector row CT angiograms shows improved vessel patency.

View larger version (84K): [in this window] [in a new window] [Download PPT slide]   Figure 5h.  Treatment of AA with percutaneous transluminal angioplasty and stent placement in a heavily calcified SMA. The 73-year-old male patient had lost 25 kg and was experiencing postprandial abdominal pain. (a) Panoramic 3D VR image shows a hypertrophic collateral circulation between the IMA and SMA via the Riolan arcade (arrow). (b-d) Three-dimensional VR (b), sagittal MIP (c), and curved MPR (d) images show stenoses of the celiac trunk and SMA. Heavy calcifications do not allow accurate grading of the stenoses. (e) Pretreatment angiograms helped confirm the high-grade stenosis of the SMA. Placement of a balloon-expandable, 31-gauge stainless-steel stent (6 x 15 mm) in the SMA resulted in complete relief of symptoms. (f-i) A comparison of pretreatment (f, g) and posttreatment (h, i) multi-detector row CT angiograms shows improved vessel patency.

View larger version (54K): [in this window] [in a new window] [Download PPT slide]   Figure 5i.  Treatment of AA with percutaneous transluminal angioplasty and stent placement in a heavily calcified SMA. The 73-year-old male patient had lost 25 kg and was experiencing postprandial abdominal pain. (a) Panoramic 3D VR image shows a hypertrophic collateral circulation between the IMA and SMA via the Riolan arcade (arrow). (b-d) Three-dimensional VR (b), sagittal MIP (c), and curved MPR (d) images show stenoses of the celiac trunk and SMA. Heavy calcifications do not allow accurate grading of the stenoses. (e) Pretreatment angiograms helped confirm the high-grade stenosis of the SMA. Placement of a balloon-expandable, 31-gauge stainless-steel stent (6 x 15 mm) in the SMA resulted in complete relief of symptoms. (f-i) A comparison of pretreatment (f, g) and posttreatment (h, i) multi-detector row CT angiograms shows improved vessel patency.

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 6a.  Percutaneous treatment of AA with stent placement in a vascular anomaly of the SMA. The patient was a 74-year-old woman with typical symptoms of AA. (a) Panoramic 3D VR image shows a hypertrophic collateral circulation between the IMA and SMA via the Riolan arcade (arrow). The anatomy shows a variant: The right hepatic artery originates from the SMA, and the celiac trunk splits into the left hepatic artery, the splenic artery, and other pancreaticoduodenal branches. (b) Coronal MIP image of the SMA shows a stenosis just proximal to the origin of the anomalous hepatic artery. (c) Paraaxial curved MPR image shows a high-grade stenosis of the celiac trunk. (d-g) Sagittal MIP (d, f) and paraaxial curved MPR (e, g) images of the SMA obtained before (d, e) and after (f, g) stent placement show restoration of patency. The "stent jail" of the right hepatic artery in the celiac trunk was well tolerated by the patient, probably because of the vast collateral circulation that developed in response to the high-grade stenoses of the SMA and celiac trunk.

View larger version (150K): [in this window] [in a new window] [Download PPT slide]   Figure 6b.  Percutaneous treatment of AA with stent placement in a vascular anomaly of the SMA. The patient was a 74-year-old woman with typical symptoms of AA. (a) Panoramic 3D VR image shows a hypertrophic collateral circulation between the IMA and SMA via the Riolan arcade (arrow). The anatomy shows a variant: The right hepatic artery originates from the SMA, and the celiac trunk splits into the left hepatic artery, the splenic artery, and other pancreaticoduodenal branches. (b) Coronal MIP image of the SMA shows a stenosis just proximal to the origin of the anomalous hepatic artery. (c) Paraaxial curved MPR image shows a high-grade stenosis of the celiac trunk. (d-g) Sagittal MIP (d, f) and paraaxial curved MPR (e, g) images of the SMA obtained before (d, e) and after (f, g) stent placement show restoration of patency. The "stent jail" of the right hepatic artery in the celiac trunk was well tolerated by the patient, probably because of the vast collateral circulation that developed in response to the high-grade stenoses of the SMA and celiac trunk.

View larger version (160K): [in this window] [in a new window] [Download PPT slide]   Figure 6c.  Percutaneous treatment of AA with stent placement in a vascular anomaly of the SMA. The patient was a 74-year-old woman with typical symptoms of AA. (a) Panoramic 3D VR image shows a hypertrophic collateral circulation between the IMA and SMA via the Riolan arcade (arrow). The anatomy shows a variant: The right hepatic artery originates from the SMA, and the celiac trunk splits into the left hepatic artery, the splenic artery, and other pancreaticoduodenal branches. (b) Coronal MIP image of the SMA shows a stenosis just proximal to the origin of the anomalous hepatic artery. (c) Paraaxial curved MPR image shows a high-grade stenosis of the celiac trunk. (d-g) Sagittal MIP (d, f) and paraaxial curved MPR (e, g) images of the SMA obtained before (d, e) and after (f, g) stent placement show restoration of patency. The "stent jail" of the right hepatic artery in the celiac trunk was well tolerated by the patient, probably because of the vast collateral circulation that developed in response to the high-grade stenoses of the SMA and celiac trunk.

View larger version (103K): [in this window] [in a new window] [Download PPT slide]   Figure 6d.  Percutaneous treatment of AA with stent placement in a vascular anomaly of the SMA. The patient was a 74-year-old woman with typical symptoms of AA. (a) Panoramic 3D VR image shows a hypertrophic collateral circulation between the IMA and SMA via the Riolan arcade (arrow). The anatomy shows a variant: The right hepatic artery originates from the SMA, and the celiac trunk splits into the left hepatic artery, the splenic artery, and other pancreaticoduodenal branches. (b) Coronal MIP image of the SMA shows a stenosis just proximal to the origin of the anomalous hepatic artery. (c) Paraaxial curved MPR image shows a high-grade stenosis of the celiac trunk. (d-g) Sagittal MIP (d, f) and paraaxial curved MPR (e, g) images of the SMA obtained before (d, e) and after (f, g) stent placement show restoration of patency. The "stent jail" of the right hepatic artery in the celiac trunk was well tolerated by the patient, probably because of the vast collateral circulation that developed in response to the high-grade stenoses of the SMA and celiac trunk.

View larger version (87K): [in this window] [in a new window] [Download PPT slide]   Figure 6e.  Percutaneous treatment of AA with stent placement in a vascular anomaly of the SMA. The patient was a 74-year-old woman with typical symptoms of AA. (a) Panoramic 3D VR image shows a hypertrophic collateral circulation between the IMA and SMA via the Riolan arcade (arrow). The anatomy shows a variant: The right hepatic artery originates from the SMA, and the celiac trunk splits into the left hepatic artery, the splenic artery, and other pancreaticoduodenal branches. (b) Coronal MIP image of the SMA shows a stenosis just proximal to the origin of the anomalous hepatic artery. (c) Paraaxial curved MPR image shows a high-grade stenosis of the celiac trunk. (d-g) Sagittal MIP (d, f) and paraaxial curved MPR (e, g) images of the SMA obtained before (d, e) and after (f, g) stent placement show restoration of patency. The "stent jail" of the right hepatic artery in the celiac trunk was well tolerated by the patient, probably because of the vast collateral circulation that developed in response to the high-grade stenoses of the SMA and celiac trunk.

View larger version (97K): [in this window] [in a new window] [Download PPT slide]   Figure 6f.  Percutaneous treatment of AA with stent placement in a vascular anomaly of the SMA. The patient was a 74-year-old woman with typical symptoms of AA. (a) Panoramic 3D VR image shows a hypertrophic collateral circulation between the IMA and SMA via the Riolan arcade (arrow). The anatomy shows a variant: The right hepatic artery originates from the SMA, and the celiac trunk splits into the left hepatic artery, the splenic artery, and other pancreaticoduodenal branches. (b) Coronal MIP image of the SMA shows a stenosis just proximal to the origin of the anomalous hepatic artery. (c) Paraaxial curved MPR image shows a high-grade stenosis of the celiac trunk. (d-g) Sagittal MIP (d, f) and paraaxial curved MPR (e, g) images of the SMA obtained before (d, e) and after (f, g) stent placement show restoration of patency. The "stent jail" of the right hepatic artery in the celiac trunk was well tolerated by the patient, probably because of the vast collateral circulation that developed in response to the high-grade stenoses of the SMA and celiac trunk.

View larger version (90K): [in this window] [in a new window] [Download PPT slide]   Figure 6g.  Percutaneous treatment of AA with stent placement in a vascular anomaly of the SMA. The patient was a 74-year-old woman with typical symptoms of AA. (a) Panoramic 3D VR image shows a hypertrophic collateral circulation between the IMA and SMA via the Riolan arcade (arrow). The anatomy shows a variant: The right hepatic artery originates from the SMA, and the celiac trunk splits into the left hepatic artery, the splenic artery, and other pancreaticoduodenal branches. (b) Coronal MIP image of the SMA shows a stenosis just proximal to the origin of the anomalous hepatic artery. (c) Paraaxial curved MPR image shows a high-grade stenosis of the celiac trunk. (d-g) Sagittal MIP (d, f) and paraaxial curved MPR (e, g) images of the SMA obtained before (d, e) and after (f, g) stent placement show restoration of patency. The "stent jail" of the right hepatic artery in the celiac trunk was well tolerated by the patient, probably because of the vast collateral circulation that developed in response to the high-grade stenoses of the SMA and celiac trunk.

View larger version (144K): [in this window] [in a new window] [Download PPT slide]   Figure 7a.  Percutaneous treatment of AA with twin stent placement in the celiac trunk and SMA. The patient was a 75-year-old man with typical symptoms of AA and complex vascular disease of the peripheral arteries. (a) Panoramic 3D VR image displays a bilateral external iliac arterial occlusion (arrows) and a left axillofemoral bypass (arrowhead). (b-d) VR and MIP images show high-grade stenoses of the celiac trunk and SMA with scattered calcifications. Stents were placed in both vessels. (e-h) Curved MPR images of the celiac trunk (e, f) and SMA (g, h) obtained before (e, g) and 4 months after (f, h) stent placement show how complete patency was achieved in both vessels.

View larger version (101K): [in this window] [in a new window] [Download PPT slide]   Figure 7b.  Percutaneous treatment of AA with twin stent placement in the celiac trunk and SMA. The patient was a 75-year-old man with typical symptoms of AA and complex vascular disease of the peripheral arteries. (a) Panoramic 3D VR image displays a bilateral external iliac arterial occlusion (arrows) and a left axillofemoral bypass (arrowhead). (b-d) VR and MIP images show high-grade stenoses of the celiac trunk and SMA with scattered calcifications. Stents were placed in both vessels. (e-h) Curved MPR images of the celiac trunk (e, f) and SMA (g, h) obtained before (e, g) and 4 months after (f, h) stent placement show how complete patency was achieved in both vessels.

View larger version (98K): [in this window] [in a new window] [Download PPT slide]   Figure 7c.  Percutaneous treatment of AA with twin stent placement in the celiac trunk and SMA. The patient was a 75-year-old man with typical symptoms of AA and complex vascular disease of the peripheral arteries. (a) Panoramic 3D VR image displays a bilateral external iliac arterial occlusion (arrows) and a left axillofemoral bypass (arrowhead). (b-d) VR and MIP images show high-grade stenoses of the celiac trunk and SMA with scattered calcifications. Stents were placed in both vessels. (e-h) Curved MPR images of the celiac trunk (e, f) and SMA (g, h) obtained before (e, g) and 4 months after (f, h) stent placement show how complete patency was achieved in both vessels.

View larger version (103K): [in this window] [in a new window] [Download PPT slide]   Figure 7d.  Percutaneous treatment of AA with twin stent placement in the celiac trunk and SMA. The patient was a 75-year-old man with typical symptoms of AA and complex vascular disease of the peripheral arteries. (a) Panoramic 3D VR image displays a bilateral external iliac arterial occlusion (arrows) and a left axillofemoral bypass (arrowhead). (b-d) VR and MIP images show high-grade stenoses of the celiac trunk and SMA with scattered calcifications. Stents were placed in both vessels. (e-h) Curved MPR images of the celiac trunk (e, f) and SMA (g, h) obtained before (e, g) and 4 months after (f, h) stent placement show how complete patency was achieved in both vessels.

View larger version (125K): [in this window] [in a new window] [Download PPT slide]   Figure 7e.  Percutaneous treatment of AA with twin stent placement in the celiac trunk and SMA. The patient was a 75-year-old man with typical symptoms of AA and complex vascular disease of the peripheral arteries. (a) Panoramic 3D VR image displays a bilateral external iliac arterial occlusion (arrows) and a left axillofemoral bypass (arrowhead). (b-d) VR and MIP images show high-grade stenoses of the celiac trunk and SMA with scattered calcifications. Stents were placed in both vessels. (e-h) Curved MPR images of the celiac trunk (e, f) and SMA (g, h) obtained before (e, g) and 4 months after (f, h) stent placement show how complete patency was achieved in both vessels.

View larger version (122K): [in this window] [in a new window] [Download PPT slide]   Figure 7f.  Percutaneous treatment of AA with twin stent placement in the celiac trunk and SMA. The patient was a 75-year-old man with typical symptoms of AA and complex vascular disease of the peripheral arteries. (a) Panoramic 3D VR image displays a bilateral external iliac arterial occlusion (arrows) and a left axillofemoral bypass (arrowhead). (b-d) VR and MIP images show high-grade stenoses of the celiac trunk and SMA with scattered calcifications. Stents were placed in both vessels. (e-h) Curved MPR images of the celiac trunk (e, f) and SMA (g, h) obtained before (e, g) and 4 months after (f, h) stent placement show how complete patency was achieved in both vessels.

View larger version (125K): [in this window] [in a new window] [Download PPT slide]   Figure 7g.  Percutaneous treatment of AA with twin stent placement in the celiac trunk and SMA. The patient was a 75-year-old man with typical symptoms of AA and complex vascular disease of the peripheral arteries. (a) Panoramic 3D VR image displays a bilateral external iliac arterial occlusion (arrows) and a left axillofemoral bypass (arrowhead). (b-d) VR and MIP images show high-grade stenoses of the celiac trunk and SMA with scattered calcifications. Stents were placed in both vessels. (e-h) Curved MPR images of the celiac trunk (e, f) and SMA (g, h) obtained before (e, g) and 4 months after (f, h) stent placement show how complete patency was achieved in both vessels.

View larger version (87K): [in this window] [in a new window] [Download PPT slide]   Figure 7h.  Percutaneous treatment of AA with twin stent placement in the celiac trunk and SMA. The patient was a 75-year-old man with typical symptoms of AA and complex vascular disease of the peripheral arteries. (a) Panoramic 3D VR image displays a bilateral external iliac arterial occlusion (arrows) and a left axillofemoral bypass (arrowhead). (b-d) VR and MIP images show high-grade stenoses of the celiac trunk and SMA with scattered calcifications. Stents were placed in both vessels. (e-h) Curved MPR images of the celiac trunk (e, f) and SMA (g, h) obtained before (e, g) and 4 months after (f, h) stent placement show how complete patency was achieved in both vessels.

For stent placement, a 7-F guiding catheter was advanced with either the femoral or brachial approach, depending on the anatomy of the celiac trunk and SMA as seen at CT angiography. The stenosis was transgressed with a .018- or .014-inch guide wire, after which a balloon-expandable stainless steel stent 6–7 mm in diameter and 15– 18 mm long (Genesis; Cordis Johnson & Johnson, Miami, Fla) was placed. Care was taken to cover the origin of the vessel. If necessary, the stent was dilated up to a diameter of 8 mm. Our current approach is to use a monorail stent system over a .014-inch guide wire, which can be accommodated in a 6-F guiding sheath.

	Multi–Detector Row CT Protocol Design

Top Abstract LEARNING OBJECTIVES Introduction Abdominal Angina Multi-Detector Row CT Protocol... Discussion Conclusions References

 
Scanning
The rationale for an optimal CT angiography protocol relies on fast, high-resolution CT performed during the arterial phase of vascular enhancement (3). To obtain this result in the abdominal region (from the diaphragmatic domes to the symphysis), multi–detector row CT combined with an effective bolus synchronization technique is mandatory.

At our institution, patients with suspected AA (in whom the main clinical finding is postprandial abdominal pain) undergo multi–detector CT angiography of the entire abdomen with a four- or 16-row CT scanner (Sensation 4 or 16; Siemens, Forchheim, Germany). Patient preparation and scanning parameters are summarized in Tables 1 and 2, respectively. The most relevant features of these protocols are the use of high resolution (eg, thin collimation) with a limited scan time (eg, an increased pitch when needed).

Reconstruction
The reconstruction parameters are as important as the scanning parameters. To exploit the isotropic resolution and achieve optimal visualization of the vessels, the proper parameters must be used. Our protocol for image reconstruction is summarized in Table 2. The most important elements are use of a thin effective section width with a 30%–50% overlapping increment to improve the spatial resolution along the z axis (longitudinal plane). The choice of convolution filter depends on image noise (eg, obese patients will likely require smooth filters) and the degree of vessel calcification (heavily calcified vessels will be better assessed with sharp filters). The use of filters will also affect the quality of postprocessing and 3D reformatted images.

Postprocessing
The nature of spiral CT and the modality of reconstruction will result in a massive number of axial sections being obtained (300–800 sections, depending on the scanner and the reconstruction parameters). Postprocessing tools are mandatory for handling and reviewing this huge amount of data. There are two possible approaches at this level. The first approach is based on the interaction of the radiologist with the data set using the full range of postprocessing tools; the second approach is based on standardization of the protocol to limit interaction with the data set to the targeted problem-solving task. The first approach is more accurate and comprehensive but also more time consuming. The second approach has several advantages and relies on the ability of the technician to provide high-quality preprocessed material.

Images are analyzed on a dedicated workstation (Leonardo, Siemens). Targeted central lumen line reformatted images (curved reformatted images) are obtained along the celiac trunk and SMA in two orthogonal (sagittal and axial curved reformatted) planes. Figures 8 and 9 illustrate the main projections and different image algorithms (axial image scrolling, MPR, MIP, VR), respectively. Image generation and interpretation requires 25 minutes. Vessel occlusion is defined as complete obstruction of the lumen with no evidence of contrast medium passage. Hemodynamically significant vessel stenosis is defined as a reduction in lumen diameter of more than 50%, whereas vessel irregularity or insignificant stenosis is defined as a reduction in lumen diameter of less than 50%.

View larger version (169K): [in this window] [in a new window] [Download PPT slide]   Figure 8a.  Standard multiplanar postprocessing of a multi-detector row CT data set for suspected AA. Postprocessing may include coronal oblique (a, b) or sagittal (c, d) thin MIP images. It may also include MPR images, shown on the facing page as sagittal (e, f) or coronal (g, h) curved MPR images of the celiac trunk or sagittal (i, k) or coronal (j, l) curved MPR images of the SMA. Arrows in a and c indicate direction of observation; yellow lines in e, g, j, and k indicate position of curved plane that generates the image. The standard thickness for MIP images is 3-4 mm, but the images can be reduced to 2 mm in thickness for heavily calcified vessels. In the presence of heavily calcified plaques or stents, MPR images are mandatory to avoid superprojection of these hyperattenuating structures onto the vessel lumen. The IMA is not visible on any of the images in Figure 8 and therefore appears to be occluded.

View larger version (165K): [in this window] [in a new window] [Download PPT slide]   Figure 8b.  Standard multiplanar postprocessing of a multi-detector row CT data set for suspected AA. Postprocessing may include coronal oblique (a, b) or sagittal (c, d) thin MIP images. It may also include MPR images, shown on the facing page as sagittal (e, f) or coronal (g, h) curved MPR images of the celiac trunk or sagittal (i, k) or coronal (j, l) curved MPR images of the SMA. Arrows in a and c indicate direction of observation; yellow lines in e, g, j, and k indicate position of curved plane that generates the image. The standard thickness for MIP images is 3-4 mm, but the images can be reduced to 2 mm in thickness for heavily calcified vessels. In the presence of heavily calcified plaques or stents, MPR images are mandatory to avoid superprojection of these hyperattenuating structures onto the vessel lumen. The IMA is not visible on any of the images in Figure 8 and therefore appears to be occluded.

View larger version (189K): [in this window] [in a new window] [Download PPT slide]   Figure 8c.  Standard multiplanar postprocessing of a multi-detector row CT data set for suspected AA. Postprocessing may include coronal oblique (a, b) or sagittal (c, d) thin MIP images. It may also include MPR images, shown on the facing page as sagittal (e, f) or coronal (g, h) curved MPR images of the celiac trunk or sagittal (i, k) or coronal (j, l) curved MPR images of the SMA. Arrows in a and c indicate direction of observation; yellow lines in e, g, j, and k indicate position of curved plane that generates the image. The standard thickness for MIP images is 3-4 mm, but the images can be reduced to 2 mm in thickness for heavily calcified vessels. In the presence of heavily calcified plaques or stents, MPR images are mandatory to avoid superprojection of these hyperattenuating structures onto the vessel lumen. The IMA is not visible on any of the images in Figure 8 and therefore appears to be occluded.

View larger version (138K): [in this window] [in a new window] [Download PPT slide]   Figure 8d.  Standard multiplanar postprocessing of a multi-detector row CT data set for suspected AA. Postprocessing may include coronal oblique (a, b) or sagittal (c, d) thin MIP images. It may also include MPR images, shown on the facing page as sagittal (e, f) or coronal (g, h) curved MPR images of the celiac trunk or sagittal (i, k) or coronal (j, l) curved MPR images of the SMA. Arrows in a and c indicate direction of observation; yellow lines in e, g, j, and k indicate position of curved plane that generates the image. The standard thickness for MIP images is 3-4 mm, but the images can be reduced to 2 mm in thickness for heavily calcified vessels. In the presence of heavily calcified plaques or stents, MPR images are mandatory to avoid superprojection of these hyperattenuating structures onto the vessel lumen. The IMA is not visible on any of the images in Figure 8 and therefore appears to be occluded.

View larger version (139K): [in this window] [in a new window] [Download PPT slide]   Figure 8e.  Standard multiplanar postprocessing of a multi-detector row CT data set for suspected AA. Postprocessing may include coronal oblique (a, b) or sagittal (c, d) thin MIP images. It may also include MPR images, shown on the facing page as sagittal (e, f) or coronal (g, h) curved MPR images of the celiac trunk or sagittal (i, k) or coronal (j, l) curved MPR images of the SMA. Arrows in a and c indicate direction of observation; yellow lines in e, g, j, and k indicate position of curved plane that generates the image. The standard thickness for MIP images is 3-4 mm, but the images can be reduced to 2 mm in thickness for heavily calcified vessels. In the presence of heavily calcified plaques or stents, MPR images are mandatory to avoid superprojection of these hyperattenuating structures onto the vessel lumen. The IMA is not visible on any of the images in Figure 8 and therefore appears to be occluded.

View larger version (136K): [in this window] [in a new window] [Download PPT slide]   Figure 8f.  Standard multiplanar postprocessing of a multi-detector row CT data set for suspected AA. Postprocessing may include coronal oblique (a, b) or sagittal (c, d) thin MIP images. It may also include MPR images, shown on the facing page as sagittal (e, f) or coronal (g, h) curved MPR images of the celiac trunk or sagittal (i, k) or coronal (j, l) curved MPR images of the SMA. Arrows in a and c indicate direction of observation; yellow lines in e, g, j, and k indicate position of curved plane that generates the image. The standard thickness for MIP images is 3-4 mm, but the images can be reduced to 2 mm in thickness for heavily calcified vessels. In the presence of heavily calcified plaques or stents, MPR images are mandatory to avoid superprojection of these hyperattenuating structures onto the vessel lumen. The IMA is not visible on any of the images in Figure 8 and therefore appears to be occluded.

View larger version (140K): [in this window] [in a new window] [Download PPT slide]   Figure 8g.  Standard multiplanar postprocessing of a multi-detector row CT data set for suspected AA. Postprocessing may include coronal oblique (a, b) or sagittal (c, d) thin MIP images. It may also include MPR images, shown on the facing page as sagittal (e, f) or coronal (g, h) curved MPR images of the celiac trunk or sagittal (i, k) or coronal (j, l) curved MPR images of the SMA. Arrows in a and c indicate direction of observation; yellow lines in e, g, j, and k indicate position of curved plane that generates the image. The standard thickness for MIP images is 3-4 mm, but the images can be reduced to 2 mm in thickness for heavily calcified vessels. In the presence of heavily calcified plaques or stents, MPR images are mandatory to avoid superprojection of these hyperattenuating structures onto the vessel lumen. The IMA is not visible on any of the images in Figure 8 and therefore appears to be occluded.

View larger version (145K): [in this window] [in a new window] [Download PPT slide]   Figure 8h.  Standard multiplanar postprocessing of a multi-detector row CT data set for suspected AA. Postprocessing may include coronal oblique (a, b) or sagittal (c, d) thin MIP images. It may also include MPR images, shown on the facing page as sagittal (e, f) or coronal (g, h) curved MPR images of the celiac trunk or sagittal (i, k) or coronal (j, l) curved MPR images of the SMA. Arrows in a and c indicate direction of observation; yellow lines in e, g, j, and k indicate position of curved plane that generates the image. The standard thickness for MIP images is 3-4 mm, but the images can be reduced to 2 mm in thickness for heavily calcified vessels. In the presence of heavily calcified plaques or stents, MPR images are mandatory to avoid superprojection of these hyperattenuating structures onto the vessel lumen. The IMA is not visible on any of the images in Figure 8 and therefore appears to be occluded.

View larger version (142K): [in this window] [in a new window] [Download PPT slide]   Figure 8i.  Standard multiplanar postprocessing of a multi-detector row CT data set for suspected AA. Postprocessing may include coronal oblique (a, b) or sagittal (c, d) thin MIP images. It may also include MPR images, shown on the facing page as sagittal (e, f) or coronal (g, h) curved MPR images of the celiac trunk or sagittal (i, k) or coronal (j, l) curved MPR images of the SMA. Arrows in a and c indicate direction of observation; yellow lines in e, g, j, and k indicate position of curved plane that generates the image. The standard thickness for MIP images is 3-4 mm, but the images can be reduced to 2 mm in thickness for heavily calcified vessels. In the presence of heavily calcified plaques or stents, MPR images are mandatory to avoid superprojection of these hyperattenuating structures onto the vessel lumen. The IMA is not visible on any of the images in Figure 8 and therefore appears to be occluded.

View larger version (132K): [in this window] [in a new window] [Download PPT slide]   Figure 8j.  Standard multiplanar postprocessing of a multi-detector row CT data set for suspected AA. Postprocessing may include coronal oblique (a, b) or sagittal (c, d) thin MIP images. It may also include MPR images, shown on the facing page as sagittal (e, f) or coronal (g, h) curved MPR images of the celiac trunk or sagittal (i, k) or coronal (j, l) curved MPR images of the SMA. Arrows in a and c indicate direction of observation; yellow lines in e, g, j, and k indicate position of curved plane that generates the image. The standard thickness for MIP images is 3-4 mm, but the images can be reduced to 2 mm in thickness for heavily calcified vessels. In the presence of heavily calcified plaques or stents, MPR images are mandatory to avoid superprojection of these hyperattenuating structures onto the vessel lumen. The IMA is not visible on any of the images in Figure 8 and therefore appears to be occluded.

View larger version (142K): [in this window] [in a new window] [Download PPT slide]   Figure 8k.  Standard multiplanar postprocessing of a multi-detector row CT data set for suspected AA. Postprocessing may include coronal oblique (a, b) or sagittal (c, d) thin MIP images. It may also include MPR images, shown on the facing page as sagittal (e, f) or coronal (g, h) curved MPR images of the celiac trunk or sagittal (i, k) or coronal (j, l) curved MPR images of the SMA. Arrows in a and c indicate direction of observation; yellow lines in e, g, j, and k indicate position of curved plane that generates the image. The standard thickness for MIP images is 3-4 mm, but the images can be reduced to 2 mm in thickness for heavily calcified vessels. In the presence of heavily calcified plaques or stents, MPR images are mandatory to avoid superprojection of these hyperattenuating structures onto the vessel lumen. The IMA is not visible on any of the images in Figure 8 and therefore appears to be occluded.

View larger version (139K): [in this window] [in a new window] [Download PPT slide]   Figure 8l.  Standard multiplanar postprocessing of a multi-detector row CT data set for suspected AA. Postprocessing may include coronal oblique (a, b) or sagittal (c, d) thin MIP images. It may also include MPR images, shown on the facing page as sagittal (e, f) or coronal (g, h) curved MPR images of the celiac trunk or sagittal (i, k) or coronal (j, l) curved MPR images of the SMA. Arrows in a and c indicate direction of observation; yellow lines in e, g, j, and k indicate position of curved plane that generates the image. The standard thickness for MIP images is 3-4 mm, but the images can be reduced to 2 mm in thickness for heavily calcified vessels. In the presence of heavily calcified plaques or stents, MPR images are mandatory to avoid superprojection of these hyperattenuating structures onto the vessel lumen. The IMA is not visible on any of the images in Figure 8 and therefore appears to be occluded.

View larger version (152K): [in this window] [in a new window] [Download PPT slide]   Figure 9a.  Comparison of VR, MIP, and MPR algorithms in the evaluation of heavily calcified plaques in a 79-year-old man with typical symptoms of AA. (a, b) Anterior (top) and posterior (bottom) (a) and right lateral (left) and anterior (right) (b) panoramic 3D VR images show the abdominal aorta with a "full calcium jacket" that encloses the origin of the SMA, thereby hindering image interpretation. (c) Sagittal MIP image does not improve quantitative analysis of the celiac trunk and SMA, even though a stenosis can be suspected in both vessels. (d, e) Paraaxial curved MPR images obtained along the celiac trunk (d) and SMA (e) improve the assessment. (f) Angiograms show a high-grade stenosis of the SMA, which was treated with percutaneous transluminal angioplasty and stent placement. (g, h) Curved MPR images from follow-up multi-detector row CT angiography performed 3 months later help confirm the restored patency of the SMA. The calcium deposits on the walls of the origin of the SMA do not prevent assessment.

View larger version (131K): [in this window] [in a new window] [Download PPT slide]   Figure 9b.  Comparison of VR, MIP, and MPR algorithms in the evaluation of heavily calcified plaques in a 79-year-old man with typical symptoms of AA. (a, b) Anterior (top) and posterior (bottom) (a) and right lateral (left) and anterior (right) (b) panoramic 3D VR images show the abdominal aorta with a "full calcium jacket" that encloses the origin of the SMA, thereby hindering image interpretation. (c) Sagittal MIP image does not improve quantitative analysis of the celiac trunk and SMA, even though a stenosis can be suspected in both vessels. (d, e) Paraaxial curved MPR images obtained along the celiac trunk (d) and SMA (e) improve the assessment. (f) Angiograms show a high-grade stenosis of the SMA, which was treated with percutaneous transluminal angioplasty and stent placement. (g, h) Curved MPR images from follow-up multi-detector row CT angiography performed 3 months later help confirm the restored patency of the SMA. The calcium deposits on the walls of the origin of the SMA do not prevent assessment.

View larger version (133K): [in this window] [in a new window] [Download PPT slide]   Figure 9c.  Comparison of VR, MIP, and MPR algorithms in the evaluation of heavily calcified plaques in a 79-year-old man with typical symptoms of AA. (a, b) Anterior (top) and posterior (bottom) (a) and right lateral (left) and anterior (right) (b) panoramic 3D VR images show the abdominal aorta with a "full calcium jacket" that encloses the origin of the SMA, thereby hindering image interpretation. (c) Sagittal MIP image does not improve quantitative analysis of the celiac trunk and SMA, even though a stenosis can be suspected in both vessels. (d, e) Paraaxial curved MPR images obtained along the celiac trunk (d) and SMA (e) improve the assessment. (f) Angiograms show a high-grade stenosis of the SMA, which was treated with percutaneous transluminal angioplasty and stent placement. (g, h) Curved MPR images from follow-up multi-detector row CT angiography performed 3 months later help confirm the restored patency of the SMA. The calcium deposits on the walls of the origin of the SMA do not prevent assessment.

View larger version (92K): [in this window] [in a new window] [Download PPT slide]   Figure 9d.  Comparison of VR, MIP, and MPR algorithms in the evaluation of heavily calcified plaques in a 79-year-old man with typical symptoms of AA. (a, b) Anterior (top) and posterior (bottom) (a) and right lateral (left) and anterior (right) (b) panoramic 3D VR images show the abdominal aorta with a "full calcium jacket" that encloses the origin of the SMA, thereby hindering image interpretation. (c) Sagittal MIP image does not improve quantitative analysis of the celiac trunk and SMA, even though a stenosis can be suspected in both vessels. (d, e) Paraaxial curved MPR images obtained along the celiac trunk (d) and SMA (e) improve the assessment. (f) Angiograms show a high-grade stenosis of the SMA, which was treated with percutaneous transluminal angioplasty and stent placement. (g, h) Curved MPR images from follow-up multi-detector row CT angiography performed 3 months later help confirm the restored patency of the SMA. The calcium deposits on the walls of the origin of the SMA do not prevent assessment.

View larger version (121K): [in this window] [in a new window] [Download PPT slide]   Figure 9e.  Comparison of VR, MIP, and MPR algorithms in the evaluation of heavily calcified plaques in a 79-year-old man with typical symptoms of AA. (a, b) Anterior (top) and posterior (bottom) (a) and right lateral (left) and anterior (right) (b) panoramic 3D VR images show the abdominal aorta with a "full calcium jacket" that encloses the origin of the SMA, thereby hindering image interpretation. (c) Sagittal MIP image does not improve quantitative analysis of the celiac trunk and SMA, even though a stenosis can be suspected in both vessels. (d, e) Paraaxial curved MPR images obtained along the celiac trunk (d) and SMA (e) improve the assessment. (f) Angiograms show a high-grade stenosis of the SMA, which was treated with percutaneous transluminal angioplasty and stent placement. (g, h) Curved MPR images from follow-up multi-detector row CT angiography performed 3 months later help confirm the restored patency of the SMA. The calcium deposits on the walls of the origin of the SMA do not prevent assessment.

View larger version (161K): [in this window] [in a new window] [Download PPT slide]   Figure 9f.  Comparison of VR, MIP, and MPR algorithms in the evaluation of heavily calcified plaques in a 79-year-old man with typical symptoms of AA. (a, b) Anterior (top) and posterior (bottom) (a) and right lateral (left) and anterior (right) (b) panoramic 3D VR images show the abdominal aorta with a "full calcium jacket" that encloses the origin of the SMA, thereby hindering image interpretation. (c) Sagittal MIP image does not improve quantitative analysis of the celiac trunk and SMA, even though a stenosis can be suspected in both vessels. (d, e) Paraaxial curved MPR images obtained along the celiac trunk (d) and SMA (e) improve the assessment. (f) Angiograms show a high-grade stenosis of the SMA, which was treated with percutaneous transluminal angioplasty and stent placement. (g, h) Curved MPR images from follow-up multi-detector row CT angiography performed 3 months later help confirm the restored patency of the SMA. The calcium deposits on the walls of the origin of the SMA do not prevent assessment.

View larger version (71K): [in this window] [in a new window] [Download PPT slide]   Figure 9g.  Comparison of VR, MIP, and MPR algorithms in the evaluation of heavily calcified plaques in a 79-year-old man with typical symptoms of AA. (a, b) Anterior (top) and posterior (bottom) (a) and right lateral (left) and anterior (right) (b) panoramic 3D VR images show the abdominal aorta with a "full calcium jacket" that encloses the origin of the SMA, thereby hindering image interpretation. (c) Sagittal MIP image does not improve quantitative analysis of the celiac trunk and SMA, even though a stenosis can be suspected in both vessels. (d, e) Paraaxial curved MPR images obtained along the celiac trunk (d) and SMA (e) improve the assessment. (f) Angiograms show a high-grade stenosis of the SMA, which was treated with percutaneous transluminal angioplasty and stent placement. (g, h) Curved MPR images from follow-up multi-detector row CT angiography performed 3 months later help confirm the restored patency of the SMA. The calcium deposits on the walls of the origin of the SMA do not prevent assessment.

View larger version (100K): [in this window] [in a new window] [Download PPT slide]   Figure 9h.  Comparison of VR, MIP, and MPR algorithms in the evaluation of heavily calcified plaques in a 79-year-old man with typical symptoms of AA. (a, b) Anterior (top) and posterior (bottom) (a) and right lateral (left) and anterior (right) (b) panoramic 3D VR images show the abdominal aorta with a "full calcium jacket" that encloses the origin of the SMA, thereby hindering image interpretation. (c) Sagittal MIP image does not improve quantitative analysis of the celiac trunk and SMA, even though a stenosis can be suspected in both vessels. (d, e) Paraaxial curved MPR images obtained along the celiac trunk (d) and SMA (e) improve the assessment. (f) Angiograms show a high-grade stenosis of the SMA, which was treated with percutaneous transluminal angioplasty and stent placement. (g, h) Curved MPR images from follow-up multi-detector row CT angiography performed 3 months later help confirm the restored patency of the SMA. The calcium deposits on the walls of the origin of the SMA do not prevent assessment.

	Discussion

Top Abstract LEARNING OBJECTIVES Introduction Abdominal Angina Multi-Detector Row CT Protocol... Discussion Conclusions References

Currently, duplex ultrasonography can be used to noninvasively study the proximal splanchnic vessels, but intraperitoneal gas, respiratory motion, obesity, and any previous abdominal surgeries may limit the gathering of diagnostic information. MR angiography has been investigated and has the potential to provide both morphologic (stenosis) and functional (flow) information (12,13).

At our institution, multi–detector row CT angiography with four- and 16-row scanners, combined with appropriate postprocessing techniques, has become the routine procedure for the diagnosis, evaluation, and treatment of suspected AA. In fact, at our institution, multi–detector row CT angiography has replaced DSA, although DSA is still widely regarded as the current standard of reference. Multi–detector row CT angiography can routinely be performed as an outpatient procedure at a lower cost and with less risk and patient discomfort than DSA (16).

In our experience, the vessel lumen and vessel stenosis are better visualized with multi–detector row CT angiography than with DSA. Any projection or plane can be created to evaluate the degree of stenosis and the anatomic configuration of the vessel. The presence of atherosclerotic plaques can also be evaluated, manifesting not only as narrowing of the vessel lumen (as at DSA), but also as tissue with a specific attenuation. The assessment of plaque attenuation could provide information regarding the composition of the plaques (lipid vs fibrous) and, therefore, their vulnerability. Further study is required to determine the clinical relevance of this parameter.

Additional information provided by multi–detector row CT is related to concomitant evaluation of the iliac vessels. This information can be relevant prior to percutaneous intervention.

Multi–detector row CT is more helpful than DSA in ruling out extrinsic causes of vessel obstruction (eg, vessel encasement or compression by lesions).

After stent placement for AA, CT can be used as a noninvasive follow-up procedure to detect in-stent restenosis. In this setting, the effectiveness of MR angiography is limited by artifacts due to stent composition.

We have encountered two main limitations of multi–detector row CT angiography. The first limitation is lack of dynamic visualization, which can be compensated for only in part by the high spatial resolution. In fact, multi–detector row CT provides a static image of the abdominal vascular anatomy. Retrograde flow can be visualized at multi–detector row CT only as increased attenuation in vessels with an obstruction upstream, whereas collateral vessel filling is depicted as the presence or hypertrophy of vessels that are normally too small to be visualized and that can represent collateral pathways for arterial vascularization. The second limitation is the difficulty in visualizing stenosis in heavily calcified vessels    (Fig 7).

	Conclusions

Top Abstract LEARNING OBJECTIVES Introduction Abdominal Angina Multi-Detector Row CT Protocol... Discussion Conclusions References

 
Recent improvements in multi–detector row CT technology represent a further step toward successful noninvasive patient treatment even in complex vascular diseases such as chronic mesenteric ischemia. Additional studies will be necessary to evaluate the performance and applications of multi–detector row CT angiography. The excellent depiction of vascular diseases makes this technique a primary tool for the evaluation of patients with suspected steno-occlusive diseases of the abdominal vessels.

	Acknowledgments

 
We thank Andries W. Zwamborn, Teun Rijsdijk, and Karin ten Wolde for their contributions to the education exhibit.

	Footnotes

 
Abbreviations: AA = abdominal angina, DSA = digital subtraction angiography, IMA = inferior mesenteric artery, MIP = maximum-intensity-projection, MPR = multiplanar reformatted, SMA = superior mesenteric artery, VR = volume-rendered, 3D = three-dimensional

	References

Top Abstract LEARNING OBJECTIVES Introduction Abdominal Angina Multi-Detector Row CT Protocol... Discussion Conclusions References

 

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