Transcript CT AORTAGRAM - Stanley Radiology

COARCTATION OF AORTA
BEFORE AND AFTER CORRECTION: THE ROLE OF
MDCT AORTOGRAPHY
ABSTRACT ID : IRIA - 1068
BACKGROUND
DEFINITION :
Coarctation of aorta refers to a narrowing of the aortic lumen. It is a
congenital condition whereby the aorta narrows in the area where the
ductus arteriosus or ligamentum arteriosum (after regression) inserts [1].
It was first described by Morgagni at autopsy in 1760 [2].
INCIDENCE :
Aortic coarctation represents 5-7% of congenital heart disease. It has a male
predominance (male-to-female ratio, 1.5:1) [2] and is known to occur in
conjunction with a variety of conditions including Turner’s syndrome, Shone
syndrome, ventricular septal defect, bicuspid aortic valve, and aneurysms of
the circle of Willis [3].
PRE DUCTAL
TYPES
POST DUCTAL
 Infantile form.
 Adult or juxtaductal form.
 Long, tubular segment of narrowed
aorta.
 Is more common.
 Diffuse type.
 From just distal to innominate to
level of ductus.
 Usually localized.
 Area of coarctation is just beyond the
origin of LSCA at level of ductus.
 Intra cardiac defects (VSD,ASD,
deformed mitral valve, PDA) present
in 50% of diffuse type.
A. Ductal
coarctation
B. Pre ductal
coarctation
C. Post ductal
Coarctation
PROGNOSIS :
 Non-treated aortic coarctation has a poor prognosis, with a reported mortality
of 75% by 46 years of age. Congestive heart failure is the most common cause of
death (25.5% of cases), followed by aortic rupture (21%), complications of
endocarditis (18%), and finally intracranial hemorrhage (11.5%) [4].
TREATMENT :
 The first surgical repair of aortic coarctation was performed by Crafoord in
1944 [4]
 Resection with primary end-to-end anastomosis[6], patch aortoplasty with
prosthetic material homograft or autologous subclavian artery.
 Bypass grafting with a prosthetic tube or autologous vascular grafts. The most
common technique in current use is resection with end-to-end anastomosis.
 Balloon dilation[5] with stent insertion for native aortic coarctation or
recoarctation is being used increasingly as an alternative to surgery and, in
some centers, has replaced surgery as the primary management strategy [7].
CASE REPORT
 We report here a case of 34 –year–old male, diagnosed with arterial
hypertension , Headache, blurring of vision and bilateral lower limb fatigueness
x 1 year , with difficult control of blood pressure values under treatment with
beta–blocker, ACE and diuretics. He had no history of cardiac problems or family
history of hypertension. K/C/O DM since 1 year on irregular treatment.
 The clinical examination showed :
Patient conscious , oriented and afebrile . Normal body development, a blood
pressure of 200/120 mmHg in the right arm and 190/110 mmHg in the left arm,
large pulsations in the suprasternal notch, normal heart sounds -60 bpm.. The
radial pulses were palpable but feeble pulse was found at the palpation of the
femoral arteries or distal to that level.
 Systemic examination :
- CVS
- RS
- CNS
- PA
NAD
IMAGING FINDINGS
CHEST X-RAY PA VIEW:
 Show bilateral rib notching “Roesler sign” caused by pressure from
intercostal blood vessels and “3 sign”.
INVESTIGATIONS
 ECG- NSR / NO significant ST –T changes.
 USG DOPPLER: Parvus tardus flow in aorta and renal arteries
 Echo – concentric LVH, bicuspid aortic valve, dilated ascending aorta
with suspicious narrowing at descending aorta, normal LV function.
“Following which patient was suspected coarctation of aorta
and hence subjected to CT aortogram”
CT AORTOGRAM-PROTOCOL
 MDCT angiography examination was performed with a 128-slice GE
Optima CT660 machine, plain and post contrast images extending from
C5 level till abdominal aortic bifurcation were acquired during a single
breath hold.
 The imaging data was acquired during an intravenous injection of
iodinated contrast agent (1.5ml/kg) at a rate of 5 ml/s.
 The scanning delay was determined with a bolus tracking technique. For
MIP and three dimensional image reconstruction, the volumetric CT
data sets were processed on a separate workstation with multiplanar
reformatting, curved planar reformatting, maximum intensity
projection, and volume rendering.
MDCT ANGIOGRAPHY
DESCENDING
SCAPULAR ARTEIES
COARCTATION
OF
AORTA
 Focal severe narrowing (coarctation) of distal isthmic part of aorta is
noted ~2.0 cm distal to the left subclavian artery ostium. Lumen calibre at
the site of coarctation is ~2.5 mm for length.
THORACIC AND ABDOMINAL COLLATERALS
LATERAL THORACIC ARTERY
POSTERIOR INTERCOSTAL ARTERIES
SUPERIOR EPIGASTRIC ARTERIES
 Bilateral subclavian arteries --> thyrocervical
and costocervical trunks-->thoraco acromial
and descending scapular arteries-->posterior
intercostal arteries-->DTA.
 Bilateral subclavian arteries ->internal mammary arteries(7mm) ->superior epigastric arteries ->inferior epigastric arteries ->external iliac arteries.
CELIAC AXIS
SMA
 Celiac axis, superior and inferior
mesenteric arteries are normal in
opacification.
Right renal artery and duplicated left
renal arteries are normal in caliber and
opacification.
 Both lungs are normal ,no evidence of
pleural/pericardial effusion.
No evidence of mediastinal
lymphadenopathy.
Liver, spleen ,kidney and visualized
bowel loops are normal.
 Features of severe post ductal coarctation of aorta with dilatation of left
subclavian artery and post stenotic DTA.
 Extensive collaterals from bilateral subclavian and axillary arteries
reconstituting the thoraco-abdominal aorta and iliac arteries.
 Mild left ventricular hypertrophy noted. No intra cardiac abnormality on
CT.
DIFFERENTIAL DIAGNOSIS
 Pseudocoarctation of the aorta is a very rare anomaly characterised by
kinking or buckling, of the aorta without a pressure gradient across
the lesion.
 Takayasu`s arteritis Various types of vasculitis produce aneurysms in
many portions of the aorta and its branches, but Takayasu arteritis is
the only type of aortitis that produces stenosis in the thoracic aorta
 Intrerrupted aortic arch (IAA) is defined as a complete luminal and
anatomic discontinuity between the ascending and descending aorta, as
described by Steidele in 1778.
 Coarctation of the abdominal aorta, also known as middle aortic
syndrome or midaortic dysplastic syndrome, is a clinical condition
caused by segmental narrowing of the abdominal or distal descending
thoracic aorta secondary either to a congenital anomaly in the
development of the abdominal aorta or to one of several acquired
conditions.
POSTOPERATIVE IMAGING
PA VIEW
 PROCEDURE :
AP VIEW
Bypass grafting of coarctation of aorta (16mm polyester graft )
- End to Side anastomosis
PREOP CT IMAGING
POST OP CT IMAGING
 Significant reduction in the collateral of internal mammary arteries ,
lateral thoracic arteries and Intercostal arteries
CONCLUSION

MDCT aortography allows excellent evaluation mapping of the aortic narrowing, associated
cardio-vascular anomalies before and after surgery. Three-dimensional and MIP reconstructions
provides angiographic-like images that enable precise measurements of the stenosis length and
With its high spatial resolution and isotropic and volumetric information, multidetector CT
performed with or without an ECG-gated technique allows accurate and fast noninvasive
characterization of aortic pathologic conditions.

Identification of collateral circulation is of importance before surgery to avoid ischemic medullary
injury. In our study had collateral vessel formation, and the origin and course of collateral vessels
were very well displayed with three-dimensional MDCT angiography.

Compared with MR angiography, MDCT angiography has the advantage of the ability to acquire
high spatial resolution in a shorter acquisition time. In addition, volume rendered and multiplanar
reconstructions are better for MDCT angiography data display than MRI.

It is an alternative tool helpful in establishing the primary diagnosis, defining anatomic landmarks
and relationships, and identifying associated vascular and cardiac anomalies and is an adjunct in
diagnosis of complications and detection of disease progression during follow-up.

Recently, time-resolved PC-MRI with velocity encoding along all three flow directions and threedimensional (3D) anatomic coverage (also termed ‘4D flow MRI’ ) has been developed and applied
for the evaluation of cardiovascular hemodynamics in multiple regions of the human body.
Advanced parallel imaging techniques such as k-t GRAPPA, have resulted in reasonable overall scan
times, e.g., 8-12 minutes for 4D flow MRI of the aorta and 10-20 minutes for whole heart
coverage.
REFERENCES
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 Alexander B. The seats and causes of diseases investigated by anatomy. London, UK: Millar
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cardiovascular disease. Mayo Clin Proc 2002; 77:646–653
 Campbell M. Natural history of coarctation of the aorta. Br Heart J 1970;32:633-640.
 Crafoord C, Nylin G. Congenital coarctation of the aorta and its surgical treatment. J
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