Cardiovascular Imaging:

Beyond US
NITI TANK MD
 Objectives

 To understand common capabilities shared by CT

and MRI
 To understand strengths and limitations of CT and
MRI
 To learn the decision process from choosing CT
versus MRI for cardiovascular imaging
Cardiac imaging
 Indications for Cardiac CT

 Diagnosis of coronary artery disease (CAD) in a

patient with symptom(s) that may represent anginal
equivalent:
 Low or intermediate probability of stenotic CAD or stenotic
bypass graft disease is sufficient.
 Stress testing is contraindicated, not tolerated, or likely to generate
artifact (body habitus, uncontrolled severe hypertension, large aortic
aneurysm, left bundle branch block, suspicion of left main or severe
multi-artery disease)
 Stress testing result is equivocal or discrepant from clinical presentation
 Persistence of symptoms despite normal stress test result – in place of
catheterization
 Evaluation of bypass graft anatomy – in place of
catheterization
 Concurrent evaluation of aorta is desired
 Indications for Cardiac CTA

 Coronary artery anomaly: < 40 years-old and

symptoms or prior imaging suggests possible coronary
anomaly
 Evaluation of Fistula, AVM, aneurysm or pseudo-
aneurysm
 Planning interventional/surgical procedures
 Evaluation for stenotic CAD before valvular or aortic surgery – in
place of catheterization
 Evaluation of bypass graft and chest wall anatomy before redo open
heart surgery
 Left atrial / pulmonary vein evaluation before EP procedures to treat
atrial fibrillation
 Evaluation of left ventricular outflow tract and aorta before TAVR
 Evaluation of cardiac mass and/or thrombus
 Cardiac CT Angiogram

 Optimal patient characteristics*

 Resting sinus heart rate < 80 beats per minute
 Able to safely take metoprolol and nitroglycerin
 Able to hold breath for 10 seconds
 Body mass index (BMI) < 40 kg/m2
 No stent or coronary artery bypass surgery

 *Expect sensitivity > 95% and specificity > 80% for detecting
stenotic CAD in patients meeting above criteria

 Strong Contraindications
 Severe contrast allergy (anaphylaxis, shock, coma, seizure)
 Creatinine clearance < 30 ml/min or acute renal failure
 More than 10 PVCs/min
 Cannot follow instructions or cannot hold breath for 10 seconds
 High suspicion for acute coronary syndrome or stenotic CAD
 Cardiac CT for Coronary artery
disease
 ECG synchronization- time image acquisition
to cardiac cycle
 Retrospective
 Prospective
 Contrast bolus types and timing depends on
particular indication
Various reformats
Malignant right coronary artery
 Cardiac Calcium Scoring

Addition of CACS to a prediction model based on traditional risk factors

significantly improved the classification of risk
Calcium Score Presence of CAD
0 No evidence of CAD
1-10 Minimal evidence of CAD
11-100 Mild evidence of CAD
101-400 Moderate evidence of CAD
Over 400 Extensive evidence of CAD

Who should be screened using CT for calcium scoring?

- Patient with risk factors for CAD (high cholesterol, DM, HTN, Smoker,
obese, FH of CAD)
What are the limitations of Cardiac CT for Calcium Scoring?
- weight limit, CAD can still be present without calcium even if your calcium
score is low, HR > 90, insurance coverage
 Cardiovascular MRI - indications

Cardiac
 Global and regional left and right ventricular
function, and volume
 Cardiac and extracardiac masses
 Cardiomyopathies
 Myocarditis
 Valvular function (qualitative/quantitative)
 Pericardial disease
 Congenital heart disease
 Myocardial viability
 Poor quality echocardiograms
 Cardiac MRI technique

 Morphology  Breath hold and ECG

 Wall motion gated
 Valve movement  Bright blood/dark blood
 Function sequence
 Blood volume  Cine
 Flow  Phase encoding
 Cardiac output  Perfusion and delay
 Tissue property postcontrast imaging
 Perfusion
 Delay enhancement
 Tumor/mass
Infarct is bright on late-
enhancement images.

When a coronary artery

is occluded -
subendocardially
progresses towards the
epicardium depending
on the duration of the
occlusion

Subendocardial infarct vs.

transmural infarct.
Myocarditis:

Delayed enhanced
imaging demonstrate
enhancement in the
mid-myocardium

often in a patchy pattern

Nonvascular distribution

Myocarditis
an abnormal protrusion
of the interatrial septum

ranging from >11mm to

>15mm beyond normal
excursion in adults

can be limited to
the fossa ovalis or entire
interatrial septum

Interatrial septal aneurysm

 Contraindications – Cardiac MRI

 Severe claustrophobia
 Foreign body near vital structures
 Metallic implants – Neurostimulators, Cochlear
implants, Bone growth stimulators, pacemakers/ICD
 Intracranial aneurysm clips
 Vascular clamp
 Insulin or infusion pump or implanted drug infusion
device
 Acute renal failure/ chronic renal dysfunction
 Nephrotoxic Systemic Fibrosis (NSF)

 occurs exclusively in patients with reduced renal

function, including dialysis patients with gado use
 Painful skin induration in extremities with
contracture
 Risk Factors:
 Any patient with eGFR <30 ml/min/1.73m2
 Acute renal failure
 eGFR < 60 AND proinflammatory conditions/event
 unenhanced MR may be a better approach for
avoiding the potentially severe adverse effects
associated with contrast materials.
 Imaging of Aorta

 Aneurysm
 Incidence of AAA – 4% of ppl > 50 yrs of age

 Thoracic Aortic aneurysm: increase incidence with age, 7.5 per

100000, male predomiance
 Dissection
 Congenital – Coartation,
 Vasculitis – GCA, Takayasu Arteritis
 CTA of aorta

 Great for evaluation of acute aortic disorder

(dissection, aneurysm rupture) and
endovascular rx planning/stent followup
 short scan time and easy to perform
 Large FOV
 Better spatial resolution (vs. MRA)

Disadvantages
 Long post-processing time
 Radiation
 Beam Harding from metallic artifact
 MRA of aorta

 Better for congenital abnormalities, serial follow up of Aneurysm,

vasculitis, younger patient population
 Endovascular rx planning in ascending aortic aneurysm with
visualization of aortic valve on cine imaging
 Large FOV
 Shorter post processing time
 No artifact related to calcifications
 Greater soft tissue contrast

Disadvantage
 Technically complex
 Longer scan time - Claustrophobia/motion artifact
 Breath holding: chest/abd
 Metallic artifact from stents
Coarctation of Aorta
 Peripheral Vascular Disease

 Occurs in approximately 1/3 of patients

 Over age 70
 Over age 50 who smoke or have DM

 Strong association with CAD

 Obvious associated risk of stroke, MI, cardiovascular death

 Progressive disease in 25% with progressive intermittent

claudication/limb threatening ischemia
 Outcomes
 Impaired QoL
 Limb Loss
 Premature Mortality
 Diagnosis modalities

 Ankle Brachial Index (ABI)

 Noninvasive vascular laboratory
 Ultrasound
 Angiography: MRA, CT, DSA
 Location based on symptoms

 Buttock/hip
 Usually indicates aortoiliac occlusive disease (Leriche's
syndrome)
 Some cases, thigh claudication too
 Question diagnosis of bilateral disease if erectile dysfunction is not
present
 Thigh
 Occlusion of the common femoral artery leads to
claudication in the thigh, calf, or both.
 Calf
 Symptoms in upper 2/3 is usually due to SFA
 Lower 1/3 is due to popliteal disease.
 Ankle Brachial Index

 Cornerstone of lower extremity vascular evaluation

 Blood pressure cuffs, Doppler

 Ankle (DP or PT) to brachial artery pressure

 Limitations

 Noncompressible vessels
 Diabetes

 Renal Failure

 ABI >1.5

 Use toe-brachial index

 Normal >0.7
 Rest pain <0.2

 Subclavian/Brachiocephalic Occlusive disease

 Duplex Doppler

 Non-invasive method of evaluating the blood vessels.

 Can obtain both anatomic and hemodynamic
information.
 Anatomical detail
 vessel wall
 intraluminal obstructive lesions
 perivascular compressive structures
 Doppler Waveform Analysis: Hemodynamic
Information

Sensitivity of 92.6% and

specificity of 97%
(angiography gold
standard)
Inaccurate at adductor
canal and the aorto-iliac
regions.
95% accuracy in the
detection of bypass graft
stenosis, but can
overestimate stenosis Polack JF. Duplex Doppler in peripheral arterial disease. Radiol
Clin N Amer 1995; 33 : 71-88.
 PAD

 Advances in noninvasive imaging methods:

 computed tomography (CT)
 magnetic resonance (MR) imaging
 replaced invasive angiographic procedures

 lowering the cost and morbidity of diagnosis

 CTA – current technique

 Multidetector CT scanner necessary

(4+)- most are now 64 Slice
 Iodinated contrast volume similar to
conventional angiography
 80-150 cc
 Automated Scan Delay
 Renal arteries to ankles
 10-minute exam
 Post processing software crucial
 CT angiogram

Advantages

 Faster study
 Intervention planning
 Excellent renal to ankle imaging – high spatial
resolution
 Images soft tissue and bone as well
 CT limitations

 Radiation
 Pregnancy
Blooming artifact from calcification
• overestimate stenosis

 Need contrast:
 renal function
 contrast allergy

 Uncooperative patient
 Bad Pump
 Inconsistent pedal vessel visualization
 Longer postprocessing time
 MRA current technique

 2D or 3D Time of Flight
 Unsaturated blood produces bright
signal and background tissue is
saturated
 Contrasted Enhanced
 20-40 cc gadolinium injection
 Automated Scan delay

 45-min exam
 Pooled sensitivity 97%, specificity
96%
 Higher temporal resolution
 MR angiogram - Advantage

 Localizing disease extent and severity

 Providence guidance for intervention
 No radiation
 Can do with and without contrast (better for patient
with renal issue or contrast allergies)
 Better for foot and ankle vascular imaging (esp in
calcified vessels)
 Evaluate inflow grafts: (aorto–biiliac,
aortobifemoral, axillobifemoral)
MRA vs. DSA
 Limitations of MRI

 Longer scan time

 Pre-screening is required- Pacemakers/ICDs,
metallic implants
 More costly
 Metal artifacts can be mistaken for stenosis
 Unable to characterize vascular calcification
 Uncooperative patient/ Claustrophobia
Carotid arterial disease
 Carotid disease and Stroke

 Up to 83% of all stroke, TIA or

amaurosis fugax – maybe from carotid
bifurcation atheromatous disease
 CEA produces an absolute reduction
of 17% in stroke at 2 years when
compared to ASA in symptomatic
patients with 70% or greater ICA
stenosis.
 Risk of no treatment is 26%.
 Risk of CEA is 9%.
 Carotid Ultrasound

 Most accurate, noninvasive cost-effective method for

diagnosis of extracranial cerebrovascular disease
 Intimal thickening and plaque morphology
 Doppler velocity spectral analysis
 High negative predictive value
 Vertebral artery evaluation (assess for subclavian
steal)
 CTA of Carotid artery

 Accurate quantitation and anatomic localization

 Luminal and non-luminal information
 Tandem stenosis
 Longitudinal follow-up
 3D visualization
 Extended coverage
 pooled sensitivity of 95% and a specificity of 98% for
the detection of >70% stenosis
 Greater for assessment of dissection
 Limitations of CTA

 Contrast allergy
 Renal dysfunction
 Radiation
 Gross patient motion artifacts
 Artifacts
 Beam hardening artifacts: amalgam, hyper-concentrated contrast
 Reconstruction artifacts
 Contrast gradient artifacts
 Stent blooming artifacts

 Simultaneous arterial and venous imaging

 Low ejection fraction (heart failure)
 Overestimation of stenosis in thick calcific plaque
 MRA - Technique

 TOF: Noncontract imaging which captures blood flow

information
 2d TOF – rapid acquisition but susceptible to motion artifact
 3d TOF – high spatial resolution (sensitive to medium to high
flow) but insensitive to low flow.
 Contrast enhanced MRA
 May be performed in 2d imagine along any plane as well as 3d
 Usually performed in coronal plane with reformats
 Fast imaging approximately 10 minutes
TOF vs.CEM
 MRA – CEM vs. TOF

Advantages
 Shorter scan time – less artifact from motion
 Large coverage
 More accurate stenosis and occlusion
 Contrast independent of flow direction
 Less contamination from short T1 materials
 Better SNR vs. TOF-MRA
 Less signal loss from slow/turbulent flow
 Great for evaluation of dissection
 MRA – CEM vs. TOF

Disadvantages
 Longer prep time – more venous signal
 Lower spatial resolution (vs. TOF-MRA and CTA)
 Stents and metallic artifact
 T2* effects with bolus
 Maki effect (k-space ordering)
 Vessel diameter varies during contrast bolus cycle
 No calcifications
 Advantage of CTA over MRA

 Provides information about vessel lumen and vessel

wall in single study vs. contrast enhanced MRA (CE-
MRA) and TOF-MRA
 No vascular signal artifacts arising from
slow/complex/turbulent/in-plane flow vs. TOF MRA
 Higher spatial resolution
 Widely available
 Easier to acquire
 Lower cost
 Disadvantage of CTA over MRA

 Radiation
 Contrast allergy (1:30,000)
 Longer processing time
 Renal insufficiency
 Simultaneous venous contamination
 Limited direct hemodynamic information.
 Gross motion and beam hardening.
 Upper extremity vascular disease

 broad spectrum of diseases ranging from acute limb-

threatening ischemia to chronic disabling disease.
 less common than lower extremity vascular disease
 affects as much as 10% of the population
 CTA Upper extremity

 evaluate for stenosis, occlusion, aneurysm, or

embolic events, especially when they affect vessels
proximal to the wrist.
 vasculitis of large and medium arteries: Takayasu
arteritis (TA), giant cell arteritis (GCA), and
thromboangiitis obliterans
 Limitation - imaging of small vessels of the hand due
to inconsistent enhancement of these vessels.
Giant cell arteritis Thromboangiitis
obliterans

Subclavian Steal
 MRA upper extremity

 Great for Large and medium vessels

 Great for small vessels below the wrist
 Evaluation of stenosis, occlusion, trauma,
vasculitides
 No radiation, can be done without contrast
 Longer study
 Usual contraindications.
MRA hand
When in doubt…call us!