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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).

View larger version (97K): [in a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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.

View larger version (130K): [in a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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.

View larger version (185K): [in a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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.

View larger version (169K): [in a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 a new window]   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 vess