DOI: 10.1148/rg.254045151
Coronary Artery Bypass Grafts: Assessment with Multidetector CT in the Early and Late Postoperative Settings1
Aletta Ann Frazier, MD,
Fauzia Qureshi, MD,
Katrina M. Read, DDR,
Robert C. Gilkeson, MD,
Robert S. Poston, MD and
Charles S. White, MD
1 From the Departments of Diagnostic Imaging (A.A.F., F.Q., K.M.R., C.S.W.) and Cardiac Surgery (R.S.P.), University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201; the Department of Radiologic Pathology, Armed Forces Institute of Pathology, Washington, DC (A.A.F.); Philips Medical Systems, Cleveland, Ohio (K.M.R.); and the Department of Radiology, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Cleveland, Ohio (R.C.G.). Recipient of a Certificate of Merit award for an education exhibit at the 2003 RSNA Annual Meeting. Received July 26, 2004; revision requested October 13 and received March 16, 2005; accepted March 17. K.M.R. is an employee of Philips Medical Systems; R.S.P. has received a grant for research on the aortic connector from St Jude Medical; C.S.W. receives grant funding from Philips Medical Systems; all other authors have no financial relationships to disclose.
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Figure 1. Three-dimensional volume-rendered image shows the typical appearances of right (arrow) and left (solid arrowhead) SVGs sutured to the anterior aorta. The left SVG is attached to the diagonal artery distally; the distal anastomosis of the right SVG to the posterior descending artery is not seen. There is also a left internal mammary artery (IMA) graft (open arrowhead), which is connected to the left anterior descending (LAD) artery.
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Figure 2. Drawing shows the normal anatomy of the coronary arteries. a = left coronary artery, b = LAD artery, c = circumflex artery, d = diagonal artery, e = obtuse marginal branch of the circumflex artery, f = right coronary artery, g = posterior descending artery, and h = acute marginal branch of the right coronary artery. The intra-cardiac locations of the circumflex artery and its obtuse marginal branch are indicated by broken lines.
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Figure 3. Drawing shows examples of CABGs. A right SVG (a) is attached to the anterior aorta proximally and to the posterior descending artery distally. A left SVG (b) has an altered appearance because it is attached to the aorta with an aortic connector device (arrow); the origin of this SVG is moved laterally to prevent kinking. A typical left IMA graft (c) is left intact at its origin and grafted to the LAD artery distally.
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Figure 4. Left lateral slab maximum intensity projection image shows the entire length of an SVG from its proximal aortic origin (white arrow) to its distal anastomosis with the LAD artery (arrowhead). A clip artifact (black arrow) overlies part of the distal graft.
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Figure 5. Photograph shows a mechanical aortic connector (Symmetry Bypass System connector). (Courtesy of St Jude Medical.)
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Figure 6. Three-dimensional volume-rendered image shows the typical appearances of right (long arrow) and left (short arrow) SVGs attached to the ascending aorta with aortic connectors. Note the raised-star footprint at the aortic attachment site of each venous graft (open arrowhead). A left IMA graft is also present (solid arrowhead).
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Figure 7. Three-dimensional volume-rendered image shows a right SVG positioned at a 90° angle relative to the aorta (long arrow) and coursing along the right atrioventricular groove. A left SVG (short arrow) has a course over the pulmonary artery (*) to protect the graft from kinking. A left IMA graft is also present (arrowhead).
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Figure 8. Three-dimensional volume-rendered image shows the typical appearance of multiple CABGs. The patient received three left SVGs (long arrow), a right SVG (short arrow), and a left IMA graft (arrowhead). Note the raised-star footprints and lateral placement of the SVGs, an appearance characteristic of the use of aortic connectors.
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Figure 9a. Left IMA grafts. (a) Three-dimensional volume-rendered image shows a left IMA graft (arrow) from its origin at the left subclavian artery to its anastomosis with the LAD artery. There is also a right SVG (arrowhead), which is attached to the posterior descending artery. Note the smaller diameter of the arterial graft compared with that of the venous graft. (b) Volume-rendered image (lateral cut plane) shows a left IMA graft (arrow), which is anastomosed to an obtuse marginal branch of the circumflex artery. There is also a right IMA graft (arrowhead), the distal aspect of which is attached to the LAD artery.
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Figure 9b. Left IMA grafts. (a) Three-dimensional volume-rendered image shows a left IMA graft (arrow) from its origin at the left subclavian artery to its anastomosis with the LAD artery. There is also a right SVG (arrowhead), which is attached to the posterior descending artery. Note the smaller diameter of the arterial graft compared with that of the venous graft. (b) Volume-rendered image (lateral cut plane) shows a left IMA graft (arrow), which is anastomosed to an obtuse marginal branch of the circumflex artery. There is also a right IMA graft (arrowhead), the distal aspect of which is attached to the LAD artery.
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Figure 10a. Right IMA graft. (a) Curved multiplanar reformation image shows a patent right IMA graft (arrows) within the anterior mediastinum. The full extent of the graft is seen from its origin to its distal anastomosis with the LAD artery. (b) Three-dimensional volume-rendered image shows the right IMA graft from its origin (arrow) to its distal anastomosis with the LAD artery (arrowhead).
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Figure 10b. Right IMA graft. (a) Curved multiplanar reformation image shows a patent right IMA graft (arrows) within the anterior mediastinum. The full extent of the graft is seen from its origin to its distal anastomosis with the LAD artery. (b) Three-dimensional volume-rendered image shows the right IMA graft from its origin (arrow) to its distal anastomosis with the LAD artery (arrowhead).
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Figure 11a. Radial artery grafts. (a) Axial multidetector CT image shows a patent radial artery graft (arrow). Its patency is confirmed by the presence of intraluminal contrast material. An SVG (arrowhead) is seen anterior to the main pulmonary artery. (b) Axial multidetector CT image shows the origin of the SVG (arrow). Note the difference in caliber between the arterial graft and the SVG. (c) Three-dimensional volume-rendered image shows multiple CABGs in another patient. The radial artery (long arrow) is smaller in caliber than the SVG (short arrow) and similar in size to the IMA graft (arrowhead).
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Figure 11b. Radial artery grafts. (a) Axial multidetector CT image shows a patent radial artery graft (arrow). Its patency is confirmed by the presence of intraluminal contrast material. An SVG (arrowhead) is seen anterior to the main pulmonary artery. (b) Axial multidetector CT image shows the origin of the SVG (arrow). Note the difference in caliber between the arterial graft and the SVG. (c) Three-dimensional volume-rendered image shows multiple CABGs in another patient. The radial artery (long arrow) is smaller in caliber than the SVG (short arrow) and similar in size to the IMA graft (arrowhead).
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Figure 11c. Radial artery grafts. (a) Axial multidetector CT image shows a patent radial artery graft (arrow). Its patency is confirmed by the presence of intraluminal contrast material. An SVG (arrowhead) is seen anterior to the main pulmonary artery. (b) Axial multidetector CT image shows the origin of the SVG (arrow). Note the difference in caliber between the arterial graft and the SVG. (c) Three-dimensional volume-rendered image shows multiple CABGs in another patient. The radial artery (long arrow) is smaller in caliber than the SVG (short arrow) and similar in size to the IMA graft (arrowhead).
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Figure 12. Volume-rendered image obtained 5 days after CABG surgery shows aortic connectors (arrows), which mark the proximal attachments of two SVGs to the ascending aorta. The grafts are not seen due to acute thrombosis. An intact left IMA graft is seen (arrowhead).
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Figure 13a. Thrombosis of an SVG. (a) Axial multidetector CT image shows an SVG with an intraluminal thrombus (arrow) near its proximal anastomosis. (b) Axial multidetector CT image obtained slightly caudad shows that the graft is patent (arrow) with no evidence of thrombosis. (c) Curved axial multiplanar reformation image of the SVG shows a stent (arrowhead) and a thrombosed segment partly occluding the lumen (arrow).
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Figure 13b. Thrombosis of an SVG. (a) Axial multidetector CT image shows an SVG with an intraluminal thrombus (arrow) near its proximal anastomosis. (b) Axial multidetector CT image obtained slightly caudad shows that the graft is patent (arrow) with no evidence of thrombosis. (c) Curved axial multiplanar reformation image of the SVG shows a stent (arrowhead) and a thrombosed segment partly occluding the lumen (arrow).
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Figure 13c. Thrombosis of an SVG. (a) Axial multidetector CT image shows an SVG with an intraluminal thrombus (arrow) near its proximal anastomosis. (b) Axial multidetector CT image obtained slightly caudad shows that the graft is patent (arrow) with no evidence of thrombosis. (c) Curved axial multiplanar reformation image of the SVG shows a stent (arrowhead) and a thrombosed segment partly occluding the lumen (arrow).
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Figure 14. Left lateral oblique slab maximum intensity projection image shows contrast material within only a short proximal segment of an SVG (arrow). This appearance represents complete occlusion of the SVG.
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Figure 15. Curved multiplanar reformation image shows kinking of a right SVG (arrow). The conduit undergoes an abrupt change in angulation as it arises from the ascending aorta (A).
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Figure 16. Three-dimensional volume-rendered image shows right and left SVGs attached to the aorta with aortic connectors. The right graft (long arrow) does not appear to be positioned at the recommended 90° angle relative to the aorta. Ongoing studies are investigating whether such malpositioning may predispose to postoperative thrombosis and graft failure. The left graft (short arrow) demonstrates the required angulation and is better supported by the pulmonary artery. A left IMA graft is also present (arrowhead).
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Figure 17. Curved multiplanar reformation image shows a radial artery graft with postoperative vasospasm. Note that the more proximal aspect of the graft (black arrow) is narrower than the distal aspect (white arrow).
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Figure 18a. Iatrogenic early graft occlusion due to a retained surgical clip. (a) Three-dimensional volume-rendered image (coronal cut plane) shows a faint shadow along the course of a right SVG (long arrow). The shadow, which corresponds to a thrombus, leads to an atraumatic spring clip (Novare, Cupertino, Calif) distally (short arrow). A normal-appearing left SVG is evident (arrowhead). (b) Axial multidetector CT image shows the retained clip (arrow) lateral to the right atrium.
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Figure 18b. Iatrogenic early graft occlusion due to a retained surgical clip. (a) Three-dimensional volume-rendered image (coronal cut plane) shows a faint shadow along the course of a right SVG (long arrow). The shadow, which corresponds to a thrombus, leads to an atraumatic spring clip (Novare, Cupertino, Calif) distally (short arrow). A normal-appearing left SVG is evident (arrowhead). (b) Axial multidetector CT image shows the retained clip (arrow) lateral to the right atrium.
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Figure 19a. Deep sternal infection after CABG surgery. (a) Axial multidetector CT image shows sternal dehiscence (short arrow) with a large fluid collection (long arrow) in the anterior mediastinum. The graft vessel is also identified (arrowhead). (b) Axial multidetector CT image shows the patent bypass graft (arrowhead) coursing through the posterior aspect of the fluid collection. The infection was confirmed by means of positive bacterial cultures.
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Figure 19b. Deep sternal infection after CABG surgery. (a) Axial multidetector CT image shows sternal dehiscence (short arrow) with a large fluid collection (long arrow) in the anterior mediastinum. The graft vessel is also identified (arrowhead). (b) Axial multidetector CT image shows the patent bypass graft (arrowhead) coursing through the posterior aspect of the fluid collection. The infection was confirmed by means of positive bacterial cultures.
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Figure 20. Three-dimensional volume-rendered image (axial cut plane) shows an unsuspected pulmonary embolism after CABG surgery. A ribbonlike thrombus (arrow) is present within the central pulmonary arteries; the patent graft (arrowhead) is seen anterior to the pulmonary trunk.
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Figure 21. Coronal multidetector CT images show an SVG with a long segment of aneurysmal dilatation and secondary thrombosis (open arrowhead), which extend to its insertion at the LAD artery (solid arrowhead). A patent second SVG is identified adjacent to the abnormal segment (arrow).
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Figure 22a. Pseudoaneurysm of an SVG. (a) Axial multidetector CT image shows a thrombosed pseudoaneurysm of a left SVG (arrowhead). (b) Left lateral volume-rendered image shows the relationship between the proximal SVG (arrowhead) and the pseudoaneurysm (arrow), which arises from the distal anastomosis.
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Figure 22b. Pseudoaneurysm of an SVG. (a) Axial multidetector CT image shows a thrombosed pseudoaneurysm of a left SVG (arrowhead). (b) Left lateral volume-rendered image shows the relationship between the proximal SVG (arrowhead) and the pseudoaneurysm (arrow), which arises from the distal anastomosis.
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Figure 23a. Use of volume-rendered images in preoperative assessment of an existing left IMA graft. (a) Left lateral image shows the course of a left IMA graft (arrow) within the anterior mediastinum. (b) Left lateral image of another patient shows a left IMA graft tethered to the sternum (arrowhead).
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Figure 23b. Use of volume-rendered images in preoperative assessment of an existing left IMA graft. (a) Left lateral image shows the course of a left IMA graft (arrow) within the anterior mediastinum. (b) Left lateral image of another patient shows a left IMA graft tethered to the sternum (arrowhead).
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Copyright © 2005 by the Radiological Society of North America.
