NITI TANK MD

Cardiovascular ImagingBeyond US

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 ndash in place of catheterization

Evaluation of bypass graft anatomy ndash in place of catheterization

Concurrent evaluation of aorta is desired

Indications for Cardiac CTA

Coronary artery anomaly lt 40 years-old and symptoms or prior imaging suggests possible coronary anomaly

Evaluation of Fistula AVM aneurysm or pseudo- aneurysm

Planning interventionalsurgical procedures Evaluation for stenotic CAD before valvular or aortic surgery

ndash 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

TAVREvaluation of cardiac mass andor thrombus

Cardiac CT Angiogram

Optimal patient characteristics Resting sinus heart rate lt 80 beats per minute Able to safely take metoprolol and nitroglycerin Able to hold breath for 10 seconds Body mass index (BMI) lt 40 kgm2

No stent or coronary artery bypass surgery Expect sensitivity gt 95 and specificity gt 80 for

detecting stenotic CAD in patients meeting above criteria

Strong Contraindications Severe contrast allergy (anaphylaxis shock coma seizure) Creatinine clearance lt 30 mlmin or acute renal failure More than 10 PVCsmin 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 CAD0 No evidence of CAD1-10 Minimal evidence of CAD11-100 Mild evidence of CAD101-400 Moderate evidence of CADOver 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 gt 90 insurance coverage

Cardiovascular MRI - indications

CardiacGlobal and regional left and right ventricular function and volumeCardiac and extracardiac massesCardiomyopathiesMyocarditisValvular function (qualitativequantitative)Pericardial diseaseCongenital heart diseaseMyocardial viabilityPoor quality echocardiograms

Cardiac MRI technique

Morphology Wall motion Valve movement

Function Blood volume Flow Cardiac output

Tissue property Perfusion Delay enhancement Tumormass

Breath hold and ECG gated

Bright blooddark blood sequence

Cine Phase encodingPerfusion and delay

postcontrast imaging

Subendocardial infarct vs transmural infarct

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

Myocarditis

Myocarditis

Delayed enhanced imaging demonstrate enhancement in the mid-myocardium

often in a patchy pattern

Nonvascular distribution

Interatrial septal aneurysm

an abnormal protrusion of the interatrial septum

ranging from gt11mm to gt15mm beyond normal excursion in adults

can be limited to the fossa ovalis or entire interatrial septum

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 ndash in place of catheterization

Evaluation of bypass graft anatomy ndash in place of catheterization

Concurrent evaluation of aorta is desired

Indications for Cardiac CTA

Coronary artery anomaly lt 40 years-old and symptoms or prior imaging suggests possible coronary anomaly

Evaluation of Fistula AVM aneurysm or pseudo- aneurysm

Planning interventionalsurgical procedures Evaluation for stenotic CAD before valvular or aortic surgery

ndash 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

TAVREvaluation of cardiac mass andor thrombus

Cardiac CT Angiogram

Optimal patient characteristics Resting sinus heart rate lt 80 beats per minute Able to safely take metoprolol and nitroglycerin Able to hold breath for 10 seconds Body mass index (BMI) lt 40 kgm2

No stent or coronary artery bypass surgery Expect sensitivity gt 95 and specificity gt 80 for

detecting stenotic CAD in patients meeting above criteria

Strong Contraindications Severe contrast allergy (anaphylaxis shock coma seizure) Creatinine clearance lt 30 mlmin or acute renal failure More than 10 PVCsmin 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 CAD0 No evidence of CAD1-10 Minimal evidence of CAD11-100 Mild evidence of CAD101-400 Moderate evidence of CADOver 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 gt 90 insurance coverage

Cardiovascular MRI - indications

CardiacGlobal and regional left and right ventricular function and volumeCardiac and extracardiac massesCardiomyopathiesMyocarditisValvular function (qualitativequantitative)Pericardial diseaseCongenital heart diseaseMyocardial viabilityPoor quality echocardiograms

Cardiac MRI technique

Morphology Wall motion Valve movement

Function Blood volume Flow Cardiac output

Tissue property Perfusion Delay enhancement Tumormass

Breath hold and ECG gated

Bright blooddark blood sequence

Cine Phase encodingPerfusion and delay

postcontrast imaging

Subendocardial infarct vs transmural infarct

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

Myocarditis

Myocarditis

Delayed enhanced imaging demonstrate enhancement in the mid-myocardium

often in a patchy pattern

Nonvascular distribution

Interatrial septal aneurysm

an abnormal protrusion of the interatrial septum

ranging from gt11mm to gt15mm beyond normal excursion in adults

can be limited to the fossa ovalis or entire interatrial septum

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 ndash in place of catheterization

Evaluation of bypass graft anatomy ndash in place of catheterization

Concurrent evaluation of aorta is desired

Indications for Cardiac CTA

Coronary artery anomaly lt 40 years-old and symptoms or prior imaging suggests possible coronary anomaly

Evaluation of Fistula AVM aneurysm or pseudo- aneurysm

Planning interventionalsurgical procedures Evaluation for stenotic CAD before valvular or aortic surgery

ndash 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

TAVREvaluation of cardiac mass andor thrombus

Cardiac CT Angiogram

Optimal patient characteristics Resting sinus heart rate lt 80 beats per minute Able to safely take metoprolol and nitroglycerin Able to hold breath for 10 seconds Body mass index (BMI) lt 40 kgm2

No stent or coronary artery bypass surgery Expect sensitivity gt 95 and specificity gt 80 for

detecting stenotic CAD in patients meeting above criteria

Strong Contraindications Severe contrast allergy (anaphylaxis shock coma seizure) Creatinine clearance lt 30 mlmin or acute renal failure More than 10 PVCsmin 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 CAD0 No evidence of CAD1-10 Minimal evidence of CAD11-100 Mild evidence of CAD101-400 Moderate evidence of CADOver 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 gt 90 insurance coverage

Cardiovascular MRI - indications

CardiacGlobal and regional left and right ventricular function and volumeCardiac and extracardiac massesCardiomyopathiesMyocarditisValvular function (qualitativequantitative)Pericardial diseaseCongenital heart diseaseMyocardial viabilityPoor quality echocardiograms

Cardiac MRI technique

Morphology Wall motion Valve movement

Function Blood volume Flow Cardiac output

Tissue property Perfusion Delay enhancement Tumormass

Breath hold and ECG gated

Bright blooddark blood sequence

Cine Phase encodingPerfusion and delay

postcontrast imaging

Subendocardial infarct vs transmural infarct

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

Myocarditis

Myocarditis

Delayed enhanced imaging demonstrate enhancement in the mid-myocardium

often in a patchy pattern

Nonvascular distribution

Interatrial septal aneurysm

an abnormal protrusion of the interatrial septum

ranging from gt11mm to gt15mm beyond normal excursion in adults

can be limited to the fossa ovalis or entire interatrial septum

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 ndash in place of catheterization

Evaluation of bypass graft anatomy ndash in place of catheterization

Concurrent evaluation of aorta is desired

Indications for Cardiac CTA

Coronary artery anomaly lt 40 years-old and symptoms or prior imaging suggests possible coronary anomaly

Evaluation of Fistula AVM aneurysm or pseudo- aneurysm

Planning interventionalsurgical procedures Evaluation for stenotic CAD before valvular or aortic surgery

ndash 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

TAVREvaluation of cardiac mass andor thrombus

Cardiac CT Angiogram

Optimal patient characteristics Resting sinus heart rate lt 80 beats per minute Able to safely take metoprolol and nitroglycerin Able to hold breath for 10 seconds Body mass index (BMI) lt 40 kgm2

No stent or coronary artery bypass surgery Expect sensitivity gt 95 and specificity gt 80 for

detecting stenotic CAD in patients meeting above criteria

Strong Contraindications Severe contrast allergy (anaphylaxis shock coma seizure) Creatinine clearance lt 30 mlmin or acute renal failure More than 10 PVCsmin 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 CAD0 No evidence of CAD1-10 Minimal evidence of CAD11-100 Mild evidence of CAD101-400 Moderate evidence of CADOver 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 gt 90 insurance coverage

Cardiovascular MRI - indications

CardiacGlobal and regional left and right ventricular function and volumeCardiac and extracardiac massesCardiomyopathiesMyocarditisValvular function (qualitativequantitative)Pericardial diseaseCongenital heart diseaseMyocardial viabilityPoor quality echocardiograms

Cardiac MRI technique

Morphology Wall motion Valve movement

Function Blood volume Flow Cardiac output

Tissue property Perfusion Delay enhancement Tumormass

Breath hold and ECG gated

Bright blooddark blood sequence

Cine Phase encodingPerfusion and delay

postcontrast imaging

Subendocardial infarct vs transmural infarct

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

Myocarditis

Myocarditis

Delayed enhanced imaging demonstrate enhancement in the mid-myocardium

often in a patchy pattern

Nonvascular distribution

Interatrial septal aneurysm

an abnormal protrusion of the interatrial septum

ranging from gt11mm to gt15mm beyond normal excursion in adults

can be limited to the fossa ovalis or entire interatrial septum

Indications for Cardiac CTA

Coronary artery anomaly lt 40 years-old and symptoms or prior imaging suggests possible coronary anomaly

Evaluation of Fistula AVM aneurysm or pseudo- aneurysm

Planning interventionalsurgical procedures Evaluation for stenotic CAD before valvular or aortic surgery

ndash 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

TAVREvaluation of cardiac mass andor thrombus

Cardiac CT Angiogram

Optimal patient characteristics Resting sinus heart rate lt 80 beats per minute Able to safely take metoprolol and nitroglycerin Able to hold breath for 10 seconds Body mass index (BMI) lt 40 kgm2

No stent or coronary artery bypass surgery Expect sensitivity gt 95 and specificity gt 80 for

detecting stenotic CAD in patients meeting above criteria

Strong Contraindications Severe contrast allergy (anaphylaxis shock coma seizure) Creatinine clearance lt 30 mlmin or acute renal failure More than 10 PVCsmin 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 CAD0 No evidence of CAD1-10 Minimal evidence of CAD11-100 Mild evidence of CAD101-400 Moderate evidence of CADOver 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 gt 90 insurance coverage

Cardiovascular MRI - indications

CardiacGlobal and regional left and right ventricular function and volumeCardiac and extracardiac massesCardiomyopathiesMyocarditisValvular function (qualitativequantitative)Pericardial diseaseCongenital heart diseaseMyocardial viabilityPoor quality echocardiograms

Cardiac MRI technique

Morphology Wall motion Valve movement

Function Blood volume Flow Cardiac output

Tissue property Perfusion Delay enhancement Tumormass

Breath hold and ECG gated

Bright blooddark blood sequence

Cine Phase encodingPerfusion and delay

postcontrast imaging

Subendocardial infarct vs transmural infarct

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

Myocarditis

Myocarditis

Delayed enhanced imaging demonstrate enhancement in the mid-myocardium

often in a patchy pattern

Nonvascular distribution

Interatrial septal aneurysm

an abnormal protrusion of the interatrial septum

ranging from gt11mm to gt15mm beyond normal excursion in adults

can be limited to the fossa ovalis or entire interatrial septum

Cardiac CT Angiogram

Optimal patient characteristics Resting sinus heart rate lt 80 beats per minute Able to safely take metoprolol and nitroglycerin Able to hold breath for 10 seconds Body mass index (BMI) lt 40 kgm2

No stent or coronary artery bypass surgery Expect sensitivity gt 95 and specificity gt 80 for

detecting stenotic CAD in patients meeting above criteria

Strong Contraindications Severe contrast allergy (anaphylaxis shock coma seizure) Creatinine clearance lt 30 mlmin or acute renal failure More than 10 PVCsmin 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 CAD0 No evidence of CAD1-10 Minimal evidence of CAD11-100 Mild evidence of CAD101-400 Moderate evidence of CADOver 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 gt 90 insurance coverage

Cardiovascular MRI - indications

CardiacGlobal and regional left and right ventricular function and volumeCardiac and extracardiac massesCardiomyopathiesMyocarditisValvular function (qualitativequantitative)Pericardial diseaseCongenital heart diseaseMyocardial viabilityPoor quality echocardiograms

Cardiac MRI technique

Morphology Wall motion Valve movement

Function Blood volume Flow Cardiac output

Tissue property Perfusion Delay enhancement Tumormass

Breath hold and ECG gated

Bright blooddark blood sequence

Cine Phase encodingPerfusion and delay

postcontrast imaging

Subendocardial infarct vs transmural infarct

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

Myocarditis

Myocarditis

Delayed enhanced imaging demonstrate enhancement in the mid-myocardium

often in a patchy pattern

Nonvascular distribution

Interatrial septal aneurysm

an abnormal protrusion of the interatrial septum

ranging from gt11mm to gt15mm beyond normal excursion in adults

can be limited to the fossa ovalis or entire interatrial septum

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 CAD0 No evidence of CAD1-10 Minimal evidence of CAD11-100 Mild evidence of CAD101-400 Moderate evidence of CADOver 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 gt 90 insurance coverage

Cardiovascular MRI - indications

CardiacGlobal and regional left and right ventricular function and volumeCardiac and extracardiac massesCardiomyopathiesMyocarditisValvular function (qualitativequantitative)Pericardial diseaseCongenital heart diseaseMyocardial viabilityPoor quality echocardiograms

Cardiac MRI technique

Morphology Wall motion Valve movement

Function Blood volume Flow Cardiac output

Tissue property Perfusion Delay enhancement Tumormass

Breath hold and ECG gated

Bright blooddark blood sequence

Cine Phase encodingPerfusion and delay

postcontrast imaging

Subendocardial infarct vs transmural infarct

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

Myocarditis

Myocarditis

Delayed enhanced imaging demonstrate enhancement in the mid-myocardium

often in a patchy pattern

Nonvascular distribution

Interatrial septal aneurysm

an abnormal protrusion of the interatrial septum

ranging from gt11mm to gt15mm beyond normal excursion in adults

can be limited to the fossa ovalis or entire interatrial septum

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 CAD0 No evidence of CAD1-10 Minimal evidence of CAD11-100 Mild evidence of CAD101-400 Moderate evidence of CADOver 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 gt 90 insurance coverage

Cardiovascular MRI - indications

CardiacGlobal and regional left and right ventricular function and volumeCardiac and extracardiac massesCardiomyopathiesMyocarditisValvular function (qualitativequantitative)Pericardial diseaseCongenital heart diseaseMyocardial viabilityPoor quality echocardiograms

Cardiac MRI technique

Morphology Wall motion Valve movement

Function Blood volume Flow Cardiac output

Tissue property Perfusion Delay enhancement Tumormass

Breath hold and ECG gated

Bright blooddark blood sequence

Cine Phase encodingPerfusion and delay

postcontrast imaging

Subendocardial infarct vs transmural infarct

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

Myocarditis

Myocarditis

Delayed enhanced imaging demonstrate enhancement in the mid-myocardium

often in a patchy pattern

Nonvascular distribution

Interatrial septal aneurysm

an abnormal protrusion of the interatrial septum

ranging from gt11mm to gt15mm beyond normal excursion in adults

can be limited to the fossa ovalis or entire interatrial septum

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 CAD0 No evidence of CAD1-10 Minimal evidence of CAD11-100 Mild evidence of CAD101-400 Moderate evidence of CADOver 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 gt 90 insurance coverage

Cardiovascular MRI - indications

CardiacGlobal and regional left and right ventricular function and volumeCardiac and extracardiac massesCardiomyopathiesMyocarditisValvular function (qualitativequantitative)Pericardial diseaseCongenital heart diseaseMyocardial viabilityPoor quality echocardiograms

Cardiac MRI technique

Morphology Wall motion Valve movement

Function Blood volume Flow Cardiac output

Tissue property Perfusion Delay enhancement Tumormass

Breath hold and ECG gated

Bright blooddark blood sequence

Cine Phase encodingPerfusion and delay

postcontrast imaging

Subendocardial infarct vs transmural infarct

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

Myocarditis

Myocarditis

Delayed enhanced imaging demonstrate enhancement in the mid-myocardium

often in a patchy pattern

Nonvascular distribution

Interatrial septal aneurysm

an abnormal protrusion of the interatrial septum

ranging from gt11mm to gt15mm beyond normal excursion in adults

can be limited to the fossa ovalis or entire interatrial septum

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 CAD0 No evidence of CAD1-10 Minimal evidence of CAD11-100 Mild evidence of CAD101-400 Moderate evidence of CADOver 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 gt 90 insurance coverage

Cardiovascular MRI - indications

CardiacGlobal and regional left and right ventricular function and volumeCardiac and extracardiac massesCardiomyopathiesMyocarditisValvular function (qualitativequantitative)Pericardial diseaseCongenital heart diseaseMyocardial viabilityPoor quality echocardiograms

Cardiac MRI technique

Morphology Wall motion Valve movement

Function Blood volume Flow Cardiac output

Tissue property Perfusion Delay enhancement Tumormass

Breath hold and ECG gated

Bright blooddark blood sequence

Cine Phase encodingPerfusion and delay

postcontrast imaging

Subendocardial infarct vs transmural infarct

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

Myocarditis

Myocarditis

Delayed enhanced imaging demonstrate enhancement in the mid-myocardium

often in a patchy pattern

Nonvascular distribution

Interatrial septal aneurysm

an abnormal protrusion of the interatrial septum

ranging from gt11mm to gt15mm beyond normal excursion in adults

can be limited to the fossa ovalis or entire interatrial septum

Cardiovascular MRI - indications

CardiacGlobal and regional left and right ventricular function and volumeCardiac and extracardiac massesCardiomyopathiesMyocarditisValvular function (qualitativequantitative)Pericardial diseaseCongenital heart diseaseMyocardial viabilityPoor quality echocardiograms

Cardiac MRI technique

Morphology Wall motion Valve movement

Function Blood volume Flow Cardiac output

Tissue property Perfusion Delay enhancement Tumormass

Breath hold and ECG gated

Bright blooddark blood sequence

Cine Phase encodingPerfusion and delay

postcontrast imaging

Subendocardial infarct vs transmural infarct

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

Myocarditis

Myocarditis

Delayed enhanced imaging demonstrate enhancement in the mid-myocardium

often in a patchy pattern

Nonvascular distribution

Interatrial septal aneurysm

an abnormal protrusion of the interatrial septum

ranging from gt11mm to gt15mm beyond normal excursion in adults

can be limited to the fossa ovalis or entire interatrial septum

Cardiac MRI technique

Morphology Wall motion Valve movement

Function Blood volume Flow Cardiac output

Tissue property Perfusion Delay enhancement Tumormass

Breath hold and ECG gated

Bright blooddark blood sequence

Cine Phase encodingPerfusion and delay

postcontrast imaging

Subendocardial infarct vs transmural infarct

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

Myocarditis

Myocarditis

Delayed enhanced imaging demonstrate enhancement in the mid-myocardium

often in a patchy pattern

Nonvascular distribution

Interatrial septal aneurysm

an abnormal protrusion of the interatrial septum

ranging from gt11mm to gt15mm beyond normal excursion in adults

can be limited to the fossa ovalis or entire interatrial septum

Subendocardial infarct vs transmural infarct

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

Myocarditis

Myocarditis

Delayed enhanced imaging demonstrate enhancement in the mid-myocardium

often in a patchy pattern

Nonvascular distribution

Interatrial septal aneurysm

an abnormal protrusion of the interatrial septum

ranging from gt11mm to gt15mm beyond normal excursion in adults

can be limited to the fossa ovalis or entire interatrial septum

Myocarditis

Myocarditis

Delayed enhanced imaging demonstrate enhancement in the mid-myocardium

often in a patchy pattern

Nonvascular distribution

Interatrial septal aneurysm

an abnormal protrusion of the interatrial septum

ranging from gt11mm to gt15mm beyond normal excursion in adults

can be limited to the fossa ovalis or entire interatrial septum

Interatrial septal aneurysm

an abnormal protrusion of the interatrial septum

ranging from gt11mm to gt15mm beyond normal excursion in adults

can be limited to the fossa ovalis or entire interatrial septum

Contraindications ndash Cardiac MRI

Severe claustrophobiaForeign body near vital structuresMetallic implants ndash Neurostimulators Cochlear

implants Bone growth stimulators pacemakersICD

Intracranial aneurysm clipsVascular clampInsulin or infusion pump or implanted drug

infusion deviceAcute 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 lt30 mlmin173m2 Acute renal failure eGFR lt 60 AND proinflammatory conditionsevent

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 ndash 4 of ppl gt 50 yrs of age Thoracic Aortic aneurysm increase incidence with

age 75 per 100000 male predomianceDissectionCongenital ndash Coartation Vasculitis ndash GCA Takayasu Arteritis

CTA of aorta

Great for evaluation of acute aortic disorder (dissection aneurysm rupture) and endovascular rx planningstent followup

short scan time and easy to performLarge FOVBetter spatial resolution (vs MRA)

DisadvantagesLong post-processing timeRadiationBeam 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 - Claustrophobiamotion artifact Breath holding chestabd Metallic artifact from stents

Coarctation of Aorta

Peripheral Vascular Disease

Occurs in approximately 13 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 claudicationlimb threatening ischemia

Outcomes Impaired QoL Limb Loss Premature Mortality

Diagnosis modalities

Ankle Brachial Index (ABI)Noninvasive vascular laboratoryUltrasoundAngiography MRA CT DSA

Location based on symptoms

Buttockhip Usually indicates aortoiliac occlusive disease

(Leriches syndrome) Some cases thigh claudication too Question diagnosis of bilateral disease if erectile

dysfunction is not presentThigh

Occlusion of the common femoral artery leads to claudication in the thigh calf or both

Calf Symptoms in upper 23 is usually due to SFA Lower 13 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 gt15 Use toe-brachial index

Normal gt07 Rest pain lt02

SubclavianBrachiocephalic 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

Sensitivity of 926 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

Doppler Waveform Analysis Hemodynamic Information

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 ndash 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 ankles10-minute examPost processing software crucial

Advantages

Faster studyIntervention planningExcellent renal to ankle imaging ndash high

spatial resolutionImages soft tissue and bone as well

CT angiogram

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

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 lt30 mlmin173m2 Acute renal failure eGFR lt 60 AND proinflammatory conditionsevent

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 ndash 4 of ppl gt 50 yrs of age Thoracic Aortic aneurysm increase incidence with

age 75 per 100000 male predomianceDissectionCongenital ndash Coartation Vasculitis ndash GCA Takayasu Arteritis

CTA of aorta

Great for evaluation of acute aortic disorder (dissection aneurysm rupture) and endovascular rx planningstent followup

short scan time and easy to performLarge FOVBetter spatial resolution (vs MRA)

DisadvantagesLong post-processing timeRadiationBeam 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 - Claustrophobiamotion artifact Breath holding chestabd Metallic artifact from stents

Coarctation of Aorta

Peripheral Vascular Disease

Occurs in approximately 13 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 claudicationlimb threatening ischemia

Outcomes Impaired QoL Limb Loss Premature Mortality

Diagnosis modalities

Ankle Brachial Index (ABI)Noninvasive vascular laboratoryUltrasoundAngiography MRA CT DSA

Location based on symptoms

Buttockhip Usually indicates aortoiliac occlusive disease

(Leriches syndrome) Some cases thigh claudication too Question diagnosis of bilateral disease if erectile

dysfunction is not presentThigh

Occlusion of the common femoral artery leads to claudication in the thigh calf or both

Calf Symptoms in upper 23 is usually due to SFA Lower 13 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 gt15 Use toe-brachial index

Normal gt07 Rest pain lt02

SubclavianBrachiocephalic 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

Sensitivity of 926 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

Doppler Waveform Analysis Hemodynamic Information

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 ndash 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 ankles10-minute examPost processing software crucial

Advantages

Faster studyIntervention planningExcellent renal to ankle imaging ndash high

spatial resolutionImages soft tissue and bone as well

CT angiogram

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

Imaging of Aorta

Aneurysm Incidence of AAA ndash 4 of ppl gt 50 yrs of age Thoracic Aortic aneurysm increase incidence with

age 75 per 100000 male predomianceDissectionCongenital ndash Coartation Vasculitis ndash GCA Takayasu Arteritis

CTA of aorta

Great for evaluation of acute aortic disorder (dissection aneurysm rupture) and endovascular rx planningstent followup

short scan time and easy to performLarge FOVBetter spatial resolution (vs MRA)

DisadvantagesLong post-processing timeRadiationBeam 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 - Claustrophobiamotion artifact Breath holding chestabd Metallic artifact from stents

Coarctation of Aorta

Peripheral Vascular Disease

Occurs in approximately 13 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 claudicationlimb threatening ischemia

Outcomes Impaired QoL Limb Loss Premature Mortality

Diagnosis modalities

Ankle Brachial Index (ABI)Noninvasive vascular laboratoryUltrasoundAngiography MRA CT DSA

Location based on symptoms

Buttockhip Usually indicates aortoiliac occlusive disease

(Leriches syndrome) Some cases thigh claudication too Question diagnosis of bilateral disease if erectile

dysfunction is not presentThigh

Occlusion of the common femoral artery leads to claudication in the thigh calf or both

Calf Symptoms in upper 23 is usually due to SFA Lower 13 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 gt15 Use toe-brachial index

Normal gt07 Rest pain lt02

SubclavianBrachiocephalic 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

Sensitivity of 926 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

Doppler Waveform Analysis Hemodynamic Information

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 ndash 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 ankles10-minute examPost processing software crucial

Advantages

Faster studyIntervention planningExcellent renal to ankle imaging ndash high

spatial resolutionImages soft tissue and bone as well

CT angiogram

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

CTA of aorta

Great for evaluation of acute aortic disorder (dissection aneurysm rupture) and endovascular rx planningstent followup

short scan time and easy to performLarge FOVBetter spatial resolution (vs MRA)

DisadvantagesLong post-processing timeRadiationBeam 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 - Claustrophobiamotion artifact Breath holding chestabd Metallic artifact from stents

Coarctation of Aorta

Peripheral Vascular Disease

Occurs in approximately 13 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 claudicationlimb threatening ischemia

Outcomes Impaired QoL Limb Loss Premature Mortality

Diagnosis modalities

Ankle Brachial Index (ABI)Noninvasive vascular laboratoryUltrasoundAngiography MRA CT DSA

Location based on symptoms

Buttockhip Usually indicates aortoiliac occlusive disease

(Leriches syndrome) Some cases thigh claudication too Question diagnosis of bilateral disease if erectile

dysfunction is not presentThigh

Occlusion of the common femoral artery leads to claudication in the thigh calf or both

Calf Symptoms in upper 23 is usually due to SFA Lower 13 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 gt15 Use toe-brachial index

Normal gt07 Rest pain lt02

SubclavianBrachiocephalic 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

Sensitivity of 926 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

Doppler Waveform Analysis Hemodynamic Information

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 ndash 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 ankles10-minute examPost processing software crucial

Advantages

Faster studyIntervention planningExcellent renal to ankle imaging ndash high

spatial resolutionImages soft tissue and bone as well

CT angiogram

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

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 - Claustrophobiamotion artifact Breath holding chestabd Metallic artifact from stents

Coarctation of Aorta

Peripheral Vascular Disease

Occurs in approximately 13 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 claudicationlimb threatening ischemia

Outcomes Impaired QoL Limb Loss Premature Mortality

Diagnosis modalities

Ankle Brachial Index (ABI)Noninvasive vascular laboratoryUltrasoundAngiography MRA CT DSA

Location based on symptoms

Buttockhip Usually indicates aortoiliac occlusive disease

(Leriches syndrome) Some cases thigh claudication too Question diagnosis of bilateral disease if erectile

dysfunction is not presentThigh

Occlusion of the common femoral artery leads to claudication in the thigh calf or both

Calf Symptoms in upper 23 is usually due to SFA Lower 13 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 gt15 Use toe-brachial index

Normal gt07 Rest pain lt02

SubclavianBrachiocephalic 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

Sensitivity of 926 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

Doppler Waveform Analysis Hemodynamic Information

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 ndash 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 ankles10-minute examPost processing software crucial

Advantages

Faster studyIntervention planningExcellent renal to ankle imaging ndash high

spatial resolutionImages soft tissue and bone as well

CT angiogram

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

Coarctation of Aorta

Peripheral Vascular Disease

Occurs in approximately 13 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 claudicationlimb threatening ischemia

Outcomes Impaired QoL Limb Loss Premature Mortality

Diagnosis modalities

Ankle Brachial Index (ABI)Noninvasive vascular laboratoryUltrasoundAngiography MRA CT DSA

Location based on symptoms

Buttockhip Usually indicates aortoiliac occlusive disease

(Leriches syndrome) Some cases thigh claudication too Question diagnosis of bilateral disease if erectile

dysfunction is not presentThigh

Occlusion of the common femoral artery leads to claudication in the thigh calf or both

Calf Symptoms in upper 23 is usually due to SFA Lower 13 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 gt15 Use toe-brachial index

Normal gt07 Rest pain lt02

SubclavianBrachiocephalic 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

Sensitivity of 926 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

Doppler Waveform Analysis Hemodynamic Information

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 ndash 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 ankles10-minute examPost processing software crucial

Advantages

Faster studyIntervention planningExcellent renal to ankle imaging ndash high

spatial resolutionImages soft tissue and bone as well

CT angiogram

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

Peripheral Vascular Disease

Occurs in approximately 13 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 claudicationlimb threatening ischemia

Outcomes Impaired QoL Limb Loss Premature Mortality

Diagnosis modalities

Ankle Brachial Index (ABI)Noninvasive vascular laboratoryUltrasoundAngiography MRA CT DSA

Location based on symptoms

Buttockhip Usually indicates aortoiliac occlusive disease

(Leriches syndrome) Some cases thigh claudication too Question diagnosis of bilateral disease if erectile

dysfunction is not presentThigh

Occlusion of the common femoral artery leads to claudication in the thigh calf or both

Calf Symptoms in upper 23 is usually due to SFA Lower 13 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 gt15 Use toe-brachial index

Normal gt07 Rest pain lt02

SubclavianBrachiocephalic 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

Sensitivity of 926 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

Doppler Waveform Analysis Hemodynamic Information

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 ndash 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 ankles10-minute examPost processing software crucial

Advantages

Faster studyIntervention planningExcellent renal to ankle imaging ndash high

spatial resolutionImages soft tissue and bone as well

CT angiogram

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

Diagnosis modalities

Ankle Brachial Index (ABI)Noninvasive vascular laboratoryUltrasoundAngiography MRA CT DSA

Location based on symptoms

Buttockhip Usually indicates aortoiliac occlusive disease

(Leriches syndrome) Some cases thigh claudication too Question diagnosis of bilateral disease if erectile

dysfunction is not presentThigh

Occlusion of the common femoral artery leads to claudication in the thigh calf or both

Calf Symptoms in upper 23 is usually due to SFA Lower 13 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 gt15 Use toe-brachial index

Normal gt07 Rest pain lt02

SubclavianBrachiocephalic 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

Sensitivity of 926 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

Doppler Waveform Analysis Hemodynamic Information

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 ndash 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 ankles10-minute examPost processing software crucial

Advantages

Faster studyIntervention planningExcellent renal to ankle imaging ndash high

spatial resolutionImages soft tissue and bone as well

CT angiogram

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

Location based on symptoms

Buttockhip Usually indicates aortoiliac occlusive disease

(Leriches syndrome) Some cases thigh claudication too Question diagnosis of bilateral disease if erectile

dysfunction is not presentThigh

Occlusion of the common femoral artery leads to claudication in the thigh calf or both

Calf Symptoms in upper 23 is usually due to SFA Lower 13 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 gt15 Use toe-brachial index

Normal gt07 Rest pain lt02

SubclavianBrachiocephalic 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

Sensitivity of 926 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

Doppler Waveform Analysis Hemodynamic Information

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 ndash 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 ankles10-minute examPost processing software crucial

Advantages

Faster studyIntervention planningExcellent renal to ankle imaging ndash high

spatial resolutionImages soft tissue and bone as well

CT angiogram

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

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 gt15 Use toe-brachial index

Normal gt07 Rest pain lt02

SubclavianBrachiocephalic 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

Sensitivity of 926 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

Doppler Waveform Analysis Hemodynamic Information

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 ndash 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 ankles10-minute examPost processing software crucial

Advantages

Faster studyIntervention planningExcellent renal to ankle imaging ndash high

spatial resolutionImages soft tissue and bone as well

CT angiogram

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

Limitations

Noncompressible vessels Diabetes Renal Failure ABI gt15 Use toe-brachial index

Normal gt07 Rest pain lt02

SubclavianBrachiocephalic 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

Sensitivity of 926 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

Doppler Waveform Analysis Hemodynamic Information

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 ndash 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 ankles10-minute examPost processing software crucial

Advantages

Faster studyIntervention planningExcellent renal to ankle imaging ndash high

spatial resolutionImages soft tissue and bone as well

CT angiogram

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

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

Sensitivity of 926 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

Doppler Waveform Analysis Hemodynamic Information

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 ndash 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 ankles10-minute examPost processing software crucial

Advantages

Faster studyIntervention planningExcellent renal to ankle imaging ndash high

spatial resolutionImages soft tissue and bone as well

CT angiogram

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

Sensitivity of 926 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

Doppler Waveform Analysis Hemodynamic Information

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 ndash 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 ankles10-minute examPost processing software crucial

Advantages

Faster studyIntervention planningExcellent renal to ankle imaging ndash high

spatial resolutionImages soft tissue and bone as well

CT angiogram

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

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 ndash 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 ankles10-minute examPost processing software crucial

Advantages

Faster studyIntervention planningExcellent renal to ankle imaging ndash high

spatial resolutionImages soft tissue and bone as well

CT angiogram

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

CTA ndash 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 ankles10-minute examPost processing software crucial

Advantages

Faster studyIntervention planningExcellent renal to ankle imaging ndash high

spatial resolutionImages soft tissue and bone as well

CT angiogram

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

Advantages

Faster studyIntervention planningExcellent renal to ankle imaging ndash high

spatial resolutionImages soft tissue and bone as well

CT angiogram

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

CT limitations

Radiation PregnancyBlooming artifact from calcificationbull overestimate stenosis

Need contrast renal function contrast allergy

Uncooperative patientBad PumpInconsistent pedal vessel visualizationLonger 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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

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 examPooled sensitivity 97

specificity 96Higher temporal resolution

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

MR angiogram - Advantage

Localizing disease extent and severityProvidence guidance for interventionNo radiationCan 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 (aortondashbiiliac

aortobifemoral axillobifemoral)

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

MRA vs DSAMRA vs DSA

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

Limitations of MRI

Longer scan timePre-screening is required- PacemakersICDs

metallic implantsMore costlyMetal artifacts can be mistaken for stenosisUnable to characterize vascular calcificationUncooperative patient Claustrophobia

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

Carotid arterial disease

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

Carotid disease and Stroke

Up to 83 of all stroke TIA or amaurosis fugax ndash 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 morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

Carotid Ultrasound

Most accurate noninvasive cost-effective method for diagnosis of extracranial cerebrovascular disease

Intimal thickening and plaque morphologyDoppler velocity spectral analysisHigh negative predictive valueVertebral artery evaluation (assess for

subclavian steal)

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

CTA of Carotid artery

Accurate quantitation and anatomic localization Luminal and non-luminal informationTandem stenosisLongitudinal follow-up3D visualizationExtended coveragepooled sensitivity of 95 and a specificity of

98 for the detection of gt70 stenosisGreater for assessment of dissection

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

Limitations of CTA

Contrast allergyRenal dysfunctionRadiationGross patient motion artifactsArtifacts

Beam hardening artifacts amalgam hyper-concentrated contrast

Reconstruction artifacts Contrast gradient artifacts Stent blooming artifacts

Simultaneous arterial and venous imagingLow ejection fraction (heart failure) Overestimation of stenosis in thick calcific plaque

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

MRA - Technique

TOF Noncontract imaging which captures blood flow information 2d TOF ndash rapid acquisition but susceptible to motion

artifact 3d TOF ndash 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 vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

TOF vsCEM

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

MRA ndash CEM vs TOF

AdvantagesShorter scan time ndash less artifact from motionLarge coverageMore accurate stenosis and occlusion Contrast independent of flow directionLess contamination from short T1 materialsBetter SNR vs TOF-MRALess signal loss from slowturbulent flowGreat for evaluation of dissection

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

MRA ndash CEM vs TOF

DisadvantagesLonger prep time ndash more venous signalLower spatial resolution (vs TOF-MRA and CTA)Stents and metallic artifactT2 effects with bolusMaki effect (k-space ordering)Vessel diameter varies during contrast bolus cycleNo 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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

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 slowcomplexturbulentin-plane flow vs TOF MRA

Higher spatial resolutionWidely availableEasier to acquireLower cost

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

Disadvantage of CTA over MRA

RadiationContrast allergy (130000)Longer processing timeRenal insufficiencySimultaneous venous contaminationLimited direct hemodynamic informationGross 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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

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 vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

Giant cell arteritis Thromboangiitis obliterans

Subclavian Steal

MRA upper extremity

Great for Large and medium vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

MRA upper extremity

Great for Large and medium vesselsGreat for small vessels below the wristEvaluation of stenosis occlusion trauma

vasculitidesNo radiation can be done without contrastLonger studyUsual contraindications

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

MRA hand

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us

When in doubthellipcall us

• Cardiovascular Imaging Beyond US
• Objectives
• Cardiac imaging
• Indications for Cardiac CT
• Indications for Cardiac CTA
• Cardiac CT Angiogram
• Cardiac CT for Coronary artery disease
• Various reformats
• Malignant right coronary artery
• Cardiac Calcium Scoring
• Cardiovascular MRI - indications
• Cardiac MRI technique
• Subendocardial infarct vs transmural infarct
• Myocarditis
• Interatrial septal aneurysm
• Contraindications ndash Cardiac MRI
• Nephrotoxic Systemic Fibrosis (NSF)
• Imaging of Aorta
• CTA of aorta
• MRA of aorta
• Coarctation of Aorta
• Peripheral Vascular Disease
• Diagnosis modalities
• Location based on symptoms
• Ankle Brachial Index
• Limitations
• Duplex Doppler
• Doppler Waveform Analysis Hemodynamic Information
• PAD
• CTA ndash current technique
• CT angiogram
• CT limitations
• MRA current technique
• MR angiogram - Advantage
• MRA vs DSA
• Limitations of MRI
• Carotid arterial disease
• Carotid disease and Stroke
• Carotid Ultrasound
• PowerPoint Presentation
• CTA of Carotid artery
• Limitations of CTA
• Slide 43
• MRA - Technique
• TOF vsCEM
• MRA ndash CEM vs TOF
• Slide 47
• Advantage of CTA over MRA
• Disadvantage of CTA over MRA
• Upper extremity vascular disease
• CTA Upper extremity
• Giant cell arteritis
• MRA upper extremity
• MRA hand
• When in doubthellipcall us