Cardiovascular Computed Tomography

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4 Cardiovascular Computed Tomography

FIGURE 4-1 Pericardial effusion.

Axial image from contrast-enhanced CT (A) with sagittal (B) and coronal (C) reconstructions. All of the images demonstrate moderate pericardial fluid (A). This fluid also extends superiorly around the great vessels and tracks inferior around the descending thoracic aorta (B).

FIGURE 4-2 Pericarditis.

A, A single short-axis postcontrast CT view of the heart demonstrates extensive calcification (C) of the pericardium adjacent to the right (A) and left (B) ventricles. Short-axis (B) and horizontal long-axis (C) postcontrast MRI views of the heart demonstrate enhancement of the pericardium (D), especially around the right ventricular wall.

FIGURE 4-3 Atrial septal defect.

A gated axial postcontrast-enhanced CT (A) with short-axis reconstruction (B) demonstrates a large ASD between the left (C) and right (D) atria. The residual anterior (A) and posterior (B) portions of the septum can be seen on the axial image. The short-axis image demonstrates the superior (E) and inferior (F) portions of the atrial septum. A gated cardiac MRI may demonstrate the direction of flow.

FIGURE 4-4 Pacer lead perforation.

Frontal chest x-ray (A) and axial noncontrast chest CT in mediastinal (B) and lung (C) windows. A, The chest x-ray demonstrates two sets of pacer leads with an atrial lead (A) that does not appear to be over the cardiac silhouette. B, Chest CT then clearly demonstrates that the atrial lead has perforated the anterior right atrial wall (A). C, The lung windows demonstrate a small anterior pneumothorax (B), not visible on the chest x-ray.

FIGURE 4-5 Right-sided arch.

Axial postcontrast-enhanced CT (A) with MIP coronal reconstruction (B) and a 3D view (C). A right-sided ascending aorta (A) is seen with a right-sided aortic arch (G) that passes posterior to the esophagus and trachea (H). Aberrant origin of the right carotid artery (C) is present but is not well visualized on this exam. The right subclavian (B) and left carotid (D) arteries are grossly unremarkable. The origin of the left subclavian artery (E) is more distal arising from the aortic arch. The aorta descends on the left side of the spine (F).

FIGURE 4-6 Anomalous great vessels.

Contrast-enhanced CT with 3D MIP views (A and B) and coronal reconstruction (C). The anomalous order of great vessels as they originate from the aortic arch is right carotid artery (A), left carotid artery (B), left subclavian artery (C), and finally right subclavian artery (D). The anomalous right subclavian artery passes behind the esophagus. The dilated origin of the right subclavian artery is called the diverticulum of Kommerell (E).

FIGURE 4-7 Persistent left SVC.

Axial contrast-enhanced CT (A) with sagittal (B) and coronal (C) reconstructions. A, The axial image shows a densely contrast filled right SVC (A) with less dense contrast in the left SVC (B). B and C, The sagittal and coronal views demonstrate the course of the left SVC draining into the coronary sinus (C). The incidence of a persistent left SVC is 0.3%.

FIGURE 4-8 Carotid stenosis.

Axial postcontrast-enhanced CT with coronal reconstruction and a curved reformat view. The coronal image (B) demonstrates a tortuous left common carotid artery (A) with a narrowing of the proximal left internal carotid artery (B) at its origin. The full extent of the stenosis is more clearly visualized on the curved reformat view. In addition, note the stenosis present in the proximal left external carotid artery (C).

FIGURE 4-9 Ascending aortic aneurysm.

Axial precontrast (A) and postcontrast (B) enhanced CT with 3D MIP view (C) and coronal reconstruction (D). Precontrast images demonstrate no evidence of an intramural hemorrhage, but the postcontrast image demonstrates a right lateral aneurysm (not dissection) (A). The coronal postcontrast image shows compression of the ascending aorta (E) by the ascending aortic aneurysm. The ascending location is also demonstrated on the 3D MIP reconstruction, along with the incidental finding of a bovine arch with right innominate artery (C) and left carotid artery (D) sharing a common origin (B).

FIGURE 4-10 Thoracic aneurysm.

Axial postcontrast enhanced CT (A) with sagittal reconstruction (B) and a 3D view (C). The axial and 3D views demonstrate a normal ascending aorta (A) and the descending thoracic aortic aneurysm (B) within the thorax. The sagittal view demonstrates a normal aortic arch (C) with the midthoracic aortic aneurysm (B).

FIGURE 4-11 Stanford type A aortic dissection.

Postcontrast enhanced CT with coronal (A) and sagittal (B) reconstructions with 3D reconstructions (C and D). The coronal and sagittal reconstructions demonstrate the dissection with contrast filling both the true (A) and false (B) lumens throughout the entirety of the dissection. The 3D reconstructions show the dissection (C) starting in the ascending aorta and continuing into the abdominal aorta.

FIGURE 4-12 Stanford type B aortic dissection.

Postcontrast enhanced CT with coronal (A) and 3D (B) reconstructions. The coronal reconstruction demonstrates dense contrast filling the true lumen of a descending aortic dissection (A) with compression and flattening of the true lumen by the false lumen (B). The false lumen is partially thrombosed (C), and the contrast visualized within the false lumen is less dense than the true lumen. The dissection is limited to the aorta distal to the left subclavian artery and is therefore classified as a Stanford type B dissection.

FIGURE 4-13 Type II endoleak.

Axial postcontrast-enhanced CT images (A and B) with sagittal (C) and coronal (D) reconstructions. The coronal view demonstrates a stent graft in the distal abdominal aorta (E) that extends into the right (A) and left (B) iliac arteries. The sagittal view demonstrates contrast within the stent graft; however, contrast is also present within the portion of the aortic aneurysm that is supposed to be excluded by the stent graft (C). The axial images demonstrate that a lumbar artery (D) with reversed flow is the source of the contrast leak. This is classified as a type II endoleak. (For reference, see White GH, May J, Waugh RC, et al. Type III and type IV endoleak: toward a complete definition of blood flow in the sac after endoluminal AAA repair. J Endovasc Surg 1998;5:305–309.)

FIGURE 4-14 Abdominal aortic aneurysm.

Axial image from a contrast-enhanced CT (A) with coronal (B) and sagittal (C) reconstructions. The images demonstrate contrast within an AAA (>5 cm) (A). Mural thrombus (B) can be seen between the contrast and the aortic wall, which contains calcium (D). The coronal image demonstrates the aneurysm extending into the right common iliac artery (C). Measurement of the aneurysm, in evaluating for possible treatment, should include the portion containing contrast and the portion with the thrombus (A and B).

FIGURE 4-15 Abdominal aortic occlusion.

A contrast-enhanced CT with coronal (A) and sagittal (B) reconstructions and 3D MIP view (C). Contrast is seen within the abdominal aorta (A) to just above the bifurcation of the iliac arteries, at which level there is complete thrombosis (B) of the distal aorta and the common iliac arteries. Note the calcification within the aortic wall at this site. The 3D reconstructions demonstrate reconstitution of the bilateral femoral arteries from collaterals (C). This is a chronic occlusion with enlargement of the collateral vessels (not seen on these images) to reconstitute the femoral arteries.

FIGURE 4-16 Ruptured AAA.

Axial postcontrast-enhanced CT (A) with sagittal reconstruction (B) and a 3D MIP view (C). The sagittal reconstruction demonstrates a large infrarenal AAA (A) with contrast (C) outside the calcified aorta. The 3D view demonstrates the large size of the AAA. The axial postcontrast image demonstrates a large intra-abdominal hematoma (B) from the ruptured aneurysm.

FIGURE 4-17 Peripheral arterial disease.

Coronal MIP views of the femoral vessels (A) and bilateral pelvic vessels (B), as well as contrasted axial midthigh (C) and distal thigh (D) CT images. The femoral MIP views demonstrate the distal portions of right (A) and left (B) femoral artery grafts as well as absent proximal SFAs and patent distal bilateral SFAs and popliteal arteries (C and D). Extensive collateral vessels with a corkscrew appearance are present in the thighs (E) that reconstitute the distal vessels. The coronal MIP image of the pelvis demonstrates the bilateral grafts (A and B) and an incidental pseudoaneurysm at the distal aspect of the right graft (F). On the axial images of the midthigh, there is no contrast in the bilateral SFAs. Only calcium (G) is noted. Contrast is seen in the reconstituted bilateral popliteal arteries in the distal thighs (H).

FIGURE 4-18 Renal artery stenosis.

Coronal reconstruction of postcontrast abdominal CT (A) with AP (B) and oblique (C) views of 3D images of the abdominal aorta and branching vessels. The coronal image shows a portion of the abdominal aorta (E) with the right (C) and left (D) renal arteries. A severe stenosis of the proximal left renal artery is present. The 3D images show the abdominal aorta with a small infrarenal aneurysm (F). The celiac (A) and superior mesenteric (B) arteries are also labeled for reference. Calcified plaque is present at the origin of the right renal artery, but there is no significant stenosis.

FIGURE 4-19 Saddle pulmonary embolism.

Axial postcontrast-enhanced CT (A) with coronal reconstruction (B). The filling defect in the main pulmonary artery (A) extends into the right and left pulmonary arteries. The axial image demonstrates that contrast is present within the patent portion of the left pulmonary artery (C). The filling defect represents the thrombus (D). The right pulmonary artery has thrombosed (E) and patent (F) portions. The thrombus can be seen extending from the left pulmonary artery into the left lower pulmonary artery on the coronal reformat. The aorta (B) is also labeled for reference.

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4 Cardiovascular Computed Tomography

FIGURE 4-1 Pericardial effusion.

Axial image from contrast-enhanced CT (A) with sagittal (B) and coronal (C) reconstructions. All of the images demonstrate moderate pericardial fluid (A). This fluid also extends superiorly around the great vessels and tracks inferior around the descending thoracic aorta (B).

FIGURE 4-2 Pericarditis.

A, A single short-axis postcontrast CT view of the heart demonstrates extensive calcification (C) of the pericardium adjacent to the right (A) and left (B) ventricles. Short-axis (B) and horizontal long-axis (C) postcontrast MRI views of the heart demonstrate enhancement of the pericardium (D), especially around the right ventricular wall.

FIGURE 4-3 Atrial septal defect.

A gated axial postcontrast-enhanced CT (A) with short-axis reconstruction (B) demonstrates a large ASD between the left (C) and right (D) atria. The residual anterior (A) and posterior (B) portions of the septum can be seen on the axial image. The short-axis image demonstrates the superior (E) and inferior (F) portions of the atrial septum. A gated cardiac MRI may demonstrate the direction of flow.

FIGURE 4-4 Pacer lead perforation.

Frontal chest x-ray (A) and axial noncontrast chest CT in mediastinal (B) and lung (C) windows. A, The chest x-ray demonstrates two sets of pacer leads with an atrial lead (A) that does not appear to be over the cardiac silhouette. B, Chest CT then clearly demonstrates that the atrial lead has perforated the anterior right atrial wall (A). C, The lung windows demonstrate a small anterior pneumothorax (B), not visible on the chest x-ray.

FIGURE 4-5 Right-sided arch.

Axial postcontrast-enhanced CT (A) with MIP coronal reconstruction (B) and a 3D view (C). A right-sided ascending aorta (A) is seen with a right-sided aortic arch (G) that passes posterior to the esophagus and trachea (H). Aberrant origin of the right carotid artery (C) is present but is not well visualized on this exam. The right subclavian (B) and left carotid (D) arteries are grossly unremarkable. The origin of the left subclavian artery (E) is more distal arising from the aortic arch. The aorta descends on the left side of the spine (F).

FIGURE 4-6 Anomalous great vessels.

Contrast-enhanced CT with 3D MIP views (A and B) and coronal reconstruction (C). The anomalous order of great vessels as they originate from the aortic arch is right carotid artery (A), left carotid artery (B), left subclavian artery (C), and finally right subclavian artery (D). The anomalous right subclavian artery passes behind the esophagus. The dilated origin of the right subclavian artery is called the diverticulum of Kommerell (E).

FIGURE 4-7 Persistent left SVC.

Axial contrast-enhanced CT (A) with sagittal (B) and coronal (C) reconstructions. A, The axial image shows a densely contrast filled right SVC (A) with less dense contrast in the left SVC (B). B and C,

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