INTRODUCTION TO

CT ANGIOGRAPHY
 COMPUTED TOMOGRAPHIC
ANGIOGRAPHY
 Evaluation of the vascular system
 CT scan
▪ Readily available – 24/7
▪ Patient comfort
▪ Fast scan time
▪ Open gantry –claustrophobia is less of an issue
† Ionizing radiation
 Non-ionic iodinated intravenous contrast material
† Allergic/contrast induced reactions
† Acute renal failure
 COMPUTED TOMOGRAPHIC
ANGIOGRAPHY
 Evaluation of the vascular system
 Minimally invasive
▪ Large bore venous access
▪ Ga 20 or bigger
▪ Antecubital vein
 Right – for pulmonary arteriogram
† Risk of contrast extravasation
▪ High flow rate of contrast administration
 Arterial and venous systems
 COMPUTED TOMOGRAPHIC
ANGIOGRAPHY
 Evaluation of the vascular system
 Anatomic body scan
▪ Other etiologies can be assessed for patient’s symptoms
▪ “Incidentalomas”
▪ Other pertinent structures can be evaluated
▪ Deeper structures are addressed
▪ Not readily seen in duplex studies
▪ Ideal imaging modality in evaluating post operative
interventions
 COMPUTED TOMOGRAPHIC
ANGIOGRAPHY
 Versus Conventional Catheter Angiography
▪ Anatomic body scan
▪ Other etiologies can be assessed for patient’s symptoms
▪ “Incidentalomas”
▪ Other pertinent structures can be evaluated
▪ Deeper structures are addressed
▪ Ideal imaging modality in evaluating of post operative interventions
▪ Less radiation exposure
▪ Less risk of bleeding and catheter-related iatrogenic
injuries
▪ Diagnostic
 COMPUTED TOMOGRAPHIC
ANGIOGRAPHY
 Versus Conventional Catheter Angiography
▪ Comparable sensitivity and specificity
▪ 4-vessel angiogram
▪ Carotid and verterbal arteriogram
▪ Aortogram
▪ Renal artery angiogram
▪ Pulmonary arteriogram
 COMPUTED TOMOGRAPHIC
ANGIOGRAPHY
 Versus Conventional Catheter Angiography
▪ Coronary arteries
▪ High negative predictive value
▪ Better evaluation of fistulas and sinuses
▪ Better pick up of myocardial bridging
▪ Soft and vulnerable plaques
† Arrhythmias
† Heart rate > 80 or 90 beats per minute
† Calcium score of > 400
 Proximal RCA and LAD
 LM
COMPUTED TOMOGRAPHIC
ANGIOGRAPHY
GENERAL PREPARATIONS
General Preparations
 NPO for at least 4 hours
 Serum creatinine (7-10 days)
 If elevated, clear with AP and/or attending
nephrologist
 Determine creatinine clearance
 Better if patient will undergo scheduled or STAT
dialysis on the day or immediately after the
procedure
 Clear with AP's and informed consent if STAT
procedure
General Preparations
 Creatinine clearance
 Cockcroft-Gault Formula
▪ 140-Age x Mass (kg.) x 0.85 (if female)
----------------------------------------------
72 x serum creatinine (mg./dL)
 Normal values
▪ Male: 55-146 mL./min.
▪ Female: 52-134 mL./min.
General Preparations
 Large bore antecubital venous access Ga. 20
or bigger
 If < Ga. 20, decrease flow rate (not < 3 mL/sec)
and increase HU threshold (at least 120 HU)
 Possibility of acquiring suboptimal images
precluding adequate evaluation
 Retrieve and review all previous pertinent
imaging studies done on the patient
General Preparations
 Special considerations
 Contemplated RAIU studies
▪ Iodinated IV contrast will interfere with future RAIU for the next three
months
▪ It decreases thyroid uptake of the I-138
 Renal impairment
▪ Renal failure
 Allergic/asthmatic patients
▪ Exacerbations
 Post chemotherapy patients
▪ Fragile peripheral venous structures
▪ Difficulty of line insertion
CORONARY CTA
PREPARATIONS
Coronary CTA Preparations
 For coronary CTA, heart rate should not be > 70
bpm and no arrhythmia
 Prepare Isordil (nitrate) 5 mg SL to be given to patient
while inside the CT scan unit – for dilatation of the
coronary arteries hence better visualization and
evaluability
▪ If OPD, monitor BP and HR for at least an hour before
sending patient home
 Retrieve/review all previous CT or conventional
coronary angiography studies, ECG results, 2D
echo, stress test (conventional and nuclear)
Coronary CTA Preparations

 Large bore access (antecubital vein) is a must,

take note of AV fistula site of dialysis patients-
IV access should be on the contralateral
extremity
 If admitted
 Inform Dr. Richard To or Dr. Almajar for Co-reading
 Inform Cardiology Fellow-on-duty
 Refer to Service of Cardiology for HR control and
BP monitoring
Coronary CTA Preparations

 If out patient
 Refer back to attending cardiologist and inform
Drs. To and Almajar for Co-reading
 If no in-house attending cardiologist, we still
inform Drs. To and Almajar
▪ If no contraindications to beta blockers (COPD, Asthma)
▪ Give Metoprolol 50 mg. PO night before and 3 to 4 hours before
the procedure
▪ If with contraindications
▪ Give Verapamil 80 mg 3 to 4 hours before the procedure (Watch
out for hypotension, determine baseline BP)
Coronary CTA Preparations

 Heart rate versus rhythm

 Prospective ECG gating
▪ Step and shoot acquisition
▪ Specific delay in the R-R interval
 Retrospective ECG gating
▪ Continuous/spiral scanning
▪ Best diastolic phase (0-90%)
▪ Manual reformation is possible
Coronary CTA Preparations

Prospective ECG gating

Retrospective ECG gating

Coronary CTA Preparations

 Heart rate versus rhythm

 “High” heart rate is technically possible
▪ Fast gantry rotation
▪ Less breath hold
 “Lower” heart rate
▪ We want an evaluable study without artifacts the first time
▪ Limited volume of contrast to be given
▪ Less radiation exposure
▪ Assures us of a study with optimal evaluability of the
vessels
Coronary CTA Preparations

 Heart rate versus rhythm

 Irregular rhythm
 Atrial fibrillation
▪ Difficult to acquire at a specific point in the R-R interval
phase
▪ Poor reconstruction
▪ Motion artifacts
▪ Step-off artifacts
Coronary CTA Preparations
BODY ANGIOGRAPHY
Body Angiography

 Chest CTA (make sure of clinical indication)

 Thoracic aorta
▪ Aortic dissection, aneurysm, rupture, stenosis
▪ Include abdominal aorta and iliac arteries
▪ Locator: aortic root
▪ 100 mL. contrast/30 mL. saline chaser @ 5 mL/sec
 Pulmonary artery (IV access should be in the right)
▪ Pulmonary embolism
▪ CT venography
▪ Locator: pulmonary trunk
▪ 60 mL. contrast/30 mL. saline chaser @ 5 mL/sec
Aortogram
Pulmonary
embolism
Body Angiography

 Abdominal aorta CTA

 Anuerysm, dissection, rupture, stenosis
 Include iliac arteries
▪ Locator: distal thoracic aorta (T12 level)
▪ 100 mL. contrast/30 mL. saline chaser @ 5 mL/sec
▪ Similar protocol for renal artery, celiac trunk, SMA, and
IMA-CTA
Body Angiography
Body Angiography
Body Angiography
Body Angiography

 Peripheral/extremity artery angiography

 Anuerysm, rupture, stenosis
 Include aortic arch (upper)
▪ Locator: ascending thoracic aorta (upper)
 Include abdominal aorta (lower)
▪ Locator: suprarenal abdominal aorta (lower)
 100 mL. contrast/30 mL. saline chaser @ 5 mL/sec
Body Angiography

 Peripheral/extremity artery angiography

 Special consideration for upper extremity
arteriography
▪ Please indicate which side is of concern
▪ Administration of contrast is thru the antecubital vein
▪ Place the venous access in the contralateral side or the
“normal” side
Body Angiography
HEAD ANGIOGRAPHY
Head/Circle of Willis CTA

 4 vessel CTA
 Stenosis and aneurysms
 Fistulas
 Collaterals
▪ Locator: Proximal ICA or distal CCA (C4 level)
▪ 60 mL. contrast/30 mL. saline chaser @ 5 mL/sec
  more medially placed
 usually smaller in
caliber
 more round in
configuration
 level of C4 vertebral
carotid C4 body
 pyriform sinus level

jugular
Head/Circle of Willis CTA

 NEURO 4D
CORONARY ANGIOGRAPHY
Coronary CTA

1. Calcium Score Study

 If Ca Score is more than or equal to 400 or calcific
plaques are at the proximal left main coronary
artery or ostium, refer/defer
2. Place venous access either right or left
3. Give Isordil 5 mg. SL or spray SL
4. CorCTA study
 50 mL. contrast/50 mL. saline chaser @ 5
mL./sec.
Coronary CTA

 maximum safe contrast administration is 150

mL./day with clearance of 48 to 72 hours
depending on initial creatinine results (longer if
borderline high creatinine results) and if with pre-
existing renal impairment
Coronary CTA

Philips 16-slice CT scan Siemens 128-slice CT scan

SPECIAL CONSIDERATIONS
 If dual procedures in one patient
 If chest CTA
▪ Do triple rule out: coronary artery disease, dissection, pulmonary
embolism
▪ Widen FOV to include entire aortic knob superiorly, the entire
chest width, and the proximal abdominal aorta (beyond T12 or L1
level)
 If body and head
▪ Do head first then body CTA
 If aortogram with conventional whole abdomen with IV
contrast
▪ CTA will serve as the arterial phase then delay scan(s) accordingly
DO NOT FORGET
*remember total amount of contrast that is
allowable in a 24 hour period: 150 mL. and
remember clearance period of 48 to 72 hours
unless cleared by attending physician(s) and
with informed consent to repeat scan within
this period
*specificity and sensitivity of CT angiography is similar
to conventional angiography for pulmonary
arteriogram and aortograms

*coronary CT angiography is ideal for screening and

has a good negative predictive value

*high calcium scores decrease the sensitivity and

specificity of coronary CT angiography

*CT angiography is only diagnostic and not

therapeutic
Thank you!