- “ MDCT with virtual angioscopy can depict the configuration of intimal tears in cases of thoracic aortic dissection, which may facilitate therapeutic planning.”
Intimal Tears in Thoracic Aortic Dissection: Appearance on MDCT With Virtual Angioscopy
Maldjiian PD eta l.
AJR 2012; 198:955-961 - “MDCT can depict feature helping to differentiate the true lumen from the false lumen. The false lumen is usually larger than the true lumen and commonly deforms the shape of the true lumen.”
Intimal Tears in Thoracic Aortic Dissection: Appearance on MDCT With Virtual Angioscopy
Maldjiian PD eta l.
AJR 2012; 198:955-961 - “Flow in the false lumen is usually slower than that in the true lumen; hence the attenuation of the false lumen tends to be lower and more heterogeneous than the attenuation of the true lumen because of mixing of contrast agent with unopacified blood.”
Intimal Tears in Thoracic Aortic Dissection: Appearance on MDCT With Virtual Angioscopy
Maldjiian PD eta l.
AJR 2012; 198:955-961
- “ Chest pain patients with negative or mild nonobstructive CTA findings can be safely discharged from the ED without further testing. Implementation of a dedicated chest pain triage protocol is critical for the success of a coronary CTA program.”
Triage of Patients Presenting With Chest Pain to the Emergency Department: Implementation of Coronary CT Angiography in a Large Urban Health Care System
Cury RC et al.
AJR 2013;200:57-65 - What patient went for CTA-
- Low to intermediate risk of acute coronary syndrome (TIMI (thrombolysis in myocardial infarction) risk score <2)
- Typical angina < 30 minutes, normal ECG findings
- Atypical symptoms, normal or nondiagnostic ECG findings, negative cardiac enzyme results - CTA Triage: 4 Groups
| 0 | Low (negative CT findings) | | 1 | Mid (1-49% stenosis) | | 2 | Moderate (50-69% stenosis) | | 3 | Severe (greater than or equal to 70% stenosis) |
- “ The sensitivity of CTA was 94%.The rate of MACEs in patients with stenosis of greater than 70% or greater (8.3%) was significantly higher than in patients with negative CTA findings(0%)or those with mild stenosis (0.2%). A 51% decrease in LOS-from 28.8 to 14.4 hours-was noted after implementation of the dedicated chest pain protocol.”
Triage of Patients Presenting With Chest Pain to the Emergency Department: Implementation of Coronary CT Angiography in a Large Urban Health Care System
Cury RC et al.
AJR 2013;200:57-65 - “Although fewer than 5% of patients with acute chest pain present with ST-segment elevation myocardial infarction (STEMI) and are directly transferred to the catheterization laboratory, the majority of patients require admission to an ED center unit for further diagnostic workup.”
Triage of Patients Presenting With Chest Pain to the Emergency Department: Implementation of Coronary CT Angiography in a Large Urban Health Care System
Cury RC et al.
AJR 2013;200:57-65 - “Coronary CTA and TRO-CTA allow a rapid and safe discharge in the majority of patients presenting with acute chest pain and an intermediate risk for ACS while at the same time identifies those with significant coronary artery stenosis.”
Coronary computed tomography and triple rule out CT in patients with acute chest pain and an intermediate cardiac risk profile. Part 1: Impact on patient management.
Gruettner J et al.
Eur J Radiol 2013 Jan; 82(1):100-5 - “Based on a negative coronary CTA 60 of 100 patients were discharged on the same day. None of the discharged patients showed MACE during the 90-day follow-up. Coronary CTA revealed a coronary stenosis >50% in 19 of 100 patients. ICC confirmed significant coronary stenosis in 17/19 patients. Among the 17 true positive patients, 9 underwent percutaneous coronary intervention with stent implantation, 7 were received intensified medical therapy, and 1 patient underwent coronary artery bypass surgery.”
Coronary computed tomography and triple rule out CT in patients with acute chest pain and an intermediate cardiac risk profile. Part 1: Impact on patient management.
Gruettner J et al.
Eur J Radiol 2013 Jan; 82(1):100-5 - “A TRO-CTA protocol was performed in 36/100 patients due to elevated d-dimer levels. Pulmonary embolism was present in 5 patients, pleural effusion of unknown etiology in 3 patients, severe right ventricular dysfunction with pericardial effusion in 1 patient, and an incidental bronchial carcinoma was diagnosed in 1 patient.”
Coronary computed tomography and triple rule out CT in patients with acute chest pain and an intermediate cardiac risk profile. Part 1: Impact on patient management.
Gruettner J et al.
Eur J Radiol 2013 Jan; 82(1):100-5 - “Due to the advances of multi-detector CT technology, dedicated coronary CT angiography provides the potential to rapidly and reliably diagnose or exclude acute coronary artery disease. Life-threatening causes of chest pain, such as aortic dissection and pulmonary embolism can simultaneously be assessed with a single scan, sometimes referred to as "triple rule out" scan. With appropriate patient selection, cardiac CT can accurately diagnose heart disease or other sources of chest pain, markedly decrease health care costs, and reliably predict clinical outcomes.”
Cardiac CT for the assessment of chest pain: imaging techniques and clinical results
Becker HC, Johnson T
Eur J Radiol Dec;81(12):3675-9
- “Comprehensive cardiothoracic CT scanning was feasible, with a similar diagnostic yield to dedicated protocols. However, it did not reduce the length of stay, rate of subsequent testing, or costs. In conclusion, although this "triple rule out" protocol might be helpful in the evaluation of select patients, these findings suggest that it should not be used routinely with the expectation that it will improve efficiency or reduce resource use.”
Usefulness of comprehensive cardiothoracic computed tomography in the evaluation of acute undifferentiated chest discomfort in the emergency department (CAPTURE)
Rogers IS et al.
Am J Cardiol 2011 March 1;107(5):643-650 - “We conducted a randomized diagnostic trial to compare the efficiency of a comprehensive cardiothoracic CT examination in the evaluation of patients presenting to the emergency department with undifferentiated acute chest discomfort or dyspnea. We randomized the emergency department patients clinically scheduled to undergo a dedicated CT protocol to assess coronary artery disease, pulmonary embolism, or aortic dissection to either the planned dedicated CT protocol or a comprehensive cardiothoracic CT protocol..”
Usefulness of comprehensive cardiothoracic computed tomography in the evaluation of acute undifferentiated chest discomfort in the emergency department (CAPTURE)
Rogers IS et al.
Am J Cardiol 2011 March 1;107(5):643-650 - "The image quality of triple rule out CTA is comparable to that of dedicated coronary CTA, showing no statistically significant difference in motion artifacts or opacification, and therefore may be alternative and useful diagnostic study in a select group of emergency patients."
Triple Rule-out and Dedicated Coronary Artery CTA: Comparison of Coronary Image Quality
Rahmani N, Jeudy J, White CS
Acad Radiol 2009; 16:604-609 - “ Therefore, in ED patients who have a low clinical suspicion of pulmonary embolism and acute aortic syndrome, especially younger patients, dedicated coronary CT angiography accompanied by modifications to reduce radiation dose is recommended.”
Coronary CT angiography in emergency department patients with acute chest pain: triple rule-out protocol versus dedicated coronary CT angiography
Lee Hy, Yoo SM, White CS
Int J Cardiovasc Imaging 2009 Mar;25(3):319-26 - “ In ED patients with atypical chest pain and low to intermediate risk, the triple rule-out protocol may be preferred, especially in older patients who have relatively lower risk of lifelong radiation-induced cancer. However, the increased radiation dose resulting from the extended volume coverage with this protocol should be fully considered prior to performing this protocol.”
Coronary CT angiography in emergency department patients with acute chest pain: triple rule-out protocol versus dedicated coronary CT angiography
Lee Hy, Yoo SM, White CS
Int J Cardiovasc Imaging 2009 Mar;25(3):319-26 - “ In ED patients with atypical chest pain and low to intermediate risk, the triple rule-out protocol may be preferred, especially in older patients who have relatively lower risk of lifelong radiation-induced cancer. However, the increased radiation dose resulting from the extended volume coverage with this protocol should be fully considered prior to performing this protocol. Therefore, in ED patients who have a low clinical suspicion of pulmonary embolism and acute aortic syndrome, especially younger patients, dedicated coronary CT angiography accompanied by modifications to reduce radiation dose is recommended.”
Coronary CT angiography in emergency department patients with acute chest pain: triple rule-out protocol versus dedicated coronary CT angiography
Lee Hy, Yoo SM, White CS
Int J Cardiovasc Imaging 2009 Mar;25(3):319-26 - “Consecutive cCTA examinations performed by a single radiologist over 1 year were reviewed. Biphasic injection protocols were employed: 70 mL of optiray-350 followed by 40 mL of saline injected at 5.5 mL/second for dedicated cCTA; 70 mL of optiray-350 followed by 25 mL of the contrast diluted with 25 mL of saline injected at 5.0 mL/second for TRO-CTA. Two independent cardiovascular radiologists reviewed the coronary vessels in each case and rated diagnostic image quality on a 5 point scale (1, suboptimal; 3, adequate; 5, excellent). Vascular enhancement was measured in the coronary arteries, aorta, and pulmonary arteries.”
Comparison of Image Quality and Arterial Enhancement with a Dedicated Coronary CTA Protocol versus a Triple Rule-Out Coronary CTA Protocol
Halpern EJ et al.
Acad Radiol 2009 Sep;16(9):1039-1048 - “There was excellent interobserver agreement between the cardiovascular radiologists (kappa = 0.91). Coronary image quality score were similar among 260 dedicated cCTA studies and 168 TRO-CTA studies (mean: 3.8-3.9. P > .18). At least one coronary segment demonstrated suboptimal image quality in 8% of examinations, including 18 dedicated cCTA studies and 16 TRO studies (P = .94). Enhancement was greater in the distal thoracic aorta of TRO patients (336 vs. 311 Hounsfield units; P = .01); no other significant differences in enhancement were identified in the aorta and coronary arteries of dedicated cCTA and TRO studies. Vascular enhancement was adequate for diagnostic evaluation of the pulmonary arteries in all TRO studies.”
Comparison of Image Quality and Arterial Enhancement with a Dedicated Coronary CTA Protocol versus a Triple Rule-Out Coronary CTA Protocol
Halpern EJ et al.
Acad Radiol 2009 Sep;16(9):1039-1048 - “Rational and Objectives
To compare the image quality of dedicated coronary computed tomography angiography (cCTA) to that of triple rule-out (TRO) CTA designed to evaluate the coronary arteries, thoracic aorta, and pulmonary arteries.
Conclusions
A TRO-CTA protocol using 95 mL of contrast can provide comparable coronary image quality and coronary vascular enhancement as compared to dedicated cCTA with 70 mL of contrast.
Comparison of Image Quality and Arterial Enhancement with a Dedicated Coronary CTA Protocol versus a Triple Rule-Out Coronary CTA Protocol
Halpern EJ et al.
Acad Radiol 2009 Sep;16(9):1039-1048 - Triple Rule Out: Challenges
-Fast Flash acquisition with high pitch values (3.2 or greater) is ideal to minimize contrast volume used by decreasing scan times to 1-2 seconds
-Split bolus common with second bolus usually having lower injection rates (5 cc vs 3 cc) and volumes (80-100 cc vs 20-30 cc). Split injection with second bolus of 70%-30% (contrast/saline) for longer injection volumes and increased volume injection times - Triple Rule Out Challenges
-Optimal opacification of both the pulmonary artery and the aortic circulations must be optimally opacified
-Although both peaks occur in close proximity the pulmonary arteries opacify well 10-12 seconds before the aorta
-To maintain optimal opacification you can increase contrast volume (130 cc) or decrease injection rates to lenghen the transit opacification time (4 cc vs 5-6cc/sec) - Triple Rule Out Protocols:
-You need to perform 2 or 3 quality exams in one CT acquisition
-Coronary CTA
-Aortic Evaluation for Dissection or Aneurysm
-Pulmonary arteriograms - “ A triple rule out protocol (TRO) may be considered if an additional suspicion of pulmonary embolism or acute aortic disease is present, when using 64-slices or more.”
Cardiac CT in the emergency department: Convincing evidence, but cautious implementation
Cury RC ey al
J Nucl Cardiol 2011;18:331-341 - “ The focus of this article is to review the current literature of the uses of Coronary CTA and “triple rule out” protocols in the emergency department setting and to provide a chest pain algorithm, showing how Coronary CTA can be implemented effectively in clinical focus.”
Cardiac CT in the emergency department: Convincing evidence, but cautious implementation
Cury RC ey al
J Nucl Cardiol 2011;18:331-341 - “ The focus of this article is to review the current available data in Coronary CTA and the extended Coronary CTA protocol or the so-called triple rule out scans in patients presenting to the ED with chest pain.”
Cardiac CT in the emergency department: Convincing evidence, but cautious implementation
Cury RC et al
J Nucl Cardiol 2011;18:331-341 - “Continued technical improvements in acquisition speed and spatial resolution of computed tomography images, and development of more efficient image reconstruction algorithms which reduce patient exposure to radiation and contrast, may result in increased popularity of MDCT for "triple rule-out”.
Evaluation of Acute Chest Pain in the Emergency Department: “Triple Rule-Out” Computed Tomography Angiography
Yoon ES, Wann S
Cardiol Rev 2011 May-Jun;19(3):115-21 - “ The triple rule-out protocol is most appropriate for patients who present with acute chest pain, but are judged to have low to intermediate increased risk for acute coronary syndrome, and whose chest pain symptoms might also be attributed to acute pathologic conditions of the aorta or pulmonary arteries. MDCT should not be used as a routine screening procedure.”
Evaluation of Acute Chest Pain in the Emergency Department: “Triple Rule-Out” Computed Tomography Angiography
Yoon ES, Wann S
Cardiol Rev 2011 May-Jun;19(3):115-21 - “MDCT is used for the detection of 3 of the most common life-threatening causes of chest pain-coronary artery disease, acute aortic syndrome, and pulmonary emboli. While triple rule-out protocol can be very useful and potentially cost effective when used appropriately, concern has risen regarding the overuse of this technology, which could expose patients to unnecessary radiation and iodinated contrast.”
Evaluation of Acute Chest Pain in the Emergency Department: “Triple Rule-Out” Computed Tomography Angiography
Yoon ES, Wann S
Cardiol Rev 2011 May-Jun;19(3):115-21 - What is a triple rule-out CT scan?
-Coronary artery stenosis >50%
-Aortic dissection
-Pulmonary embolism - “ Compared with cardiac CT, the triple rule out approach was associated with higher radiation dose (12.0±5.6 mSv versus 8.2±4.0 mSv), a greater incidence of subsequent emergency center evaluations, and more downstream pulmonary embolism protocol CT angiography.”
Comparative diagnostic yield and 3 month outcomes of “triple rule-out” and standard protocol coronary CT angiography in the evaluation of acute chest pain
Madder RD et al.
J Cardiovascular Comput Tomogr (2011)5, 165-171 - “ Among patients with acute chest pain, a triple rule-out approach resulted in higher radiation exposure compared with cardiac CT, but was not associated with improved diagnostic yield, reduced clinical events, or diminished downstream resource use.”
Comparative diagnostic yield and 3 month outcomes of “triple rule-out” and standard protocol coronary CT angiography in the evaluation of acute chest pain
Madder RD et al.
J Cardiovascular Comput Tomogr (2011)5, 165-171 - “ Among 2068 patients (272 triple rule-out and 1796 cardiac CT angiograms) the composite diagnostic yield was 14.3% with triple rule-out and 16.3% with cardiac CT and was driven by the diagnosis of obstructive pulmonary disease.”
Comparative diagnostic yield and 3 month outcomes of “triple rule-out” and standard protocol coronary CT angiography in the evaluation of acute chest pain
Madder RD et al.
J Cardiovascular Comput Tomogr (2011)5, 165-171 "Currently available evidence suggests that CT-based approaches with modern scan technology are safe, accurate, and potentially cost-saving, although large scale clinical trials are needed to ascertain the precise role of CT in the evaluation of chest pain." Cardiac CT in the Assessment of Acute Chest Pain in the Emergency Department
Bastarrika G et al.
AJR 2009; 193:397-409 "Three important life threatening causes of chest pain are aortic dissection, pulmonary embolism, and acute coronary syndrome. Simple clinical tools should be applied to exclude these diagnoses and avoid CT whenever possible." Role of computed tomography in the evaluation of acute chest pain
Urbania TH et al.
J Cardiovasc Comput Tomogr (2009) 3. Supplement 1, S13-S22 "Triple rule out” protocols designed to simultaneously assess the aorta, pulmonary arteries and coronary arteries are a comprimise between dedicated protocols for each diagnosis. The diagnostic value and appropriate clinical use of these protocols remain to be shown by randomized, controlled, outcomes based trials." Role of computed tomography in the evaluation of acute chest pain
Urbania TH et al.
J Cardiovasc Comput Tomogr (2009) 3. Supplement 1, S13-S22 "This practice equates with ineffective resource utilization, increased health care costs, and unnecessary radiation and contrast exposure." CT Angiography in the Evaluation of Acute Pulmonary Embolus
Costantino MM et al.
AJR 2008; 191;471-474 "Our data showed suboptimal use of the Wells criteria and subjective overestimation of the probability of PE before ordering of CTA. Although a definitive acceptable PE positivity rate for CTA has not been established, the 10% yield represents overuse of CTA as a screening rather than diagnostic examination." CT Angiography in the Evaluation of Acute Pulmonary Embolus
Costantino MM et al.
AJR 2008; 191;471-474
- Current Standard of Care for Low Risk Chest Pain Patients
- Serial cardiac enzymes
- Serial ECGs
- Cardiac stress test
- This may take up to 30 hours to complete and charges are high in the 8,000 dollar range "In low risk patients with chest pain, discharge from the emergency department based on negative cardiac CT, enzyme tests, and ECG may signifiicantly decrease both length of stay and hospital charges compared with the standard of care." Low-Risk Patients With Chest Pain in the Emergency Deprtment: Negative 64-MDCT Coronary Angiography May Reduce Length of Stay and Hospital Charges
May JH et al
AJR 2009; 193:150-154 - Triple Rule Out Protocol
- Scan is from above arch (1-2 cm) thru the base of the heart
- CT angiography begins 5 seconds after contrast reaches the left atrium (64 MDCT)
- Injection is biphasic with 70 ml of iodine 350 followed by 50 ml of diluted contrast (25 ml of iodine 350 and 25 ml saline)
- Beta blockers critical
Triple-Rule-Out CT Angiography for Evaluation of Acute Chest Pain and Possible Acute Coronary Syndrome
Halpern EJ
Radiology 2009; 252:332-345
"The primary goal of triple-rule-out CT in the emergency department is to facilitate the safe rapid discharge of patients judged to be at low to intermediate risk of acute coronary syndrome." Triple-Rule-Out CT Angiography for Evaluation of Acute Chest Pain and Possible Acute Coronary Syndrome
Halpern EJ
Radiology 2009; 252:332-345 "Triple-rule-out (TRO) computed tomographic angiography can provide cost effective evaluation of the coronary arteries, aorta, pulmonary arteries, an adjacent intrathoracic structures for the patient with acute chest pain. TRO CT is most appropriate for the patient who is judged to be at low to intermediate risk for acute coronary syndrome and whose symptoms may also be attributable to acute pathologic conditions of the aorta or pulmonary arteries." Triple-Rule-Out CT Angiography for Evaluation of Acute Chest Pain and Possible Acute Coronary Syndrome
Halpern EJ
Radiology 2009; 252:332-345 - Why do adult patients visit the ER?
- Chest pain
- Abdominal pain
- Back pain
- Headache
- Shortness of breath
- This list if for patients over 15 years of age
- Triple Rule-Out CT Protocol
- 64 MDCT Scanner
- Cephalic to caudal direction scanning
- 130 cc of contrast injected over 66 seconds (80 cc at 5 cc/sec, 50 cc at 2 cc/sec, then 50 cc saline at 2 cc/sec)
- Triple Rule-out and Dedicated Coronary Artery CTA: Comparison of Coronary Image Quality Rahmani N, Jeudy J, White CS Acad Radiol 2009; 16:604-609 "The image quality of triple rule out CTA is comparable to that of dedicated coronary CTA, showing no statistically significant difference in motion artifacts or opacification, and therefore may be alternative and useful diagnostic study in a select group of emergency patients." Triple Rule-out and Dedicated Coronary Artery CTA: Comparison of Coronary Image Quality
Rahmani N, Jeudy J, White CS
Acad Radiol 2009; 16:604-609
- Triple Rule-Out CT Protocol
- Dual Source CT Scanner
- 110 ml of contrast injected at 4 cc/sec followed by 30 ml of saline
- Trigger set in ascending aorta
- Scanning was done in a cranial caudal direction
- Triple Rule-Out CT in Patients with Suspicion of Acute Pulmonary Embolism: Findings and Accuracy Schertler T et al. Acad Radiol 2009; 16:708-717
"Triple rule-out CT is feasible in patients with suspicion of PE, reveals a wide range of vascular and non-vascular chest disease, and offers an excellent overall diagnostic performance." Triple Rule-Out CT in Patients with Suspicion of Acute Pulmonary Embolism: Findings and Accuracy
Schertler T et al.
Acad Radiol 2009; 16:708-717 - Chronic Pulmonary Thromboembolism: Collateral Systemic Supply
- Dilated bronchial arteries
- Bronchial artery blood flow is usually 1-2% of cardiac output, in chronic thromboembolic pulmonary hypertension it is up to 30% of systemic blood flow
- Chronic Pulmonary Thromboembolism: Pulmonary Hypertension
- Main pulmonary artery diameter of greater than 29 mm
- When the ratio of main pulmonary artery to the aorta is greater than 1:1 there is a strong correlation with elevated pulmonary artery pressure in patients younger than 50 years of age
- Chronic Pulmonary Thromboembolism: Direct Pulmonary Arterial Signs
- Complete obstruction
- Partial filling defects
- Bands and webs
- Calcified thrombus
- Chronic Pulmonary Thromboembolism: Vascular Signs
- Direct Pulmonary Arterial Signs
- Signs due to pulmonary hypertension
- Signs due to systemic collateral supply "In summary, initial investigations suggest that CT angiography has considerable potential to streamline chest pain evaluation in the ED, but further investigation is imperative to establish its precise role."
Chest Pain in the Emergency Department: Role of Multidetector CT
White CS, Kuo D
Radiology 2007; 245:672-681
- Coronary Artery Aneurysms: Etiology
- Congenital
- Acquired
–Atherosclerosis
–Trauma
–Post angioplasty (procedure related)
–Arteritis
–Kawasaki’s disease
–Connective tissue disease (Marfan’s, Lupus, etc.)
- Coronary Artery Aneurysms: Management
- Conservative management (watchful waiting)
- Bypass grafts
- Covered stent placement
- Coronary Artery Fistulae: Facts
- 0.1-0.2% of patients undergoing cardiac cath
- Right coronary artery most commonly involved
- Drainage much more common to right side of the heart
- Can result in myocardial ischemia
- Coronary Artery Aneurysms: Facts
- Most common causes are atherosclerotic,congenital and mycotic-embolic disease
- Kawasaki’s disease has giant aneurysms and up to 25% of patient with acute Kawasaki’s disease will develop aneurysms
- Triple Chest Pain Protocol
- Acute coronary ischemia and myocardial infarction
- Aortic dissection
- Pulmonary embolism
- MDCT of Myocardial Infarction
- Repeat study 5 minutes after contrast injection (delayed phase imaging)
- Hypoenhancement zone (ischemic zone) may only be seen at this point
- Myocardial Infarction:CT Findings
- Early hypodensity in the myocardium
- Persistent hypodensity in the myocardium
- Delayed enhancement of area of hypodensity seen on early phase imaging (first pass).
- This may be in the periphery
- " CT coronary angiography using a 16-MDCT scanner enables accurate noninvasive detection of significant coronary artery disease in patients hospitalized for acute chest pain syndrome."
16-MDCT Coronary Angiography versus Invasive Coronary Angiography in Acute Chest Pain Syndrome: A Blinded Prospective Study
Ghersin E et al.
AJR 2006; 186:177-184
- Acute Chest Pain: Possibilities
- Pulmonary Embolism
- Aortic dissection
- Coronary artery disease
- Pneumonia
- Pleural effusions
- "ECG-gated MDCT appears to be logistically feasible and shows promise as a comprehensive method for evaluating cardiac and noncardiac chest pain in stable emergency department patients."
Chest Pain Evaluation in the Emergency Department: Can MDCT Provide a Comprehensive Evaluation? White CS et al. AJR 2005; 185:533-540
- "Sensitivity and specificity for the establishment of a cardiac cause of chest pain were 83% and 96% respectively. Overall sensitivity and specificity for all other cardiac and noncardiac causes were 87% and 96% respectively."
Chest Pain Evaluation in the Emergency Department: Can MDCT Provide a Comprehensive Evaluation? White CS et al. AJR 2005; 185:533-540
- "The chest pain protocol can be used to assess both the pulmonary arteries and the thoracic aorta, whereas the ECG-gating protocol appears to be a promising adjunct for a comprehensive single chest pain protocol."
MDCT Angiography of Acute Chest Pain: Evaluation of ECG-Gated and Nongated Techniques
Raptopoulos VD et al.
AJR 2006; 186:S346-S356k. - "The daily use of MDCT studies for the evaluation of pulmonary embolic disease or aortic abnormalities can reveal incidental PDAs. Small incidental PDAs can be identified on chest MDCT angiography timed for either the pulmonary arteries or the aorta."
Incidental Finding on MDCT of Patent Ductus Arteriosus: Use of CT and MRI to Assess Clinical Importance
Goitein O et al.
AJR 2005;184:1924-1931
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