Cinematic Rendering of the Thoracic Aorta: A New Look at an Old Problem
Cinematic Rendering of the Thoracic Aorta: A New Look at an Old Problem M. Yasrab, MD; Linda C. Chu, MD; Elliot K. Fishman, MD EK Fishman is a co-founder of HipGraphics Inc and receives institutional grant support from Siemens Healthineers and GE Healthcare LC Chu and M Yasrab have no disclosures |
CT Imaging of Thoracic Aorta Disease Owing to its wide accessibility and fast scan times, computed tomography (CT) based imaging is frequently the first-line modality for initial diagnosis and assessment of thoracic aorta pathology Applications include:
1. Isselbacher, E. M. et al. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 146, e334–e482 (2022). 2. Shmukler, A., Alis, J., Patel, S., Latson, L. & Ko, J. P. Pitfalls and Pearls of Imaging Non-traumatic Thoracic Aortic Disease. Seminars in Ultrasound, CT and MRI 43, 204–220 (2022). 3. Eid, M. et al. Cinematic Rendering in CT: A Novel, Lifelike 3D Visualization Technique. American Journal of Roentgenology 209, 370–379 (2017). 4. Valente, T. et al. MDCT Imaging of Non-Traumatic Thoracic Aortic Emergencies and Its Impact on Diagnosis and Management—A Reappraisal. Tomography 8, 200–228 (2022). 5. Fellner, F. A. Introducing Cinematic Rendering: A Novel Technique for Post-Processing Medical Imaging Data. Journal of Biomedical Science and Engineering 9, 170–175 (2016). |
3D Cinematic Rendering
7. Al Khalifah, A., Zimmerman, S. L. & Fishman, E. K. Visualization of acute aortic injury with cinematic rendering. Emerg Radiol 29, 1043–1048 (2022). 6. Rowe, S. P., Chu, L. C., Recht, H. S., Lin, C. T. & Fishman, E. K. Black-blood cinematic rendering: A new method for cardiac CT intraluminal visualization. J Cardiovasc Comput Tomogr 14, 272–274 (2020). 7. Zimmerman, S. L., Rowe, S. P. & Fishman, E. K. Cinematic rendering of CT angiography for visualization of complex vascular anatomy after hybrid endovascular aortic aneurysm repair. Emerg Radiol 28, 839–843 (2021). 8. Rowe, S. P., Johnson, P. T. & Fishman, E. K. Cinematic rendering of cardiac CT volumetric data: Principles and initial observations. Journal of Cardiovascular Computed Tomography 12, 56–59 (2018). |
Clinical Applications: Acute Emergencies |
Case 1: Traumatic Aortic Injury (TAI) 58-year-old male presenting to the emergency after a motor vehicle accident (MVA) resulting in a TAI (pseudoaneurysm) at the distal arch  |
Case 1 Cont. 3D CR clearly shows the dissection at the distal arch and the pseudoaneurysm abutting the left subclavian artery with a small adjacent hematoma  |
Case 2: TAI, Intramural Hematoma (IMH) 36-year-old male brought to the emergency after extensive TAI (a large IMH and pseudoaneurysm)  |
Case 2 Cont. 3D CR helps visualize the full extent of the intramural and periaortic hematomas, as well as delineate the dissection flap and contained pseudoaneurysm Postprocessing modifications allow selectively viewing the surrounding bleed or the dissection itself  |
Case 3: Ruptured Focal Dissection 49-year-old hypertensive male presenting with substernal chest pain CT shows focal dissection along the ascending aorta  |
Case 3 Cont. 3D CR shows evidence of a focal dissection to the left of the aortic root, extending near the left anterior descending artery Postprocessing and color coding allow a holistic view of the hemopericardium and hemomediastinum and the ability to see through the lumen and the anatomical relationships grossly  |
Case 4: Type B Intramural Hematoma 63-year-old male with an increasing type B IMH and penetrating ulcer  |
Case 4 Cont. 3D CR nicely captures the type B dissection with the penetrating ulceration projecting posteriorly, best defined on sagittal views Full extent of the IMH is appreciated from the arch down into the abdominal aorta Minimal calcifications in the aortic arch appreciated  |
Case 5: Type A Dissection & Pseudoaneurysms 55 year old male with a weeklong history of chest pain CT scan showing a pseudoaneurysm and dissection into the arch CR helps appreciate the 3D lobulated nature of the pseudoaneurysm, arising medially and wrapping around  |
Case 5 Cont. Acute changes were better appreciated on CR and treating physicians were promptly informed CR also characterizes the large pericardial effusion, aneurysmal aortic root, and the bilateral ulcerations bulging laterally  |
Repair and Surveillance |
Case 6: Penetrating Ulcers/Mycotic Aneurysms 76-year-old male end stage renal disease and MSSA bacteremia developing mycotic aneurysms/penetrating ulcers with moderate atherosclerosis Coronal and sagittal CR orient us to the left sided suspected mycotic aneurysm/penetrating ulcer for more comprehensive preoperative planning  |
Case 6 Cont. Follow up after endovascular stent placement 3D CR provides a photorealistic view of the endovascular stent in the descending thoracic aorta and the contained rupture/increasing pseudoaneurysm, as well as the bleed around the aorta possibly related to postoperative changes  |
Case 7: Dilated Root & Prior Repair 51-year-old male with a dilated aortic root and prior repair of the ascending aorta, here for follow up CR delineates the changes secondary to surgical repair, the 3D dilation of the root, and calcifications in the ascending aorta  |
Case 8: Post Aneurysm Repair, New Dissection 59-year-old female s/p endovascular graft repair due to history of thoracic aortic aneurysm, presenting with chest pain Interval development of type A dissection from root to origin of brachiocephalic artery with a periaortic hematoma  |
Case 8 Cont. 3D CR coronal views best highlight the type A dissection and surrounding hematoma/pooling. Realistic lighting and shadowing provide a clearer delineation of the prior repair, and the associated ectatic changes in the descending aorta  |
Inflammatory Conditions & Atherosclerosis |
Case 9: Takayasu Arteritis 26-year-old female with known history of Takayasu arteritis CT shows diffuse segmental foci of wall thickening in the thoracic aorta, both calcified and noncalcified secondary to aortitis  |
Case 9 Cont. Realistic contouring and shadows via 3D CR improve appreciation of vessel thickening Thickening and irregularity of the right brachiocephalic artery is observed as well as the left carotid and left subclavian arteries, including some compromise of the left subclavian lumen Thoracic aorta thickening above the diaphragm and moderate plaques are also noted  |
Case 10: Takayasu Arteritis 52-year-old female with known Takayasu arteries and prior left common carotid to left subclavian graft Occluded left subclavian artery with mild stenosis at proximal anastomosis of the bypass graft Stenosis at the right common carotid and innominate arteries as well  |
Case 10 Cont. 3D CR enables us to fully appreciate the branch vessel changes, soft tissue thickening, and minimal plaques owing to photorealistic images and realistic lighting The full length of the occluded left subclavian artery is easy to evaluate as well as the right carotid to subclavian graft, making CR an excellent tool for follow up in such chronic inflammatory states  |
Case 11: Impending Mycotic Aneurysm Rupture 60-year-old male with a history of prior dissection repair developed saccular outpouching inferomedial to the graft in the background of bacteremia  |
Case 11 Cont. Sagittal, oblique, and coronal CR views fully distinguish the impending mycotic aneurysm rupture Active extravasation is represented by the outpouchings of the thoracic aorta aneurysm, and its bilobed nature is appreciated Good visualization of the hematoma is defined The endovascular stent is also seen in place  |
Case 12: Saccular Aneurysm Operative Planning 75-year-old female with marked atherosclerotic disease, diffuse ulcerating plaques and penetrating ulcers, underwent imaging for operative planning of an ulcerating saccular aneurysm of the aortic arch  |
Case 12 Cont. CR (sagittal views in particular) shows the downward projection aneurysm and ulcerating plaques, giving the operating physician a complete, photorealistic spatial orientation of the anatomy Left subclavian artery proximal aneurysm and occlusion as well as reconstitution with the left vertebral artery representing subclavian steal is also appreciated  |
Congenital Anomalies & Anatomical Variants |
Case 13: Coarctation (Initial) 15-year-old male presented for evaluation of a recently diagnosed coarctation of the aorta  |
Case 13 Cont. 3D CR shows evidence of coarctation beyond the left subclavian, with prominent and tortuous collaterals Coronal and sagittal views help define the near total occlusion minimal flow at best for both surgical planning and effective patient education  |
Case 14: Coarctation, Post-Repair 29-year-old female, known case of Shone syndrome, post-repair via stent for coarctation of the aorta  |
Case 14 Cont. 3D CR allows visualization of the complete, patent stent traversing the junction of the arch and the descending aorta, abutting the origin of the left subclavian artery, particularly in the sagittal views Focal dilation of the arch appreciated at the carotid artery takeoff Photorealistic images enable easier patient education and improved understanding of the repair procedure  |
Case 15: Hypoplastic Arch and Calcification 25-year-old male, known case of Williams Syndrome, with a history of supravalvular aortic stenosis with obstructive calcification in the ascending aorta, a hypoplastic arch and descending aorta, and a fluid filled cystic outpouching  |
Case 15 Cont. Photorealistic CR are especially useful for a holistic view of anomalous anatomical configurations The tortuous collaterals are clearly captured as well as the mass effect of the cystic outpouching with extensive calcifications, including its 3D associations and extraluminal appearance The hypoplastic mid to distal portions of the arch and descending thoracic aorta can be better appreciated in realistic lighting and shadows  |
Limitations and Future Direction
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Conclusion
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Literature Review
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