The Role of CTA with 3D Mapping in the Evaluation of Vascular Stents beyond the Abdominal Aorta: Techniques, Interpretation, and Pitfalls

Introduction

Complications of Stent Placement

Technique: Data Interpretation

Interactive 2D and 3D Rendering

Axial images and 2D MPRs perpendicular to long axis of stent to evaluate stent lumen

Interactive 2D and 3D Rendering

VR (volume rendering) and MIP (maximum intensity projection) to create vascular map and show distal vessel patency. Volume rendering conveys 3D relationships and is best for evaluation of end organs because tissue density is maintained; MIP is better for small branch visualization.

Indications

Mesenteric Ischemia

Mesenteric Ischemia

SMA Stenosis

66 year old woman, long standing smoker with severe atherosclerotic disease s/p aortobifemoral bypass and stenting of SMA for stenosis. Coronal and coronal oblique color coded volume renderings show show stent in the proximal SMA with patency of the distal vessel.

SMA Stenosis

66 year old woman, long standing smoker with severe atherosclerotic disease s/p aortobifemoral bypass and stenting of SMA for stenosis. Sagittal and coronal MPRs show stent in the proximal SMA with patency of the distal vessel.

Mesenteric Ischemia: Stent Occlusion

45 year old woman with history of chronic mesenteric ischemia secondary to multiple vascular occlusions, s/p multiple arterial stents (celiac artery, proximal and distal SMA) shown with coronal and sagittal VR, which provide a nice overview of the anatomy.

Occluded SMA Stent

45 year old woman with history of chronic mesenteric ischemia secondary to multiple vascular occlusions, s/p multiple arterial stents. Sagittal MPR and MIP demonstrate the thrombosed lumen of the inferior SMA stent and absence of enhancement in the artery distal to the stent.

Chronic Mesenteric Ischemia

Celiac Artery Stent for MALS

46 year old woman with long history of postprandial abdominal pain who underwent division of median arcuate ligament and celiac artery stent placement. Coronal color coded volume rendering shows patent celiac axis. Modification of the rendering parameters and application of a clip plane with a sagittal MIP rendering document patency of the stent lumen.

Celiac Artery Stent for MALS

43 year old man with median arcuate ligament syndrome s/p surgical repair with celiac artery stent. Axial image shows stent, but patency best demonstrated by sagittal MPR through the lumen and sagittal volume rendering to show distal vessel perfusion.

Visceral Arterial Aneurysms

Visceral Arterial Aneurysms

Splenic Artery Aneurysm

62 year old woman with splenic artery aneurysm s/p attempted stent placement complicated by splenic artery dissection. Coronal volume renderings in various obliquities show persistent aneurysm of the splenic artery despite presence of stent.

Mesenteric Artery Dissection

• Isolated celiac or superior mesenteric artery dissection (right images) can occur exclusive of aortic dissection
• Approximately 10% of patients will have both vessels involved
• May present acutely w/ abdominal pain
• Often incidentally identified on CT for other indication
• Commonly stable without complication
• In some cases, intervention required for persistent symptoms, expansion of the false lumen or true lumen malperfusion

SMA Dissection

66 year old man with marfanoid connective tissue disorder presented with acute abdominal pain. Diagnosed with SMA dissection and underwent stent placement in SMA and celiac arteries. Coronal and coronal oblique color coded volume renderings nicely map patent celiac artery and SMA following stent placement.

SMA Dissection

66 year old man with marfanoid connective tissue disorder who presented with acute abdominal pain. Diagnosed with SMA dissection and underwent stent placement in SMA and celiac arteries. Stent patency confirmed by axial image through the lumen and vascular mapping with sagittal MIP, demonstrating perfusion distal to the stents.

Renal Artery Stenosis

RAS: Benefits of Stenting

Renal Artery Stenosis

63 year old man s/p infrarenal abdominal aortic repair and bilateral renal artery stents for renovascular hypertension. Axial CT and coronal MPR show perfused stent lumen. Coronal MIP and volume rendering depict aortoiliac graft, patent renal arteries and symmetric renal enhancement in a single image.

Renal Artery Aneurysms

Renal Artery Aneurysm

59-year-old woman with left renal artery aneurysm, treated by endoluminal stent placement. Coronal volume renderings shows aneurysm (left) and stent patency after intervention (right) by applying a clip plane to visualize the lumen.

©2010 by American Roentgen Ray Society, Johnson P T et al. AJR 2010;194:1001-1012

Aortic Aneurysm

Aortic Aneurysm

77 year old man with 6.5 cm infrarenal abdominal aortic aneurysm involving branch vessels. Repair included individual stent placement in celiac, SMA and renal arteries. Color coded volume rendering provides overview and shows patent distal vessels. Stent lumen patency demonstrated with axial images.

Endoluminal Aortic Repair and Renal Artery Compromise

Left kidney perfusion compromised by aortic endoluminal stent crossing renal artery orifice. Diminished renal enhancement shown on axial image (ring).

Endoluminal Aortic Repair and Renal Artery Compromise

Left renal artery compromise (ring) treated with left renal artery stent (arrow), which restored perfusion to the left kidney.

Conclusion

References