Bottom up cardiac CT for CABG assessment to resolve breathing artefact

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1 Bottom up cardiac CT for CABG assessment to resolve breathing artefact Poster No.: C-0589 Congress: ECR 2010 Type: Educational Exhibit Topic: Cardiac Authors: P. Glass, P. Donnelly, P. Hanley, D. Higginson, P. Ball; Belfast/UK Keywords: CT coronary angiography, Coronary artery bypass graft, Artefact DOI: /ecr2010/C-0589 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 23

2 Learning objectives Fig. References: P. Glass; Dept of Radiology, The Ulster Hospital, Belfast, UNITED KINGDOM To illustrate the differences in breathing artefact between two scan protocols for CT coronary angiography of bypass grafts, classical "cranio-caudal" versus "caudocranial" (Bottom up). In this poster, comparison of 30 classical "cranio-caudal" with "caudo-cranial" protocol scans is made by 2 experienced CT coronary angiography readers who scored the clarity of the origin of the graft, the anastamosis and breathing artefact using a three point Liekart grading score. The HU of contrast in the subclavian vein on the side of contrast administration was also measured. In those cases with an IMA graft, a liekart score was used to assess whether the origin of the vessel was affected by artefact from contrast in the subclavian vein. The aim is to improve our protocol to provide the cardiac surgeon/cardiologist with reliable information on graft anatomy and patency whilst minimising artefact secondary to breathing and contrast. Page 2 of 23

3 Images for this section: Page 3 of 23

4 Page 4 of 23

5 Fig. 1: Surface rendered reconstruction showing RIMA and LIMA grafts. Page 5 of 23

6 Background The typical acquisition time for retrospective dose modulated MDCT cardiac angiography in bypass patients is 16 seconds compared to 9 seconds in non bypass patients. This is secondary to the larger acquisition length required to include the origins of the internal mammary arteries (Fig. 1). The longer acquisition time increases the risk of respiratory motion artefact (Fig.2). Original acquisition protocols for CT pulmonary angiography on single slice spiral scanners typically had acquisition times of up to 24 seconds on a single breath hold(1), and therefore were highly susceptible to respiratory motion artefact. For this reason, initial acquisition protocols in CT pulmonary angiography used caudocranial acquisition to minimize respiratory motion artefact in the lower lobes where chest movement is greatest. Accurate assessment of the distal anastomosis of the graft with the native artery is vital and the acquisition technique used should aim to minimise artefact at the distal anastomosis. Respiratory motion is greatest at the lung bases, within the range of the distal anastomoses. Due to the longer acquisition time, this potentially puts graft patients at risk of respiratory motion artefact if scanned in the craniocaudal direction. By scanning in the caudocranial direction we aim to show reduced artefact at the distal anastomsis. Respiratory motion artefact is less at the apices, close to the origins of the IMAs, native arteries used in bypass grafts. Pathology is less likely to occur at the origins of these arteries. Also, by scanning in the caudocranial direction we aim to show reduced artefact from contrast in the subclavian vein which could affect assessment of the origin of the IMA. For similar reasons other studies, relating to CT pulmonary angiography, have used caudocranial acquisition to reduce artefacts from high contrast material concentration in the superior vena cava. (2) Images for this section: Page 6 of 23

7 Page 7 of 23

8 Fig. 1: Surface rendered reconstruction showing RIMA and LIMA grafts. Page 8 of 23

9 Fig. 2: Breathing artefact with mis-registration at diaphragms. Page 9 of 23

10 Imaging findings OR Procedure details Our Population From 08/05/08 to 20/11/09, 60 consecutive CT coronary angiography bypass patients were randomly assigned to either "cranio-caudal" or "caudo-cranial" group. "Cranio-caudal" MDCTA scanning Protocol Patients not already on betablocker were prescribed betablocker (bisoprolol 5mg/daily) for one week prior to CTA unless contraindication. On arrival, 18G cannula inserted into vein in antecubital fossa. Connected to 3 lead heart rate monitor and heart rate controlled with iv metoprolol (up to 30mg) to control rate below 70bpm to avoid harmonic artefact. Philips Brilliance 64 MDCT Start position from above the medial clavicle (assessed on an AP scout). Finish point estimated at 4mm from base of heart (assessed on a lateral scout). ROI placed in descending aorta. Bolus track (Sure StartTM). Threshold set at 120HU. Delay time 6s. Rotation time 420msec, Pitch 0.2, increment 0.45mm, FOV 220, 120kV, 800mAs Reconstruction with wide FOV 350 for lung parenchymal assessment Dose modulated retrospective cardiac gated scan (Dose right cardiac) at 75% of cardiac cycle performed unless contraindication due to cardiac rhythm or rate. In these cases a full retrospective study was performed. 125mls Ioversol (Optiray) 300mg/ml with 30mls Normal saline "chase" at 6mls/second. Page 10 of 23

11 "Caudo-cranial" MDCTA scanning Protocol As above with inverted start and finish positions and delay of 6.5secs. MDCTA reformat Philips cardiac CT angiography software package 3mm MIP images WW 750 WC 90. Grafts assessed in three conventional planes and cardiac axis. Wide FOV 1mm slice thickness axial/sagittal and coronal assessment for breathing artefact on lung window setting WW 1600 WC Assessment was made by two experienced Cardiac CT readers, each with 7 years experience, blinded to the study protocol. They assessed the image quality of the origin and distal anastomosis of each graft according to a three point Liekart scale: Artefact present which affects diagnostic quality Mild artefact, not sufficient to affect diagnosis No artefact. Occluded grafts were excluded from assessment. Assessment Table Patient No. Sex Age Mean Acquisition Graft HR Time Liekart LiekartSubclavian Breathing Origin Distal Vein Artefact Anastomosis HU (side) ROI HU measurement of subclavian vein on side contrast administered was assessed independently by a general radiologist with no cardiac CT training who was blind to the nature of the study. Page 11 of 23

12 Results Craniocaudal Group Caudocranial Group Number of Patients Mean acquisition time (seconds) Mean Heart rate (Bpm) Number of Grafts Number of occluded anastomoses Liekart Score Liekart Score Liekart Score Number with Breathing Artefact Analysis of 1 of the LIMA origins in the caudocranial group was not possible as it was not included on the scan. Hounsfield Unit measurement in Subclavian Vein Analysis Craniocaudal Group Caudocranial Group Mean Subclavian Vein HU Standard Deviation Standard Error The mean Hounsfield Unit is significantly higher in the craniocaudal group when compared with the caudocranial group (Unpaired t-test; p<0.0001) Liekart scores were analysed using Chi square and Fisher's exact tests. Page 12 of 23

13 IMA Graft Origin Craniocaudal Group Caudocranial Group Liekart Score Liekart Score Liekart Score See Figs. 1, 2 and 3. See Graph, Fig. 5. There is a significant difference in proportion of patients across Liekart grades between (craniocaudal and caudocranial) groups (Chi square; p:0.0003) See Graph, Fig. 6. Craniocaudal group has a significantly higher proportion of patients Liekart 1 than Liakart 2 or 3 compared with the Caudocranial group (Fisher's exact test; p:0.0001) Other Graft Origin Craniocaudal Group Caudocranial Group Liekart Score Liekart Score Liekart Score No statistical analysis required. Distal Graft Anastomosis Page 13 of 23

14 Craniocaudal Group Caudocranial Group Liekart Score Liekart Score Liekart Score See Graph, Fig. 7. There is no significant difference between the proportions of patients across Liekart scores in the craniocaudal and caudocranial groups (Chi square; p:0.249) A higher proportion of patients in the caudocranial group are Liekart 3 than Liekart 1 or 2, but this did not reach statistical significance (Fisher's exact test; p:0.177) See Fig 4. and Graph, Fig. 8. Images for this section: Page 14 of 23

15 Fig. 1: Streak Artefact from contrast in Left Subclavian vein affecting view of origin of LIMA (Craniocaudal acquisition) Page 15 of 23

16 Fig. 2: Origin of LIMA well seen on Caudocranial acquisition. Note reduced attenuation of Left Subclavian vein compared with Fig. 1. Page 16 of 23

17 Fig. 3: Obscured RIMA from contrast in right Subclavian vein. Page 17 of 23

18 Fig. 4: SVG breathing artefact, craniocaudal acquisition. Page 18 of 23

19 Fig. 5: Graph showing number of cases of each Liekart Score at IMA origin on both acquisition protocols Page 19 of 23

20 Fig. 6: Graph showing proportion of Liekart scores at IMA origin on each acquisition protocol Page 20 of 23

21 Fig. 7: Graph showing number of cases of each Liekart score at distal anastomosis on each acquisition protocol Fig. 8: Graph showing proportion of each Liekart score at distal anastomosis on each acquisition protocol. Page 21 of 23

22 Conclusion The study confirms the benefit in scanning CT graft studies in the caudocranial direction "bottom up". At the IMA origin, there is a statistically significant increase in the proportion of patients in Liekart Group 1, than Liekart 2 or 3 in the craniocaudal group compared with the caudocranial group. The majority of the Liekart 1 scores were secondary to high contrast in the adjacent subclavian vein. There is a tendency to less motion artefact at the distal anstomosis in the caudocranial group, but this does not reach statistical signficance. This may be secondary to a small population group. Whilst it has not reached statistical significance for the distal anastomosis respiratory motion artefact, due to the statistically significant reduction in contrast artefact from the subclavian vein, we would still recommend caudocranial scanning as best practice. It would also be best practice to aim to cannulate the opposite arm to the side of IMA graft. Incidentally we noted a slight increase in the concentration of contrast in the right ventricle due to the earlier time of imaging in the caudocranial group. The view of the RCA can in theory be affected by this, however this is not considered diagnostically significant as we do not routinely assess the native vessel prior to the anastamosis. These patients would have had previous catheter angiograms to assess these vessels prior to grafting. Personal Information P. Glass - Specialist Registrar Radiology, Ulster Hospital Dondonald, Belfast, UK. P. Donnelly - Consultant Cardiologist, Ulster Hospital Dondonald, Belfast, UK. P. Hanley - Consultant Radiologist, Ulster Hospital Dondonald, Belfast, UK. Page 22 of 23

23 D, Higginson - Consultant Cardiologist, Ulster Hospital Dondonald, Belfast, UK. P. Ball - Consultant Radiologist, Ulster Hospital Dondonald, Belfast, UK. References 1. Kavita Garg, Loren Macey. CT Scanning in the Diagnosis of Pulmonary Embolism. Respiration 2003; 70: Revel M., Petrover D. Et al.. Diagnosing Pulmonary Embolism with Four-Detector Row Helical CT: Prospective Evaluation of 216 Outpatients and Inpatients. Radiology 2005; 234: Page 23 of 23

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