Patient preparation and coronary CTA techniques. Gregory Kicska, M.D. Ph.D. University of Washington, Thoracic Imaging
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1 Patient preparation and coronary CTA techniques Gregory Kicska, M.D. Ph.D. University of Washington, Thoracic Imaging
2 Overview 1. Patient preparation 2. Scanning techniques
3 Patient preparation Preparation related to any contrast CT examination Preparation specific to coronary CTA
4 Exclude contraindications Patient safety Study quality
5 Contraindications: patient saftey Contrast renal insufficiency allergy (anaphylaxis) Radiation pregnancy radiation dose/age Claustrophobia Medically unstable
6 Contraindications: patient saftey Contrast renal insufficiency GFR (ml/ min/1.73 m 2 ) Risk of contrast induced nephrotoxicity Intravenous iodinated contrast media 60 Negligible Safe Moderate Use only if clinically essential prophylaxis required <30 High Contraindicated
7 Contraindications: patient saftey Contrast renal insufficiency GFR (ml/ min/1.73 m 2 ) Risk of contrast induced nephrotoxicity Intravenous iodinated contrast media 60 Negligible Safe Moderate Use only if clinically essential prophylaxis required <30 High Contraindicated
8 Contraindications: patient saftey Radiation pregnancy radiation dose/age
9 Contraindications: patient saftey Claustrophobia Diazapam 5 mg oral* Medically unstable *Dose adjustment needed specific conditions
10 Contraindications: study quality Motion Breath hold Gating Artifact Inability to raise arms Metal Obesity
11 Contraindications: study quality Motion Breath hold ( slice) 270 ms acquisition dual source
12 Contraindications: study quality Motion Gating atrial fibrillation or frequent PVCs
13 Contraindications: study quality Artifact Inability to raise arms Metal Obesity
14 The ideal patient HR < 65, sinus Calm Thin Large veins Pearl diver (able to hold breath) Able to follow commands
15 Preparation: 24-1 hr pre-exam No caffeine (24 hrs) No viagra (24 hrs) No energy supplement (24 hrs) No food (4 hrs) No liquid (1 hr)
16 Preparation: 24-1 hr pre-exam Cardiac medications should not be suspended!
17 Preparation: 24-1 hr pre-exam Non-anaphylactic contrast reaction 50 mg 13,7,1 hrs before exam oral Benadryl 1 hour before exam
18 Preparation: 1 hr pre-exam IV access gauge needle Right arm
19 Preparation: 1 hr pre-exam Satisfactory IV access Contraindications excluded / mitigated Proceed to HR control
20 Preparation: 1 hr pre-exam Satisfactory IV access Contraindications excluded / mitigated Proceed to HR control
21 Preparation: 1 hr pre-exam Oral metoprolol (50 mg tabs) mg Wait 90 minutes, check BP/HR Consider additional 50 mg IV metoprolol (5 mg) Give 5 mg IVP Wait 20 minutes, check BP/HR Consider additional 5 mg x 2 Contraindications Metoprolol allergy Bronchospastic disease (asthma) Aortic valve disease Worsening heart failure Heart block
22 Preparation: 1 hr pre-exam
23 Preparation: 1 hr pre-exam Beta blocker contraindication? Consider oral Verapamil
24 Preparation: 1 hr pre-exam HR < 65 bpm Proceed to Ca++ score
25 Examination: patient positioning Center heart in scanner
26 Examination: patient positioning Center heart in scanner = Lowest noise
27 Examination: patient positioning Center heart in scanner = Lowest noise
28 Examination: Ca++ score Ca++ score coverage
29 Examination: Ca++ score Voxels are 3 x 1.3 x 1.3 mm non-overlapping Threshold of 130 H.U. Agatston volume mass score
30 Examination: Ca++ score = 0 - CAD unlikely > high risk of stenosis Predicting Stenosis Ca++ Score Sensitivity Specificity >1 >100 > % 75% 73% 90% 30% 98% Low false negative No false positive Low sensitivity on CTA
31 Examination: Ca++ score 0 < Agatston score < Proceed to CTA planning
32 Examination: gating Retrospective no modulation Retrospective with modulation Prospective
33 Retrospective no modulation Retrospective with modulation Prospective Rate < 70 no function no calcium Age < 40 Prospective Rate > 70 function calcium Age > 40 Retrospective Modulation A-fib Retrospective No modulation
34 Examination: CTA coverage Coronary CTA coverage (retrospective) Ca++ score coverage Top slice with CA Bottom slice with CA
35 Examination: CTA coverage Coronary CTA coverage (prospective) Ca++ score coverage Top slice with CA Bottom slice with CA
36 Examination: dose Set kvp and MAS. Automatic exposure control set desired held soon in its standard deviation set upper and lower limits to avoid spikes in current due to hardware Weight table
37 Examination: dose
38 Examination: dose Participate in dose related QA
39 Examination: contrast 80 ml 5 ml/s 40 ml 4 ml/s 50 ml 4 ml/s 100% 40% 60% 100%
40 Examination: nitroglycerin Contraindications Head trauma/bleed Systolic BP < 100 Nitrate Allergy Phosphodiesterase inhibitors Adverse Headaches - 50%
41 Examination: nitroglycerin 4 minutes
42 Examination: nitroglycerin 4 minutes elapsed Proceed to CTA scanning
43 Examination: scanning
44 Examination: reconstruction Main reconstruction for 3D station Thin section (0.625 mm) axial cardiac kernal < 32cm FOV 50% overlap
45 Examination: reconstruction Additional reconstruction for 2D station Axial 2.5 mm, lung kernel, lung FOV Axial 2.5 mm, body kernel, body FOV Coronal/sagittal, body kernel
46 Conclusions Exclude contraindications related to patient safety or exam quality ensure proper patient preparation for contrast exam control heart rate with beta blocker calcium scoring is used to plan CTA or terminate exam scanner gating is one of the most effective ways to reduce dose utilize automatic exposure control when possible
47 Thank you
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