CME Information. Activity Title: Radiology Update, April 2015: Managing Incidental Vascular Abnormalities Detected on Imaging Studies

Transcription

1 CME Information CONTINUING MEDICAL EDUCATION INFORMATION Activity Title: Radiology Update, April 2015: Managing Incidental Vascular Abnormalities Detected on Imaging Studies Purpose: Radiology Inc. in conjunction with Mount Carmel, will work together to provide the most updates information available per the American College of Radiology. This article provides general guidance for managing and following up asymptomatic, incidental vascular findings frequently detected on imaging studies of the chest, abdomen, and pelvis. Target Audience: MCHS Physicians: Family Practitioners, Internists, Obstetricians and Gynecologists, and Oncologists Educational Objectives: At the end of this activity, participants should be able to: 1. Evaluate the appropriate imaging modality for various disease states and symptoms 2. Apply the appropriate radiologic study based upon the rapidly changing technology 3. Provide case studies that illustrate minimum ionizing radiation at the minimal cost available Faculty and Planning Committee: Mitchell Brack, MD; David Neal, MD; Stacey Lowe, MBA; Jeanine Hatfield Disclosures: CME Committee member Michael Jopling discloses the following: Grant/Research Recipient: Covidien; Consultant: Covidien; Honorarium/Travel: Baxter, Covidien, Malinkrodt; Stock Shareholder: Cardiox; Employee: Cardiox; Advisory/Review Board: West Virginia University Physics. These conflicts of interest have been resolved by the CME Office. No one else in a position to control content has any relationships with commercial interests. Commercial Support: No commercial support was received for this activity. Medium/Software Requirements: In order to participate in this CME activity, participants who use a Window platform must have Windows XP or later, Internet Explorer 7.0 or later, and Adobe Flash Player or later. Also, sound is required. Estimated Time to Complete: One hour Date of Original Release: April 13, 2015 Expiration Date: April 13, 2017 CME Credit and Provider Information: The Mount Carmel Health System is accredited by the Ohio State Medical Association to provide continuing medical education for physicians. The Mount Carmel Health System designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity.

2 In order to obtain Category 1 Credit, participants must: 1. Review all course chapters 2. Complete post test and receive 80% or above 3. Submit an evaluation form Once the above information is completed online, a certificate will be sent to the participants within 30 days for their records. The OSMA requires CME providers to maintain records of attendance for 6 years after participation. Currently there is no fee to obtain Category 1 Credit for this CME credit. Please contact the CME Office with any questions: the CME Office at: cme@mchs.com Mount Carmel Health System Medical Education Department, CME Office 793 West State Street Columbus, OH (phone) (fax)

3 RADIOLOGY UPDATE David E. Neal, M.D. by DAVID E. NEAL, M.D. APRIL, 2015 VOLUME VII, ISSUE 1 Managing Incidental Vascular Abnormalities Detected on Imaging Studies INTRODUCTION: This article provides general guidance for managing and following up asymptomatic, incidental vascular findings frequently detected on imaging studies of the chest, abdomen, and pelvis. Fig. 1. CXR shows ascending thoracic aortic aneurysm. Radiopedia.org Fig cm Ascending Aortic Aneurysm on CT. Litmanovich et al. AJR Thoracic Aortic Dilatation (TAA) The prevalence of TAA is 4.2% in individuals without predisposing factors. Most are incidentally diagnosed on chest radiographs (Fig 1) or chest CTs performed for an unrelated reason (Fig 2). TAAs are increasingly being detected on screening CTs: Present in 3% of pts undergoing lung cancer screening. Most are asymptomatic. Those that cause symptoms are usually large and at risk for rupture. Risk of rupture is related to size: 0% if <4cm, 16% if cm, 31% if >6cm. TAAs rupture at smaller diameters in pts with Marfan syndrome or other connective tissue disorders. The normal diameter of the thoracic aorta varies with age, gender and body habitus. For practical purposes, an ascending aortic diameter of >4cm is considered abnormally dilated. A descending thoracic aortic diameter > 3cm is considered abnormally dilated. If the ascending aortic diameter > 4cm, follow-up CTA or MRA is suggested in 6 months to assess interval growth. If the diameter is stable, further imaging can be done annually. Ideally, the imaging should be done at the same center using the same imaging technique. For isolated aortic arch aneurysms < 4.0 cm in diameter, it is reasonable to reimage with CTA or MRA at 12-month intervals, to detect enlargement of the aneurysm. For isolated aortic arch aneurysms > 4.0 cm in diameter, it is reasonable to reimage with CTA or MRA, at 6-month intervals. Surgery is typically considered for ascending aortic aneurysms in asymptomatic patients when : the aneurysm is >5.5 cm (although dependent on body size) the aneurysm is 4-5 cm when the patient has an underlying connective tissue disease that may increase rupture risk If the aneurysm increases > 0.5 cm per year Penetrating Aortic Ulcer (PAU) Occurs when an atherosclerotic plaque ulcerates through the aortic intima allowing blood to enter the media of the aortic wall. PAU is occasionally detected incidentally on CT scans of the chest in elderly patients with underlying atherosclerosis. The mid descending thoracic aorta is most commonly involved (90%). PAU may be asymptomatic or present with chest pain similiar to dissection.

4 Imaging appearance: Collection of contrast outside the aortic lumen, within the aortic wall (Fig 3). Most ulcerlike aortic lesions remain unchanged over time and do not cause symptoms, although about one-third of lesions weaken the aortic wall, resulting in mild interval aortic enlargement. Fig. 3. Penetrating aortic ulcer on CT. Walsh et al. West J Emerg Med 2010 Infrequently, PAU may progress to dissection or saccular aneurysm. If asymptomatic and incidental : Annual follow-up CTA is recommended. Incidental Pulmonary Emboli (PE) PE is detected incidentally in asymptomatic patients in up to 1.5% of the general population. These are usually small emboli seen in the lung bases on an abdominal CT or within the segmental/subsegmental arteries on a chest CT (Fig 4), performed for an unrelated indication. In the absence of evidence from controlled studies, the significance and treatment implications for incidental pulmonary emboli in non-oncology patients are not known. Fig 4. Small peripheral pulmonary embolism on CT. Radiology 2012;263:271-8 Importantly, an ongoing prospective cohort study is assessing the safety of withholding treatment for stable patients with isolated subsegmental pulmonary embolism (Clinical- Trials.gov Identifier: NCT ). The results are expected in 2017 Abdominal Aortic Aneurysm (AAA) Dilatation of the abdominal aorta greater than 2 cm is considered abnormal, but a diameter of more than 3 cm or > 1.5 times the diameter of the more proximal aorta is considered diagnostic of an AAA Using the above definition, 9% of people> 65 years old have an AAA Annual risk of aneurysm rupture: Less than 4.0 cm in diameter = less than 0.5 percent Between 4.0 to 4.9 cm in diameter = 0.5 to 5 percent Between 5.0 to 5.9 cm in diameter = 3 to 15 percent Between 6.0 to 6.9 cm in diameter = 10 to 20 percent Between 7.0 to 7.9 cm in diameter = 20 to 40 percent Greater than or equal to 8.0 cm in diameter = 30 to 50 percent If an aneurysm is incidentally detected by CT or MRI, usually no immediate further imaging is needed. If detected on radiographs (Fig 5), abdominal US is recommended to more accurately evaluate the size. CTA (Fig 6), or MRA are preferred for defining the extent, size, and branch involvement allowing the correct choice of treatment. Screening for AAA is typically performed with ultrasound Who should be screened? 1. Men age 65 or older. 2. Women age 65 or older with cardiovascular risk factors. 3. Patients age 50 or older with a family Fig 5. AAA on lateral spine xray. history of aortic and/or peripheral vascular aneurysmal disease. 4. Patients with a personal history of peripheral vascular aneurysmal disease Recommended intervals for initial follow-up imaging of ectatic aortas and abdominal aortic aneurysms Aortic Diameter (mm) Imaging Interval y y y y mo, referral to vascular subspecialist mo, referral to vascular subspecialist

5 CME Information CONTINUING MEDICAL EDUCATION INFORMATION Activity Title: Radiology Update, April 2015: Managing Incidental Vascular Abnormalities Detected on Imaging Studies Purpose: Radiology Inc. in conjunction with Mount Carmel, will work together to provide the most updates information available per the American College of Radiology. This article provides general guidance for managing and following up asymptomatic, incidental vascular findings frequently detected on imaging studies of the chest, abdomen, and pelvis. Target Audience: MCHS Physicians: Family Practitioners, Internists, Obstetricians and Gynecologists, and Oncologists Educational Objectives: At the end of this activity, participants should be able to: 1. Evaluate the appropriate imaging modality for various disease states and symptoms 2. Apply the appropriate radiologic study based upon the rapidly changing technology 3. Provide case studies that illustrate minimum ionizing radiation at the minimal cost available Faculty and Planning Committee: Mitchell Brack, MD; David Neal, MD; Stacey Lowe, MBA; Jeanine Hatfield Disclosures: CME Committee member Michael Jopling discloses the following: Grant/Research Recipient: Covidien; Consultant: Covidien; Honorarium/Travel: Baxter, Covidien, Malinkrodt; Stock Shareholder: Cardiox; Employee: Cardiox; Advisory/Review Board: West Virginia University Physics. These conflicts of interest have been resolved by the CME Office. No one else in a position to control content has any relationships with commercial interests. Commercial Support: No commercial support was received for this activity. Medium/Software Requirements: In order to participate in this CME activity, participants who use a Window platform must have Windows XP or later, Internet Explorer 7.0 or later, and Adobe Flash Player or later. Also, sound is required. Estimated Time to Complete: One hour Date of Original Release: April 13, 2015 Expiration Date: April 13, 2017 CME Credit and Provider Information: The Mount Carmel Health System is accredited by the Ohio State Medical Association to provide continuing medical education for physicians. The Mount Carmel Health System designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits(s). Physicians should claim only the credit commensurate with the extent of their participation in the activity. In order to obtain Category 1 Credit, participants must: 1. Review all course chapters 2. Complete post test and receive 80% or above 3. Submit an evaluation form Once the above information is completed online, a certificate will be sent to the participants within 30 days for their records. The OSMA requires CME providers to maintain records of attendance for 6 years after participation. Currently there is no fee to obtain Category 1 Credit for this CME credit. Please contact the CME Office with any questions: the CME Office at: cme@mchs.com Mount Carmel Health System Medical Education Department, CME Office 793 West State Street Columbus, OH (phone) (fax)

6 In contrast to true aneurysms, splenic artery pseudoaneurysms are rare, caused by pancreatitis or trauma, almost always symptomatic, and have a high rate of rupture (37%). Renal Artery Aneurysm Fig 8 Calcified splenic artery aneurysm Typically detected on abdomen xray. incidentally on an abdominal CT (Fig 10), when small and asymptomatic. Fig 6. AAA with intraluminal thrombus on CT. Moghul et al Iliac Artery Aneurysms Most commonly involve the common iliac (Fig 7), and internal iliac arteries. Defined as diameter >1.5 times normal or >2.5cm. Aneurysms < 3cm are typically asymptomatic, rarely rupture, and grow slowly. Aneurysms cm should be followed by CT or MRI in 6 months and then if stable, annual follow-up. Aneurysms>3.5cm are at increased risk of rupture and should be treated or followed more closely. Splenic Artery Aneurysms Most common visceral artery aneurysm with a prevalance of 0.8% Risk factors for development are similiar to other aneurysms: HTN, obesity, CAD, hypercholesterolemia. Fig 7 Left iliac artery aneurysm on 3-D image from CTA. Sakamoto et al, Radiographics 25: 2005 Usually calcified and therefore incidentally detected on radiographs (Fig 8), and on CT (Fig 9). Rupture rate is 2-3%. Risk factors for rupture include: Diameter>2cm, rapid growth, cirrhosis, pregnancy, and symptoms due to the aneurysm. If the aneurysm is < 2cm: Annual CT follow up is probably safe although risk factors should be assessed. If the aneurysm is >2cm: Endovascular therapy should be considered. Fig 9. CT shows splenic artery aneurysm. A. Alsheikhly Etiologies include: Fibromuscular dysplasia (younger women) and atheroslcerosis. Renal artery aneurysms may rupture or be associated with renal artery HTN. If 1-1.5cm and asymptomatic: CT follow-up every 1-2 years is recommended. If >1.5cm: Consider endovascular or surgical repair. If the aneurysm is located in the renal parenchyma, it is likely a post-traumatic pseudo aneurysm and shorter interval follow-up is recommended. Other Visceral Artery Aneurysms Aneurysms occasionally are detected in the hepatic, celiac, gastoduodenal, gastric, and mesenteric arteries. Criteria for safe observation of these aneurysms has not been clearly established. Therapy is generally recommended for aneurysms > 2cm. If the decision is made to observe rather than treat: Annual CT follow up is typically recommended. Pancreaticoduodenal aneurysms have a higher rate of rupture, therefore some authors recommend all undergo therapy.

7 IMAGING CENTERS Mount Carmel East Mount Carmel West Mount Carmel St. Ann's Mount Carmel New Albany Surgical Hospital Mount Carmel Grove City Medical Center Mount Carmel Imaging Center at Westar Fig 10. Renal artery aneurysm on CT. ult.sagepub.com Incidental Venous Findings Compression of the left common iliac vein by the anterior right common iliac artery (iliocaval compression syndrome). May be associated with left leg edema or venous thrombosis. Is frequently seen as an incidental finding: 25% of the population has this anatomic variant Most patients are not symptomatic Follow-up not necessary unless symptoms arise. Compression of left renal vein between the aorta and superior mesenteric artery (nutcracker syndrome). Localized varices may be present If asymptomatic (no HTN, proteinuria, or hematuria) this finding is likely clinically insignificant. Fig 11. Dilated pelvic veins on CT. www. radrounds.com Dilated pelvic and ovarian veins (Fig 11). Can cause pelvic congestion syndrome (dull pelvic pain, dysmenorrhea, dyspareunia), however are a common (47%) incidental finding in asymptomatic multiparous women. If dilated pelvic veins are present in an asymptomatic female, no further imaging or intervention is recommended. Ovarian vein thrombosis Common (80%) incidental finding in patients who have undergone TAH BSO and retroperitoneal lymph node dissection. No treatment is necessary in cases uncomplicated by thrombophlebitis or pulmonary embolism. Mount Carmel Imaging Center at Mill Run Highfeld MRI Polaris Hilliard Diley Ridge Medical Center CONTACT: STACEY LOWE for questions regarding Radiology, Inc. physicians at: stacey.lowe@radadvocate.com or THIS AUTHOR: neal@columbus.rr.com REFERENCES Khosa et al. Managing Incidental Findings on Abdominal and Pelvic CT and MRI, Part 2: White Paper of the ACR Incidental Findings Committee II on Vascular Findings, Z, Volume 10, Issue 10, Pages Litmanovich et al. CT and MRI in Diseases of the Aorta. AJR 2009; 193 Guidelines for the Diagnosis and Management of Patients with Thoracic Aortic disease. American College of cardiology Guidelines. March 2010 Castaner et al. CT in Nontraumatic Acute Thoracic Disease: Typical and Atypical Features and Complications. Radiographics 2003; Vol 23 Pallardo Y. When a test is too good: how CT pulmonary angiomgrams find pulmonary emboli that do not need to be found. BMJ 2013;347 Yassa et al. Ovarian vein thrombosis: a common incidental finding in patients who have undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy with retroperitoneal lymph node dissection AJR1999; 172:45-47 Acknowledgemen wledgements: This newsle wsletter er was created ed with the assistanc ance and advice of Dr. John Sturgeon, MD, Dr. David Neal, MD, and Tracy Wineland MS CIS, CIIP (Senior Digital Imaging Analyst (PACS Support).) A list of print and online sources utilized may be obtained by ing the newsle wsletter er author. CONTACT: STACEY LOWE for questions regarding Radiology, Inc. physicians at: stacey.lowe@radadvocate.com or THIS AUTHOR: neal@columbus.rr.com

8 To take quiz, please print a copy and fax your answers to In order to receive 1 CME credit you must receive a 80% score. CME QUIZ 1. Which of the following concerning thoracic aortic aneurysms is true? a. Almost all are symptomatic b. The descending aorta is most commonly involved. c. If the ascending aortic diameter > 4cm, follow-up CTA or MRA is suggested in 6 months to assess interval growth. d. Surgery is typically performed when the ascending aorta reaches 3.5 cm in diameter. 2. Which of the following statements about penetrating aortic ulcer is true? a. If asymptomatic and incidental : Annual follow-up CTA is recommended. b. They most commonly occur in the distal abdominal aorta near the bifurcation. c. The most common cause is mycotic aortitis. d. Progression to rupture is the rule. 3. Which of the following statements concerning abdominal aortic aneurysm is true? a. Men age 50 or older should be screened with ultrasound b. CT angiography is the preferred method for aneurysm screening in asymptomatic patients c. An aneurysm is defined as a diameter>3cm or 1.5 times the diameter of the more proximal aorta. d. Annual risk of rupture when an aneurysm is 5.0 to 5.9 cm in diameter is less than Which of the following statements concerning iliac artery aneurysms is true? a. Should be treated if the diameter is > 1.5cm b. Aneurysms cm can be followed by CT or MRI in 6 months and then if stable, annual follow-up. c. The distal external iliac artery is the most common location of involvement. d. Aneurysms of the internal iliac artery are at high risk for rupture and therefore should be treated regardless of size. 5. All of the following concerning splenic artery aneurysms is true EXCEPT? a. Risk factors for rupture include: Diameter>2cm, rapid growth, cirrhosis, pregnancy, and symptoms due to the aneurysm. b. If the aneurysm is < 2cm: Annual CT follow up is probably safe although risk factors should be assessed. c. If the aneurysm is >2cm: Endovascular therapy should be considered. d. Splenic artery pseudoaneurysms are common and have a low rate of rupture.

9 6. What is the recommended management of an asymptomatic 1.2 cm renal artery aneurysm? a. Endovascular therapy, typically using coils. b. CT follow-up every 1-2 years. c. No follow up needed. d. Conventional angiography, followed by Duplex ultrasound every two years. 7. Which of the following has a high rate of rupture? a. Pancreaticoduodenal aneurysms. b. Pelvic varices. c. Left renal vein when compressed betweeen the aorta and superior mesenteric artery d. 2.0 cm internal iliac artery aneurysm 8. All of the following require follow-up when asymptomatic except? a. 3.5 cm abdominal aortic aneurysm b. 3.0 cm iliac artery aneurysm c. Iliac vein compression by the right common iliac artery. d. Renal post-traumatic pseudoaneurysm