CT: Common Protocols. Michael Steigner, M.D. Director, Vascular CT/MR Assistant Professor of Radiology

Transcription

1 CT: Common Protocols BRIGHAM AND WOMEN S HOSPITAL Heart & Vascular Center Harvard Medical School Teaching Hospital Michael Steigner, M.D. Director, Vascular CT/MR Assistant Professor of Radiology msteigner@bwh.harvard.edu

2 CT-Protocols

3 CT-Protocol Descriptions Protocol Protocol Description CV AAA I+ IV: 4cc/sec with saline chaser PHASES: I-: none BOLUS TRACKING: A/P DELAY: none CV AAA, I- IV: none PHASES: I-: A/P BOLUS TRACKING: none DELAY: none CV AAA, Post-op Stent-graft IV: 4cc/sec with saline chaser PHASES: I-: A/P BOLUS TRACKING: A/P DELAY: 70sec Note: **All scan ranges, FOV, and center must be identical!** CV AAA, Pre-op Stent-graft IV: 4cc/sec with saline chaser PHASES: I-: A/P BOLUS TRACKING: A/P DELAY: none Note: **All scan ranges, FOV, and center must be identical!** CV Calcium Scoring IV: none PHASES: I-: gated carina to base of heart with small FOV recons of the heart and large FOV recons of the chest CV Coronary CTA IV: 5-6cc/sec with saline chaser PHASES: I-: none BOLUS TRACKING: gated carina to base of heart with small FOV recons of the heart and large FOV recons of the chest DELAY: none CV Lower Extremity Runoff CTA IV: 5cc/sec with saline chaser PHASES: I-: top of kidneys to toes BOLUS TRACKING: top of kidneys to toes with additional small FOV recons of each leg DELAY: mid-thigh to toes with additional small FOV recons of each leg CV Lower Extremity Runoff CTA with CTV IV: 5cc/sec with saline chaser PHASES: I-: top of kidneys through toes BOLUS TRACKING: top of kidneys through toes with additional small FOV recons of each leg DELAY: top of kidneys through 180 sec CV Upper Extremity Runoff CTA with CTV IV: inject unaffected 5cc/s with saline chaser POSITIONING: place affected arm above the head PHASES: I-: arch thru fingers BOLUS TRACKING: arch thru fingers with small FOV recons of affected arm DELAY: arch thru 180 sec CV DIEAP CTA IV: 5cc/sec with saline chaser PHASES: I-: none BOLUS TRACKING: A/P - scan from bottom up - trigger above aortic bifurcation DELAY: none CV Gated Thoracic Aorta *Chest Only* CTA IV: 4cc/sec with saline chaser PHASES: I-: non-gated chest BOLUS TRACKING: gated chest DELAY: none CV Gated Thoracic Aorta CAP CTA IV: 4cc/sec with saline chaser PHASES: I-: non-gated chest BOLUS TRACKING: gated chest DELAY: A/P immediately following chest CV LIMA Graft-Redo Sternotomy Protocol IV: 5cc/sec with saline chaser PHASES: I-: none BOLUS TRACKING: gated chest from above clavicles to base of heart with small FOV recons to include RIMA and LIMA and large FOV recons of entire chest DELAY: none CV Mesenteric CTA with CTV IV: 5cc/sec with saline chaser PHASES: I-: none BOLUS TRACKING: A/P DELAY: A/P 60 sec and 90 sec Note: **All scan ranges, FOV, and center must be identical!** CV TAVR protocol IV: use injector preset PHASES: I-: none BOLUS TRACKING: gated--chest DELAY: A/P immediately following chest with no overlap of scan ranges CV Pulmonary Vein *Gated* IV: 5cc/sec with saline chaser PHASES: I-: none BOLUS TRACKING: gated--2 cm above carina to base of heart with small FOV recons of the heart and large FOV recons of the chest -- Ascending Aorta DELAY: none CV Pulmonary Vein *Non-Gated* IV: 5cc/sec with saline chaser PHASES: I-: none BOLUS TRACKING: nongated--2 cm above carina to base of heart with small FOV recons of the heart and large FOV recons of the chest -- Ascending Aorta DELAY: none CV Renal Arteries CTA IV: 5cc/sec with saline chaser PHASES: I-: none BOLUS TRACKING: celiac to below aortic bifurcation DELAY: none CV Renal Donor IV: 5cc/sec with saline chaser PHASES: I-: Abdomen only BOLUS TRACKING: celiac to below aortic bifurcation DELAY: Abdomen 100 sec then 6 min CV Renal Recipient IV: 5cc/sec with saline chaser PHASES: I-: none BOLUS TRACKING: A/P DELAY: 150sec Note: **All scan ranges, FOV, and center must be identical!** CV RV Function IV: 4cc/sec with saline chaser PHASES: I-: none BOLUS TRACKING: gated carina to base of heart with small FOV recons of the heart and large FOV recons of the chest DELAY: none CV CTV Chest, SVC syndrome IV: 3cc/sec with saline chaser PHASES: I-: none BOLUS TRACKING: none DELAY: mid neck to 50 sec and 100 sec Note: **All scan ranges, FOV, and center must be identical!** CV TAA, Post-op Stent-graft IV: 4cc/sec with saline chaser PHASES: I-: non-gated chest though stent BOLUS TRACKING: non-gated chest though stent DELAY: non-gated chest though 70sec Note: **All scan ranges, FOV, and center must be identical!** CV TAA, Pre-op Stent-graft IV: 4cc/sec with saline chaser PHASES: I-: non-gated chest BOLUS TRACKING: non-gated chest DELAY: non-gated 70sec Note: **All scan ranges, FOV, and center must be identical!** CV CTV Pelvic Vein Thrombosis DVT IV: 3cc/sec with saline chaser PHASES: I-: none BOLUS TRACKING: none DELAY: 100 sec and 180 sec Note: **All scan ranges, FOV, and center must be identical!**

4 t protocolid protocolname description Series BWH CV AAA I+ {74174} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not : IV: 4mL/sec with saline chaser I-: none BOLUS TRACKING: A/P DELAY: none BWH CV AAA, I- {74176} IV: none I-: A/P BOLUS TRACKING: none DELAY: none BWH CV AAA, Post-op Stentgraft/Extravasation {74174} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 100 4mL/sec with saline chaser I-: A/P BOLUS TRACKING: A/P DELAY: 70sec BWH CV AAA, Pre-op Stent-graft {74174} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 100 4mL/sec with saline chaser I-: A/P BOLUS TRACKING: A/P DELAY: none BWH CV Coronary Calcium Scoring {75571} IV: none I-: prospective gating with single phase (75% if HR <75, if HR >75 then 40%) carina to base of heart BOLUS TRACKING: none DELAY: none Abd Pel CTA Ax 3x3 soft Abd Pel CTA Cor 3x3 soft Abd Pel CTA Sag 3x3 soft Abd Pel CTA Ax 1x0.8 soft Abd Pel CTA Ax MIP 8x2 soft Abd Pel CTA Cor MIP 8x2 soft Abd Pel I- Ax 3x3 soft Abd Pel I- Cor 3x3 soft Abd Pel I- Sag 3x3 soft Abd Pel I- Ax 1x0.8 soft Abd Pel I- Ax 3x3 soft Abd Pel I- Cor 3x3 soft Abd Pel I- Sag 3x3 soft Abd Pel I- Ax 1x0.8 soft Abd Pel I- Ax 3x3 soft Abd Pel I- Cor 3x3 soft Abd Pel I- Sag 3x3 soft Abd Pel I- Ax 1x0.8 soft Ca score 0.5x0.5 (cardiac phase) small FOV Ca score 3x3 (cardiac phase) small FOV Chest I- Ax 3x3 soft Chest I- Cor 3x3 soft Chest I- Sag 3x3 soft Chest I- Ax MIP 10x1 soft Abd Pel CTA Ax 3x3 soft Abd Pel CTA Cor 3x3 soft Abd Pel CTA Sag 3x3 soft Abd Pel CTA Ax 1x0.8 soft Abd Pel CTA Ax MIP 8x2 soft Abd Pel CTA Cor MIP 8x2 soft Abd Pel CTA Ax 3x3 soft Abd Pel CTA Cor 3x3 soft Abd Pel CTA Sag 3x3 soft Abd Pel CTA Ax 1x0.8 soft Abd Pel CTA Ax MIP 8x2 soft Abd Pel CTA Cor MIP 8x2 soft Abd Pel 70s Ax 3x3 soft Abd Pel 70s Cor 3x3 soft Abd Pel 70s Sag 3x3 soft Abd Pel 70s Ax 1x0.8 soft BWH CV Coronary CTA {75574} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not administer contrast otherwise: IV: prescribed by fellow at the scanner (default 6mL/sec) with saline chaser BWH CV CTV Chest, SVC syndrome {71275] I-: none BOLUS TRACKING: gated carina to base of heart DELAY: none Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 100 4mL/sec with saline chaser I-: none BOLUS TRACKING: none DELAY: mid neck to 50 sec and 100 sec BWH CV DIEAP CTA {74174} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 100 5mL/sec with saline chaser I-: none BOLUS TRACKING: A/P - scan from bottom up - trigger above aortic bifurcation Aorta Chest only CTA **low risk** Dissection Monitored{71275} DELAY: none Indications: Chest pain with concern for aortic dissection. MUST BE MONITORED BY A RADIOLOGIST. - For most ER patients with suspected thoracic aorta dissection - Rarely, will need to hold patient for 10 min delayed "I-" scan if question intramural hematoma. Prefer 18G antecub IV, minimum IV requirement is 20G in forearm or greater. No IV's in wrist or hand. Inject from control room. Administer prescribed intravenous iodinated contrast agent per the following instructions: IV contrast dosing, followed by 40 ml of saline at the same rate: 50 ml at 4 ml/sec for scans at 100 kvp 75 ml at 5 ml/sec for scans at 120 kvp - Contact radiologist for egfr <30 to determine whether to perform scan for emergent need - Use CarekV where available - FLASH scans on the ER scanner, unless extremely large. - Do not exceed 9 sec scan duration. - Bolus track on DESCENDING aorta (80 HU threshold). Cardiac 0.5x0.25 (cardiac phase) small FOV Chest Ax 3x3 soft Chest Cor 3x3 soft Chest Sag 3x3 soft Chest Ax MIP 10x1 soft Chest 50s Ax 3x3 soft Chest 50s Cor 3x3 soft Chest 50s Sag 3x3 soft Chest 50s Ax 1x0.8 soft Chest 50s Ax MIP 10x1 soft Abd Pel CTA Ax 3x3 soft Abd Pel CTA Cor 3x3 soft Abd Pel CTA Sag 3x3 soft Abd Pel CTA Ax 1x0.8 soft Abd Pel CTA Ax MIP 16x2 soft Abd Pel CTA Cor MIP 16x2 soft Chest CTA Ax 3x3 (cardiac phase) soft Chest CTA Cor 3x3 (cardiac phase) soft Chest CTA Sag 3x3 (cardiac phase) soft Chest CTA Ax 1x0.8 (cardiac phase) soft Chest CTA Ax MIP 10x1 soft Chest 100s Ax 3x3 soft Chest 100s Cor 3x3 soft Chest 100s Sag 3x3 soft Chest 100s Ax 1x0.8 soft Chest 100s Ax MIP 10x1 soft Abd Pel CTA Ax 3x3 soft Abd Pel CTA Cor 3x3 soft Abd Pel CTA Sag 3x3 soft Abd Pel CTA Ax 1x0.8 soft BWH CV Aorta CAP CTA **High Risk** Dissection {71275;74174} BWH CV Gated Thoracic Aorta *Chest Only* CTA {71275} BWH CV Gated Thoracic Aorta" Chest Only" Non Contrast {71250} BWH CV LIMA Graft-Redo Sternotomy Protocol {75574} BWH CV Lower Extremity Runoff CTA {75635} BWH CV Lower Extremity Runoff CTA with CTV {73706} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 100 4mL/sec with saline chaser PHASES: I-: Chest with prospective gating with single cardiac phase (75% if HR <75, if HR >75 then 40%) or FLASH or mindose, if unavailable then non-gated BOLUS TRACKING: Chest with prospective gating with single cardiac phase as above or FLASH, if unavailable then non-gated. If FLASH then CAP. Trigger descending Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 100 4mL/sec with saline chaser PHASES: I-: Chest with prospective gating with single phase (75% if HR <75, if HR >75 then 40%) or FLASH. BOLUS TRACKING: Chest with prospective gating with single phase as above or FLASH or mindose. Trigger descending DELAY: none Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: none I-: Chest with prospective gating with single phase (75% if HR <75, if HR >75 then 40%) or FLASH BOLUS TRACKING: none DELAY: none Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 100 5mL/sec with saline chaser I-: none BOLUS TRACKING: Chest with prospective gating with single phase (75% if HR <75, if HR >75 then 40%). Trigger descending DELAY: none Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 125 5mL/sec with saline chaser I-: top of kidneys to toes unless *low risk* then may skip BOLUS TRACKING: L3 CTA top of kidneys to toes at 150 HU with scan time of 30sec (adjust scan time directly or adjust pitch or rotation time). DELAY: Scan Immediately- knee to toes Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 125 5mL/sec with saline chaser I-: top of kidneys to toes unless *low risk* then may skip BOLUS TRACKING: L3 CTA top of kidneys to toes at 150 HU with scan time of 30sec (adjust scan time directly or adjust pitch or rotation time). DELAY: Scan Immediately- knee to toes 180s scan top of kidneys to toes Chest I- Ax 3x3 (cardiac phase) soft Chest I- Cor 3x3 (cardiac phase) soft Chest I- Sag 3x3 (cardiac phase) soft Chest I- Ax 1x0.8 (cardiac phase) soft Chest I- Ax MIP 10x1 soft On trigger card check: If range 70-80% then phase start 75%. If range 30-80% then phase start 70%. If range 30-50% then phase start 40%. MUST change phase start for all reconstructions. Chest I- Ax 3x3 (cardiac phase) soft Chest I- Cor 3x3 (cardiac phase) soft Chest I- Sag 3x3 (cardiac phase) soft Chest I- Ax 1x0.8 (cardiac phase) soft Chest I- Ax MIP 10x1 soft On trigger card check: If range 70-80% then phase start 75%. If range 30-80% then phase start 70%. If range 30-50% then phase start 40%. MUST change phase start for all reconstructions. Chest I- Ax 3x3 (cardiac phase) soft Chest I- Cor 3x3 (cardiac phase) soft Chest I- Sag 3x3 (cardiac phase) soft Chest I- Ax 1x0.8 (cardiac phase) soft Chest I- Ax MIP 10x1 On trigger card check: If range 70-80% then phase start 75%. If range 30-80% then phase start 70%. If range 30-50% then phase start 40%. MUST change phase start for all reconstructions. Chest CTA 0.5x0.5 (cardiac phase) small FOV Chest CTA 3x3 (cardiac phase) small FOV Chest CTA Ax 3x3 soft Chest CTA Cor 3x3 soft Chest CTA Sag 3x3 soft Chest CTA Ax MIP 10x1 On trigger card check: If range 70-80% then phase start 75%. If range 30-80% then phase start 70%. If range 30-50% then phase start 40%. MUST change phase start for all reconstructions. Runoff I- Ax 3x3 soft Runoff I- Ax 1x0.8 soft Runoff I- Ax 3x3 soft Runoff I- Ax 1x0.8 soft Chest CTA Ax 3x3 (cardiac phase) soft Chest CTA Cor 3x3 (cardiac phase) soft Chest CTA Sag 3x3 (cardiac phase) soft Chest CTA Ax 1x0.8 (cardiac phase) soft On trigger card check: If range 70-80% then phase start 75%. If range 30-80% then phase start 70%. If range 30-50% then phase start 40%. MUST change phase start for all reconstructions. Chest CTA Ax 3x3 (cardiac phase) soft Chest CTA Cor 3x3 (cardiac phase) soft Chest CTA Sag 3x3 (cardiac phase) soft Chest CTA Ax 1x0.8 (cardiac phase) soft On trigger card check: If range 70-80% then phase start 75%. If range 30-80% then phase start 70%. If range 30-50% then phase start 40%. MUST Runoff CTA Ax 3x3 soft Runoff CTA Cor 3x3 soft Runoff CTA Sag 3x3 soft Runoff CTA Ax 1x0.8 soft Runoff CTA Cor MIP 8x2 mm Runoff CTA Sag MIP 8x2 mm Rt knee down CTA Ax 0.5x0.5 soft small FOV Lt knee down CTA Ax 0.5x0.5 soft small FOV Runoff CTA Ax 3x3 soft Runoff CTA Cor 3x3 soft Runoff CTA Sag 3x3 soft Runoff CTA Ax 1x0.8 soft Runoff CTA Cor MIP 8x2 mm Runoff CTA Sag MIP 8x2 mm Rt knee down CTA Ax 0.5x0.5 soft small FOV Lt knee down CTA Ax 0.5x0.5 soft small FOV Abd Pel CTA Ax 3x3 soft Abd Pel CTA Cor 3x3 soft Abd Pel CTA Sag 3x3 soft Abd Pel CTA Ax 1x0.8 soft Runoff delay Ax 3x3 soft Runoff delay Ax 1x0.8 soft Runoff delay Cor MIP 8x2 mm Runoff delay Sag MIP 8x2 mm Rt knee down delay Ax 0.5x0.5 soft small FOV Lt knee down delay Ax Runoff delay Ax 3x3 soft Runoff delay Ax 1x0.8 soft Runoff delay Cor MIP 8x2 mm Runoff delay Sag MIP 8x2 mm Rt knee down delay Ax 0.5x0.5 soft small FOV Lt knee down delay Ax Runoff 180s Ax 3x3 soft Runoff 180s Cor 3x3 soft Runoff 180s Sag 3x3 soft Runoff 180s Ax 1x0.8 soft

5 BWH CV Lower Extremity Runoff CTA with CTV {73706} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 125 5mL/sec with saline chaser I-: top of kidneys to toes unless *low risk* then may skip BOLUS TRACKING: L3 CTA top of kidneys to toes at 150 HU with scan time of 30sec (adjust scan time directly or adjust pitch or rotation time). DELAY: Scan Immediately- knee to toes 180s scan top of kidneys to toes BWH CV Mesenteric CTA with CTV {74174} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 5mL/sec with saline chaser I-: none BOLUS TRACKING: A/P. 150 HU in proximal abdominal aorta DELAY: A/P@60s and A/P@90s BWH CV TAVR protocol {71275;74174} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 100mL use injector preset I-: Ca Score BOLUS TRACKING: Prospectively gated entire R-R interval from carina to base of heart. Trigger ascending 150HU DELAY: Scan immediately full CAP from above head of clavical to femoral head. BWH CV Pelvic Vein Thrombosis CTV Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not {72191} IV: 3mL/sec with saline chaser I-: none BOLUS TRACKING: none DELAY: A/P@100s and A/P@180s BWH CV Pulmonary Vein *Gated* {71275} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR<30 do not administer contrast otherwise IV: 5mL/sec with saline chaser I-: none BOLUS TRACKING: prospective gating with single phase (75% if HR <75, if HR >75 then 40%) from 2 cm above carina to base of heart. Trigger Descending 150 HU DELAY: same scan as BWH CV Pulmonary Vein *Non-Gated* {71275} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR<30 do not administer contrast otherwise IV: 5mL/sec with saline chaser I-: none BOLUS TRACKING: 2 cm above carina to base of heart. Trigger Descending 150 HU DELAY: same scan as Note: **All scan ranges, FOV, and center must be identical! Also same kv must be used for both scans.** BWH CV Renal Arteries CTA {74174} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 5mL/sec with saline chaser I-: none BOLUS TRACKING: celiac to below aortic bifurcation. Trigger proximal abdominal DELAY: none BWH CV Renal Donor {74174} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 5mL/sec with saline chaser I-: Abdomen only BOLUS TRACKING: celiac to below aortic bifurcation DELAY: Abdomen 100 sec then 6 min Runoff I- Ax 3x3 soft Runoff I- Ax 1x0.8 soft Abd Pel CTA Ax 3x3 soft Abd Pel CTA Cor 3x3 soft Abd Pel CTA Sag 3x3 soft Abd Pel CTA Ax 1x0.8 soft Abd Pel CTA Ax MIP 8x2 soft Abd Pel CTA Cor MIP 8x2 soft Ca score 0.5x0.5 (cardiac phase) small FOV Ca score 3x3 (cardiac phase) small FOV Abd Pel 100s Ax 3x3 soft Abd Pel 100s Cor 3x3 soft Abd Pel 100s Sag 3x3 soft Abd Pel 100s Ax 1x0.8 soft Cardiac 0.5x0.5 (cardiac phase) small FOV Cardiac 3x3 (cardiac phase) small FOV Chest Ax 3x3 soft Chest Cor 3x3 soft Chest Sag 3x3 soft Chest Ax MIP 10x1 soft Cardiac 0.5x0.5 small FOV Cardiac 3x3 small FOV Chest Ax 3x3 soft Chest Cor 3x3 soft Chest Sag 3x3 soft Chest Ax MIP 10x1 soft Abd CTA Ax 3x3 soft Abd CTA Cor 3x3 soft Abd CTA Sag 3x3 soft Abd CTA Ax 1x0.8 soft Abd CTA Ax MIP 8x2 soft Abd CTA Cor MIP 8x2 soft Abd I- Ax 3x3 soft Abd I- Cor 3x3 soft Abd I- Sag 3x3 soft Runoff CTA Ax 3x3 soft Runoff CTA Cor 3x3 soft Runoff CTA Sag 3x3 soft Runoff CTA Ax 1x0.8 soft Runoff CTA Cor MIP 8x2 mm Runoff CTA Sag MIP 8x2 mm Rt knee down CTA Ax 0.5x0.5 soft small FOV Lt knee down CTA Ax 0.5x0.5 soft small FOV Abd Pel 60s Ax 3x3 soft Abd Pel 60s Cor 3x3 soft Abd Pel 60s Sag 3x3 soft Abd Pel 60s Ax 1x0.8 soft Cardiac 0.5x0.5 (cardiac phase) small FOV Note: reconstruct every phase of cardiac cycle from 0-95% every 5% Abd Pel 180s Ax 3x3 soft Abd Pel 180s Cor 3x3 soft Abd Pel 180s Sag 3x3 soft Abd Pel 180s Ax 1x0.8 soft Cardiac 60s 0.5x0.5 (cardiac phase) small FOV Cardiac 60s 3x3 (cardiac phase) small FOV Cardiac 60s 0.5x0.5 small FOV Cardiac 60s 3x3 small FOV Abd CTA Ax 3x3 soft Abd CTA Cor 3x3 soft Abd CTA Sag 3x3 soft Abd CTA Ax 1x0.8 soft Abd CTA Ax MIP 8x2 soft Abd CTA Cor MIP 8x2 soft Runoff delay Ax 3x3 soft Runoff delay Ax 1x0.8 soft Runoff delay Cor MIP 8x2 mm Runoff delay Sag MIP 8x2 mm Rt knee down delay Ax 0.5x0.5 soft small FOV Lt knee down delay Ax Abd Pel 90s Ax 3x3 soft Abd Pel 90s Cor 3x3 soft Abd Pel 90s Sag 3x3 soft Abd Pel 90s Ax 1x0.8 soft CAP CTA Ax 3x3 soft CAP CTA Cor 3x3 soft CAP CTA Sag 3x3 soft CAP CTA Ax 1x0.8 soft Chest CTA Ax MIP 10x1 soft (chest only) Abd 100s Ax 3x3 soft Abd 100s Cor 3x3 soft Abd 100s Sag 3x3 soft Abd 100s Ax 1x0.8 soft Runoff 180s Ax 3x3 soft Runoff 180s Cor 3x3 soft Runoff 180s Sag 3x3 soft Runoff 180s Ax 1x0.8 soft Abd Pel 6m Ax 3x3 soft Abd Pel 6m Cor 3x3 soft Abd Pel 6m Sag 3x3 soft Abd Pel 6m Ax 1x0.8 soft BWH CV Renal Recipient {74174} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 5mL/sec with saline chaser I-: A/P BOLUS TRACKING: A/P. Trigger proximal descending 150HU DELAY: 150sec BWH CV Cardiac Function {75572} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not administer contrast otherwise: IV: prescribed by fellow at the scanner (default 5mL/sec) with saline chaser I-: none BOLUS TRACKING: prospective gating of entire R-R interval or retrospective gating carina to base of heart DELAY: none BWH NEW CV Cardiac Mass {75572} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not administer contrast otherwise: IV: prescribed by fellow at the scanner (default 5mL/sec) with saline chaser I-: prospective gating with single phase (75% if HR <75, if HR >75 then 40%) carina to base of heart BOLUS TRACKING: prospective gating of entire R-R interval or retrospective gating carina to base of heart DELAY: prospective gating with single phase (75% if HR <75, if HR >75 then 40%) carina to base of heart Note: **All scan ranges, FOV, and center must be identical! Also same kv must be used for all scans.** Abd I- Ax 3x3 soft Abd I- Cor 3x3 soft Abd I- Sag 3x3 soft Cardiac 0.5x0.5 (cardiac phase) small FOV Note: reconstruct every phase of cardiac cycle from 0-95% every 5% Cardiac 3x3 (cardiac phase) small FOV Chest Ax 3x3 soft Chest Cor 3x3 soft Chest Sag 3x3 soft Chest Ax MIP 10x1 soft Ca score 0.5x0.5 (cardiac phase) small FOV Ca score 3x3 (cardiac phase) small FOV Chest I- Ax 3x3 soft Chest I- Cor 3x3 soft Chest I- Sag 3x3 soft Chest I- Ax MIP 10x1 soft Abd Pel CTA Ax 3x3 soft Abd Pel CTA Cor 3x3 soft Abd Pel CTA Sag 3x3 soft Abd Pel CTA Ax 1x0.8 soft Abd Pel CTA Ax MIP 8x2 soft Abd Pel CTA Cor MIP 8x2 soft Cardiac 0.5x0.5 (cardiac phase) small FOV Note: reconstruct every phase of cardiac cycle from 0-95% every 5% Cardiac 3x3 (cardiac phase) small FOV Chest Ax 3x3 soft Chest Cor 3x3 soft Chest Sag 3x3 soft Abd Pel 150s Ax 3x3 soft Abd Pel 150s Cor 3x3 soft Abd Pel 150s Sag 3x3 soft Abd Pel 150s Ax 1x0.8 soft Cardiac 60s 0.5x0.5 (cardiac phase) small FOV Cardiac 60s 3x3 (cardiac phase) small FOV BWH CV SGAP/PAP Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 5mL/sec with saline chaser Patient position: PRONE Scan direction: Top down I-: none BOLUS TRACKING: umbilicus to knees. Trigger above aortic 150 HU. BWH CV TAA, Post-op Stentgraft/Extravasation {71275} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 5mL/sec with saline chaser I-: non-gated chest though bottom of stent if stent extends into abdomen BOLUS TRACKING: non-gated chest though bottom of stent if stent extends into abdomen. Trigger descending 150HU BWH CV TAA, Pre-op Stent-graft {72175} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: 5mL/sec with saline chaser I-: non-gated chest BOLUS TRACKING: non-gated chest. Trigger descending 150HU DELAY: none BWH CV Upper Extremity Runoff CTA with CTV {73202} Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: inject unaffected arm with 5mL/s with saline chaser PATIENT POSITION: place affected arm above the head I-: none BOLUS TRACKING: arch thru fingers. Trigger 150HU with scan time of 15sec (adjust scan time directly or adjust pitch or rotation time). DELAY: Scan Immediately. Antecubital through fingers. NEW CV Thoracic Outlet CTA with CTV "Administer prescribed intravenous iodinated contrast agent per the following instructions: If GFR <30 do not IV: opposite the affected arm; 5mL/sec with saline chaser; split dose in 1/2 for two injections Patient position: 1st injection=both arms down 2nd injection=affected arm up PHASES: I-: none BOLUS TRACKING: non-gated from bottom of mandible to mid chest. Trigger 150HU 100sec non-gated from bottom of mandible to mid chest Abd-knee CTA Ax 3x3 soft Abd-knee CTA Cor 3x3 soft Abd-knee CTA Sag 3x3 soft Abd-knee CTA Ax 1x0.8 soft Abd-knee CTA Ax MIP 16x2 soft Abd-knee CTA Cor MIP 16x2 soft Chest I- Ax 3x3 soft Chest I- Cor 3x3 soft Chest I- Sag 3x3 soft Chest I- Ax 1x0.8 soft Chest I- Ax MIP 10x1 soft Chest I- Ax 3x3 soft Chest I- Cor 3x3 soft Chest I- Sag 3x3 soft Chest I- Ax 1x0.8 soft Chest I- Ax MIP 10x1 soft UpExt CTA Ax 3x3 soft UpExt CTA Ax 1x0.8 soft UpExt CTA Cor MIP 8x2 mm (relative to patient's arm) UpExt CTA Sag MIP 8x2 mm (relative to patient's arm) UpExt CTA Ax 0.5x0.5 soft small FOV (relative to patient's arm) Chest CTA Ax 3x3 soft Chest CTA Cor 3x3 soft Chest CTA Sag 3x3 soft Chest CTA Ax 1x0.8 soft Chest CTA Ax 3x3 soft Chest CTA Cor 3x3 soft Chest CTA Sag 3x3 soft Chest CTA Ax 1x0.8 soft Chest CTA Ax 3x3 soft Chest CTA Cor 3x3 soft Chest CTA Sag 3x3 soft Chest CTA Ax 1x0.8 soft UpExt delay Ax 3x3 soft UpExt delay Ax 1x0.8 soft UpExt delay Cor MIP 8x2 mm (relative to patient's arm) UpExt delay Sag MIP 8x2 mm (relative to patient's arm) UpExt delay Ax 0.5x0.5 soft small FOV (relative to Chest 100s Ax 3x3 soft Chest 100s Cor 3x3 soft Chest 100s Sag 3x3 soft Chest 100s Ax 1x0.8 soft Chest 70s Ax 3x3 soft Chest 70s Cor 3x3 soft Chest 70s Sag 3x3 soft Chest 70s Ax 1x0.8 soft Chest Arm Up CTA Ax 3x3 soft Chest Arm Up CTA Cor 3x3 soft Chest Arm Up CTA Sag 3x3 soft Chest Arm Up CTA Ax 1x0.8 soft Chest Arm Up 100s Ax 3x3 soft Chest Arm Up 100s Cor 3x3 soft Chest Arm Up 100s Sag 3x3 soft Chest Arm Up 100s Ax 1x0.8 soft

6 Dictation Templates

7 CT vs. MRI

8 Advanced Post-processing Protocols Aortic measurements Vascular mapping ( TAVR, Stent-graft ) Renal Donor DIEP

9 Aorta CTA Main clinical indications dissection aneurysm Patients generally come to our service for follow-up and to evaluate the aorta post-repair. Image post-processing: You are expected to generate and permanently archive doubleoblique short axis views of the aorta using the 3D software. Measurements include the maximum short-axis dimension (if aneurysmal then include both max and min diameters). Images will be sent to PACS after approval of the attending 3D lab will generate 3D VR rotating batch Prior studies: It is essential that we deliver accurate information for follow-up aorta measurements. Careless measurements will not be tolerated. For aneurysm follow-up, generate and permanently archive comparison study measurements if not already on PACS.

10 Aortic Measurements The measurements are obtained at standard levels. Always evaluate the images first to determine the largest segment in each level. Standard levels Sinuses of Valsalva Sinotubular junction Ascending Arch prevascular proximal transverse arch (Brachiocephalic Left common carotid) Aortic isthmus Descending Aortic hiatus Proximal abdominal Juxtarenal Infrarenal Common iliacs distal transverse arch (Left common carotid Left subclavian) postvascular

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13 Vascular Mapping This study is performed for percutaneous Transcatheter Aortic Valve Implantation. Preprocedure CT is required in these patients to ensure that the catheter system can be safely introduced from the groin to the heart. The referring clinicians want the thin section data from the distal abdominal aorta through both femoral arteries. This is to be loaded into Vitrea web and stored so that all automated measurements can be viewed by scrolling through the vessels. Make sure that the saved state is correct so that it can be accessed remotely in the cath lab.

14 AAA, Pre-op Stent-graft When the AAA reaches the size criteria to consider EVAR this protocol is used. I- for calcification CTA for vascular mapping of the aneurysm 3D Lab performs vascular mapping of the aneurysm

15 TAVR Aortobifemoral segmentation: -Use aortic stent planning preset -crop the segmentation at the bottom of the femoral head -hit the space bar to toggle between aorta, right iliac and left iliac -correct the lumen segmentation from distal aorta to common femoral -save a snapshot for each side so that the surgeons can easily restore it -create rotating batch 3DVR of the vessels with the base semitransparent. This helps with the visualization of vessel tortuosity. Aortic root segmentation: -perform multiphase recons of the aortic root and send to APPISERVER and PACS -short axis MPR of the aortic root with measurements in the longest and shortest diameter, mean diameter and ROI for circumference coronary ostia heights leaflet lengths gantry angles Images on PACS: 1. 3DVR rotating 360 aortobifemoral segmentation using vessels with calcification preset and semitransparent base 2. Annulus measurements

16 TAVR (

17 Renal donor CT The screening for renal donors required mapping of the arteries and veins. Our transplant surgeons use a percutaneous nephrectomy approach, so the absolute number and dimensions of the vessels is critical. -load the thin slice CTA images -use the renal CTA preset -segment the volume leaving only the renal arteries, kidneys and aorta -create rotating 3DVR batch 360* -segment each renal artery using the vessel probe tool -perform measurement from the renal ostium to the birfucation -label image and take snapshot -segment each renal vein -for renal vein segmentation the centerline needs to be performed manually -perform distance measurements from the IVC to the renal vein confluence -perform measurement from the IVC to the left gonadal vein -perform measurement from the IVC to the left adrenal vein *note: if the the gonadal vein and adrenal vein are not visualized on this series then use the 100 sec volume -load the delayed series -perform urogram segmentation and create 3DVR rotation 360* batch -use this series to perform long axis measurements of each kidney Images on PACS 1. 3DVR rotating 360* of CTA 2. cmpr of each left and right renal artery with measurement from ostium to bifurcation 3. cmpr of each renal vein from IVC to confluence 4. cmpr of left renal vein from IVC to left gonadal vein 5. cmpr of left renal vein from IVC to left adrenal vein 6. 3DVR urogram rotating 360* 7. long axis measurements of each kidney from delayed series

18 Renal donor CT

19 Renal donor CT (

20 DIEP CTA Deep Inferior Epigastric Artery Perforator This study is designed to image abdominal wall vessels for planning a free flap breast reconstruction in patients with breast cancer. Segmentation of the skin Create MIP and 3DVR of anterior abdominal wall Measure distance of DIEPs to umbilicus and send snapshots to PACS

21 Other Vascular Protocols

22 Renal artery stenosis Patients typically are being worked up for hypertension. If there is a lesion, it should be profiled with a MPR, MIP, or both. All images need to be sent to PACS and verified. Load the thin images to Vitrea and do reformations. Both CT and MR can be used. For CT, normal studies may not require additional post-processing findings such as high grade stenosis/occlusion may be processed by loading the thin section data into Vitrea MR studies will have subtracted angiography and 3d GRE; the later of which can be reformatted by the technologists if needed.

23 Mesenteric Imaging Main indications ischemia aneurysm follow-up Both CT and MR can be used. For CT, normal studies may not require additional post-processing findings such as high grade stenosis/occlusion may be processed by loading the thin section data into Vitrea MR studies will have subtracted angiography and 3d GRE; the later of which can be reformatted by the technologists if needed.

24 Multiphase scanning post-op stent/bleeding runoff

25 AAA, Post-op Stent-graft Surveillance I- for calcification CTA for endoleak 3D Lab performs vascular mapping of the aneurysm 70s scan for delayed endoleak

26 Extravasation Protocol Exactly the same as Post-op Stent-graft I- for hyperdense objects precontrast CTA for pseudoaneurysm/ arterial bleed 70 sec delay for pooling of contrast or venous bleeding

27 Extravasation Protocol

28 CT Runoff Make sure that all the thin images are on PACS. Small FOV series for each leg from above the knee down to the foot in addition to full FOV recon from the top of diaphragm to the knees. 3D Lab will create 3D VR

29 Field of View: 350mm specifies the in-plane reconstruction field of view CT matrix size = 512 x 512, mostly for best resolution, FOV should be optimized for spatial resolution of 170mm the scanner matrix x pixel resolution = FOV eg 512 x 0.35 = 179

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