M.

DINESHKUMAR

s.no PAGE.NO
CONTENT
1 INTRODUCTION
2
COMPUTER TOMOGRAPHY
ANGIOGRAPHY
3 PROTOCAL FOR CAROTID
ANGIOGRAPHY
4
PROTOCAL FOR PULMONARY
ANGIOGRAPHY

1
5
PROTOCAL FOR CORONARY
ANGIOGRAPHY
6 PROTOCAL FOR RENAL
ANGIOGRAPHY

7 PROTOCAL FOR CEREBRUM

ANGIOGRAPHY

8 PROTOCAL FOR PHERIPHERAL

ANGIOGRAPHY
9 CONCULASION

COMPUTED
TOMOGRAPHY

2
INTRODUCTION
• Computed tomography (CT) scanning, also known as
computerised axial tomography scanning, is a diagnostic
imaging procedure that uses X-rays to build cross-sectional
images ("slices") of the body. Cross-sections are
reconstructed from measurements of attenuation coefficients
of X-ray beams in the volume of the object studied.

• CT is based on the fundamental principle that the density of

the tissue passed by the X-ray beam can be measured from
the calculation of the attenuation coefficient. Using this
3
 principle, CT allows the reconstruction of the density of the
body, by two-dimensional section perpendicular to the axis
of the acquisition system.

• There are basically two processes of the absorption: the

photoelectric effect and the Compton effect. This
phenomenon is represented by a single coefficient, In the
particular case of the CT, the emitter of X-rays rotates around
the patient and the detector, placed in diametrically opposite
side, picks up the image of a body section (beam and detector
move in synchrony).

• Unlike X-ray radiography, the detectors of the CT scanner

does not produce an image. They measure the transmission of
a thin beam (1-10mm) of X-rays through a full scan of the
body. The image of that section is taken from different
angles, and this allows to retrieve the information on the
depth (in the third dimension).

• In order to obtain tomographic images of the patient from the

data in "raw" scan, the computer uses complex mathematical
algorithms for image reconstruction.

• If the X-ray at the exit of the tube is made monochromatic or

quasi-monochromatic with the proper filter, one can calculate
the attenuation coefficient corresponding to the volume of
irradiated tissue by the application of the general formula of
absorption of the X-rays in the field.

• The outgoing intensity I(x) of the beam of photons measured

will depend on the location. In fact, I(x) is smaller where the
body is more radio-opaque.

4
• Hounsfield chose a scale that affects the four basic densities,
with the following values:

 Air = -1000
 Fat = -60 to -120
 Water = 0
 Compact bone = +1000

• The image of the section of the object irradiated by the Xray,

is reconstructed from a large number of measurements of
attenuation coefficient. It gathers together all the data coming
from the elementary volumes of material through the
detectors. Using the computer, it presents the elementary
surfaces of the reconstructed image from a projection of the
data matrix reconstruction, the tone depending on the
attenuation coefficients.

• The image by the CT scanner is a digital image and consists

of a square matrix of elements (pixel), each of which
represents a voxel (volume element) of the tissue of the
patient.
• In conclusion, a measurement made by a detector CT is
proportional to the sum of the attenuation coefficients.
• The typical CT image is composed of 512 rows, each of 512
pixels, i.e., a square matrix of 512 x 512 = 262144 pixels
(one for each voxel). In the process of the image, the value of
attenuated coefficient for each voxel corresponding to these
pixel needs to be calculated.

5
 • Each image point is surrounded by a halo-shaped star that
degrades the contrast and blurs the boundary of the object.
To avoid this, the method of filtered back projection is used.
The action of the filter function is such that the negative
value created is the filtered projection, when projected
backwards, is removed, and an image is produced, which is
the accurate representation of the original object.

Non-ionic iodinated contrast media

• Iodinated contrast media is a contrast media containing

iodine that is used in radiography to increase the clarity of
the image. Iodinated contrast media can be divided into the
two groups: ionic and non-ionic. Each group varies in their
uses, properties and toxic effects. In non-ionic iodinated
contrast media the iodine is bound to an organic (non-ionic)
compound OMNIPAQUE 140 contains 302 mg of
iohexolequivalent to 140 mg of organic iodine per mL;
OMNIPAQUE 180 contains 388 mg of iohexolequivalent to
180 mg of organic iodine per mL;

6
  OMNIPAQUE 240 contains 518 mg of iohexolequivalent to 240
mg of organic iodine per mL;
 OMNIPAQUE 300 contains 647 mg of iohexolequivalent to 300
mg of organic iodine per mL; and
 OMNIPAQUE 350 contains 755 mg of iohexol equivalent to 350
mg of organic iodine per mL.
• Each milliliter of iohexol solution contains 1.21 mg
tromethamine and 0.1 mg edetate calcium disodium with the
pH adjusted between 6.8 and 7.7 with hydrochloric acid or
sodium hydroxide.
• All solutions are sterilized by autoclaving and contain no
preservatives. Unused portions must be discarded. Iohexol
solution is sensitive to light and therefore should be protected
from exposure.

Contraindications
7
Contraindications for the use of iodinated contrast media:

• Allergy to iodine
• Toxic goitre of the thyroid
• Planned radioiodine treatment of thyroid cancer.

Contraindications against the use of ion-based contrast media in patients:

 Children below 2 years of age

 Pregnant women
 Persons over 60 years of age
 Persons with complications after the previous administration of a
contrast medium

 Persons with acute and chronic circulatory and respiratory failure

 Persons with hepatic and renal failure (also dialyzed patients)
 Persons with asthma and pulmonary oedemas
 Persons with allergies
 Persons with insulin-dependent diabetes
 Persons with hypertension
 Persons with convulsions of cerebral aetiology
 Persons with glaucoma

8
 Computed tomography angiography

Computed tomography angiography (also called CT angiography or

CTA) is a computed tomography technique used to visualize arterial and
venous vessels throughout the body. Using contrast injected into the
blood vessels, images are created to look for blockages, aneurysms
(dilations of walls), dissections (tearing of walls), and stenosis
(narrowing of vessel). CTA can be used to visualize the vessels of the
heart, the aorta and other large blood vessels, the lungs, the kidneys, the
head and neck, and the arms and legs.

Medical uses
CTA can be used to examine blood vessels in many key areas of the
body including the,

• Brain
• Heart
• Kidneys  Pelvis  The lungs.

Coronary CT angiography
Coronary CT angiography (CCTA) is the use of CT angiography to
assess the arteries of the heart.

The patient receives an intravenous injection of contrast and then the

heart is scanned using a high speed CT scanner. With the advances in
CT technology, patients are typically able to be scanned without needing
medicines by simply holding their breath during the scan.
CTA is used to assess heart or vessel irregularities, location of stents
and whether they are still open, and occasionally to check for
atherosclerotic disease.

9
This method displays the anatomical detail of blood vessels more
precisely than magnetic resonance imaging (MRI) or ultrasound.

Today, many patients can undergo CTA in place of a conventional

catheter angiogram, a minor procedure during which a catheter is passed
through the blood vessels all the way to the heart, however CCTA has
not fully replaced this procedure.

CCTA is able to detect narrowing of blood vessels in time for corrective

therapy to be done.

CCTA is a useful way of screening for arterial disease because it is

safer, much less time-consuming than catheter angiography, and is also a
cost-effective procedure.

Aorta and great arteries

CTA can be used in the chest and abdomen to identify aneurysms in the
aorta or other major blood vessels.

These areas of weakened blood vessel walls that bulge out can
lifethreatening if they rupture.

CTA is the test of choice when assessing aneurysm before and after
endovascular stenting due to the ability to detect calcium within the
wall.

Another positive of CTA in abdominal aortic aneurysm assessment is it

allows for better estimation of blood vessel dilation and can better detect
blood clots as compared to standard angiography.

CTA is used also to identify arterial dissection, including aortic

dissection in the aorta or its major branches.
Arterial dissection is when the layers of the artery wall peel away from
each other; this causes pain and can be life-threatening.

CTA is a quick and non-invasive method of identifying dissections and

can show the extent of the disease and if there is leakage.

10
Pulmonary arteries
CT pulmonary angiogram (CTPA) is used to examine the pulmonary
arteries in the lungs, most commonly to rule out pulmonary embolism
(PE), a serious but treatable condition.

It has become the technique of choice for detection of pulmonary

embolism due to its wide availability, short exam time, ability to see
other diseases that may present like pulmonary embolisms, and a high
degree of confidence in the validity of the test.

In this test, a PE will appear as a dark spot inside the blood vessel or a
sudden stop of the bright contrast material.

CT angiography should not be used to evaluate for pulmonary embolism

when other tests indicate that there is a low probability of a person
having this condition.

A D-dimer assay might be a preferred alternative to test for pulmonary

embolism, and that test and a low clinical prediction score on the Wells
test or Geneva score can exclude pulmonary embolism as a possibility.

Renal arteries

11
Volume rendered CTA of renal arteries in patient with medial
fibromuscular dysplasia.

Visualization of blood flow in the renal arteries (those supplying

the kidneys) in patients with high blood pressure and those
suspected of having kidney disorders can be performed using CTA.

Stenosis (narrowing) of a renal artery is a cause of hypertension (high

blood pressure) in some patients and can be corrected.

A special computerized method of viewing the images makes renal CT

angiography a very accurate examination.

CTA is also used in the assessment of native and transplant renal

arteries. While CTA is great for imaging of the kidneys, it lacks the
ability to perform procedures at the same time.

Thus traditional catheter angiography is used in cases of acute renal

hemorrhage or acute arterial obstruction.

Carotid, vertebral and intracranial vessels

12
CTA of a vascular malformation with intraventricular hemorrhage.

CTA can be used assess acute stroke patients by identifying clots in the
arteries of the brain.

It can also be used to identify small aneurysms or arteriovenous

malformation inside the brain that can be life-threatening.

While CTA can produce high quality images of the carotid arteries for
grading the level of stenosis (narrowing of the vessel), calcium deposits
(calcified plaques) in the area where the vessels split can lead to
interference with accurate stenosis grading.

Because of this, magnetic resonance angiography is used more often for

this purpose.

Peripheral arteries
CTA can be used in the legs to detect atherosclerotic disease that has
narrowed the arteries.
It can also be used to image vessels in suspected blockages, trauma
cases, or patients with surgical complications

13
Vasculature of the Heart:

 The entire body must be supplied with nutrients and oxygen via the
circulatory system and the heart is no exception.
 The coronary circulation refers to the vessels that supply and drain
the heart. Coronary arteries are named as such due to the way they
encircle the heart, much like a crown.

Coronary Arteries
There are two main coronary arteries which branch to supply the entire
heart. They are named the left and right coronary arteries, and arise
from the left and right aortic sinuses within the aorta.
The aortic sinuses are small openings found within the aorta behind the
left and right flaps of the aortic valve. When the heart is relaxed, the
back-flow of blood fills these valve pockets, therefore allowing blood
to enter the coronary arteries.
The left coronary artery (LCA) initially branches to yield the left
anterior descending (LAD), also called the anterior interventricular
artery. The LCA also gives ou the left marginal artery (LMA) and the
left circumflex artery (Cx). In ~2025% of individuals, the left
circumflex artery contributes to the posterior interventricular artery
(PIv).
The right coronary artery (RCA) branches to form the right marginal
artery (RMA) anteriorly. In 80- 85% of individuals, it also branches
into the posterior interventricular artery (PIv) posteriorly.

14
 Anterior view of the arterial supply to the heart.

Overview of the branching structure of the coronary arteries.

15
Cardiac Veins
Blood travels from the subendocardium into the thebesian veins, which
are small tributaries running throughout the myocardium.
These in turn drain into larger veins that empty into the coronary
sinus. The coronary sinus is the main vein of the heart, located on the
posterior surface in the coronary sulcus, which runs between the left
atrium and left ventricle.
The sinus drains into the right atrium. Within the right atrium, the
opening of the coronary sinus is located between the right
atrioventricular orifice and the inferior vena cava orifice.

There are five tributaries which drain into the coronary sinus:

 The great cardiac vein is the main tributary. It originates at the

apex of the heart and follows the anterior interventricular groove
into the coronary sulcus and around the left side of the heart to join
the coronary sinus.

 The small cardiac vein is also located on the anterior surface of

the heart.
This passes around the right side of the heart to join the coronary sinus.
 Another vein which drains the right side of the heart is the middle
cardiac vein. It is located on the posterior surface of the heart.
 The final 2 cardiac veins are also on the posterior surface of the
heart: On the left posterior side is the left marginal vein.
 In the centre is the left posterior ventricular vein which runs
along the posterior interventricular sulcus to join the coronary
sinus.

16
Anterior view of the venous drainage of the heart. Supplied by the great and small
cardiac veins

Posterior view of the heart, showing the venous drainage.

Distribution of the Coronary Arteries:

In general, the area of the heart which an artery passes over will be the
area that it perfuses.
17
The following describes the anatomical course of the coronary arteries.
See Appendix A for a tabular overview of the arterial distribution.

The RCA passes to the right of the pulmonary trunk and runs along the
coronary sulcus before branching.

The right marginal artery arises from the RCA and moves along the right
and inferior border of the heart towards the apex.

The RCA continues to the posterior surface of the heart, still running
along the coronary sulcus. The posterior interventricular artery then
arises from the RCA and follows the posterior interventricular groove
towards the apex of the heart.

The LCA passes between the left side of the pulmonary trunk and the
left auricle. The LCA divides into the anterior interventricular branch
and the circumflex branch.

The anterior interventricular branch (LAD) follows the anterior

interventricular groove towards the apex of the heart where it
continues on the posterior surface to anastomose with the posterior
interventricular branch.

The circumflex branch follows the coronary sulcus to the left border
and onto the posterior surface of the heart. This gives rise to the left
marginal branch which follows the left border of the heart.

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Carotid Arteries
We shall start at the origin of the carotid arteries. The right common
carotid artery arises from a bifurcation of the brachiocephalic trunk
19
(the right subclavian artery is the other branch). This bifurcation occurs
roughly at the level of the right sternoclavicular joint.

The left common carotid artery branches directly from the arch of
aorta. The left and right common carotid arteries ascend up the neck,
lateral to the trachea and the oesophagus. They do not give ou any
branches in the neck.
At the level of the superior margin of the thyroid cartilage (C4), the
carotid arteries split into the external and internal carotid arteries. This
bifurcation occurs in an anatomical area known as the carotid triangle.
The common carotid and internal carotid are slightly dilated here, this
area is known as the carotid sinus, and is important in detecting and
regulating blood pressure.

Origin of the blood vessels of the upper limb. Note how the left common
carotid and subclavian arteries arise directly from the arch of aorta.

20
 Lateral vein of the neck, showing the origin and bifurcation of the
common carotid artery.

External Carotid Artery

The external carotid artery supplies the areas of the head and neck
external to the cranium. After arising from the common carotid artery,
it travels up the neck, posterior to the mandibular neck and anterior to
the lobule of the ear.
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The artery ends within the parotid gland, by dividing into the
superficial temporal artery and the maxillary artery.
Before terminating, the external carotid artery gives our six branches:
• Superior thyroid artery
• Lingual artery
• Facial artery
• Ascending pharyngeal artery Occipital artery
• Posterior auricular artery
The facial, maxillary and superficial temporal arteries are the major
branches of note. The maxillary artery supplies the deep structures of
the face, while the facial and superficial temporal arteries generally
supply superficial areas of the face.

Blood supply to the superficial structures of the face. Note the maxillary artery before it
disappears into the pterygopalatine fossa, to supply the deep structures of the face.

22
 Lateral view of the skull, showing the path of the meningeal arteries. Note
the pterion, a weak point of the skull, where the anterior middle meningeal
artery is at risk of damage.

Internal Carotid Artery

The internal carotid arteries do not supply any structures in the neck,
entering the cranial cavity via the carotid canal in the petrous part of the
temporal bone.

Within the cranial cavity, the internal carotid artery supplies:

 The brain
 Eyes
 Forehead

Vertebral Arteries
 The right and left vertebral
arteries arise from the subclavian
arteries, medial to the anterior
scalene muscle.
 They then ascend up the posterior
side of the neck, through holes in
the transverse processes of the
cervical vertebrae, known as
foramen transversarium.
 The vertebral arteries enter the
cranial cavity via the foramen
23
 magnum, and converge. They then give rise to the basilar
arteries, which supply the brain.
 The vertebral arteries supply no branches to the neck, or
extracranial structures.

Other Arteries of the Neck

 The neck is supplied by arteries other than the carotids. The right
and left subclavian arteries give rise to the thyrocervical trunk.
From this trunk,several vessels arise, which go on to supply the
neck.

 The first branch of the thyrocervical trunk is the inferior thyroid

artery. It supplies the thyroid glandThe ascending cervical
artery arises from the inferior thyroid artery, as it turns medially
in the neck. This vessel supplies the posterior
prevertebralmuscles.

 The transverse cervical artery is the next branch o_ the

thyrocervical trunk. It crosses the base of the carotid triangle, and
supplies the trapezius andrhomboid muscles.

 Lastly, the suprascapular artery arises. It supplies the posterior

shoulder area.

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 ANATOMY OF PULMONARY ARTERY

Introduction
The primary pulmonary circulation comprising of the pulmonary arterial
tree, extensive capillary bed and pulmonary venous tree, connected in
series is a low pressure, high capacitance system which provides large
surface area for gas exchange. The bronchial circulation which provides
nutrients to the lungs is a low capacitance, high pressure system and
normally does not participate in blood oxygenation.

Pulmonary arterial system

The main pulmonary artery arises from the right ventricular outflow tract
and courses posteriorly and superiorly to the left of and posterior to the
aorta (1). Below the aortic arch, it bifurcates into right and left main
pulmonary arteries at the level of the carina. The right and left
pulmonary arteries divide into 2 lobar branches each, and subsequently
into segmental and sub segmental branches. Segmental and sub
segmental pulmonary arteries generally parallel segmental and sub
segmental bronchi and are named according to the bronchopulmonary
segments that they feed (Figure 1).

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• The bronchopulmonary segment is a functionally and anatomically
discrete portion of lung supplied by its own segmental bronchus
and artery.
• The right lung has 3 lobes divided into 10 segments: the right
upper lobe has apical, posterior and anterior segments, middle lobe
has medial and lateral segments and the lower lobe has superior
(apical) and 4 basal segments (anterior, medial, posterior and
lateral).
• The left lung has 8 segments with the left upper lobe apical and
posterior segments supplied by a common segmental bronchus and
the left lower lobe anterior and medial segments supplied by a
common segmental bronchus; the left upper lobe has
apicoposterior and anterior segments, lingula has superior and
inferior segments and the lower lobe has superior (apical) and 3
basal segments (anteromedial, posterior and lateral)
• The root of the lungs where the pulmonary arteries and bronchi
enter and pulmonary veins leave the lungs, is referred to as the
pulmonary hilum.
• The relationship of the pulmonary artery, main stem bronchus, and
pulmonary veins at the hilum is well defined and constant (3).

26
 • The left hilum is higher than the right in 97% of individuals. There
is however great variation in the segmental and sub segmental
arterial pattern.

Right pulmonary artery

The right pulmonary artery is within the pericardium for more than
three-fourths of its length and runs horizontally to the right behind the
ascending aorta and superior vena cava. As it leaves the pericardium, it
lies anterior and inferior to the right main stem bronchus. After the
origin of its first branch, the truncus anterior, the interlobar pulmonary
artery runs inferiorly between the bronchus intermedius posteriorly and
the superior pulmonary vein anteriorly. It turns posteriorly behind the
origin of the middle lobe bronchus, continues as the common basal trunk
and terminates in branches to the basal segments. The truncus anterior
supplies the right upper lobe; and the interlobar artery, which runs in the
interlobar fissure, supplies the right middle and right lower lobes.

Segmental arteries of right upper lobe

• In the most common arterial pattern there is a single, high anterior
trunk or truncus anterior supplying the apical and anterior
segments and a single ascending branch supplying the posterior
segment.
• Other common variants include trifurcation of the truncus anterior
to supply the apical, anterior and posterior segments and 2 separate
branches to the posterior segment.
• Occasionally there may be segmental supply to the upper lobe from
the middle lobe or superior segmental right lower lobe artery.

27
Segmental arteries of right middle lobe
• The middle lobe segmental arteries arise from the anteromedial
aspect of the right interlobar artery as it courses anterior to the
bronchus intermedius.
• There may be separate or common origin of the arteries to the
medial and lateral segments of the middle lobe.

Segmental arteries of right lower lobe

• Typically, the superior segment of the right lower lobe receives one
segmental artery, arising posteriorly from the interlobar artery,
following which the common basal trunk divides into 2 terminal
branches which subsequently divide to supply the medial basal,
posterior basal, lateral basal and anterior basal segments.
• In up to 70% of cases, the second branch of right lower lobar artery
is the medial basal branch. Occasionally there may be 2 separate
branches to the apical segment.

Left pulmonary artery

• The left pulmonary artery passes inferiorly and posteriorly and

exits the pericardium below the aortic arch at the ligamentum
arteriosum.
• It arches over and behind the left mainstem bronchus and curves
around three-fourths of the circumference of the left upper lobe
bronchus.
• The left main pulmonary artery has a long extra pericardial length
before giving off its first branch. It continues as the common basal
trunk and terminates in branches to the basal segments.

Segmental arteries of left upper lobe

• Anatomic variations on the left are far more common than on the
right.
28
 • Number of pulmonary arterial branches to the left upper lobe vary
from 2 to 7. Most commonly, the apicoposterior and anterior
segments receive blood supply from an apicoanterior trunk.
• In some cases, the arteries for apical, anterior and posterior
segments originate separately. In 80% of cases, lingula is supplied
by one branch of the pulmonary artery, which gives off arteries for
superior and inferior segments.

Segmental arteries of left lower lobe

• In most cases, there is a single superior segmental artery after
which the pulmonary artery is referred to as “basal part”.
• It then divides into two terminal divisions which branch into
segmental and subsegmental branches supplying the antero-medial,
posterior and lateral basal segments.

Pulmonary capillary bed

• The pulmonary arterial tree subdivides rapidly and branches into

pulmonary capillaries, which form a dense web in the alveolar
wall, increasing the maximum surface area available for
gasexchange.
• In addition to pulmonary arterial branches running alongside a
bronchus there are “supernumerary” arteries which leave the axial
branches at irregular but frequent intervals to enter the lung
parenchyma, resulting in the pulmonary arterial tree having many
more branches than the bronchial tree.

• Due to thin walls and smaller amount of smooth muscle, the

pulmonary capillaries are more distensible and compressible than
systemic vessels and offer much less resistance to blood flow.
Following gas exchange in the capillary beds oxygenated blood is
returned to the heart by pulmonary veins.
29
Pulmonary veins

• Typically, there are four pulmonary veins with superior and

inferior pulmonary veins on either side, draining into the left
atrium.
• The distal segments of the pulmonary veins are intrapericardial.
• The right superior vein drains the right upper lobe and right middle
lobe, right inferior vein drains the right lower lobe; left superior
vein drains the left upper lobe and lingula and left inferior vein
drains the left lower lobe.
• They enter the mediastinum below and anterior to the pulmonary
arteries. The ostia of the inferior pulmonary veins are more
posterior and medial than those of the superior pulmonary veins,
and the ostia of the left pulmonary veins are located higher than
those of the right pulmonary veins.
• In both hilae the superior pulmonary vein is the most anterior
structure and the inferior pulmonary vein is the most inferior
structure.
• The parenchymal pulmonary vein branches, run within interlobular
septa and do not parallel the segmental or sub segmental
pulmonary artery branches and bronchi.
• There may be anomalous drainage into the left atrium or systemic
veins. On the left side there may be convergence of the left
pulmonary veins into a short or long common trunk that drains into
the left atrium.
• Anatomic variants on the right side are less common and include
accessory veins such as accessory right middle or upper pulmonary
veins draining independently into the left atrium

30
Figure2

Diagrams illustrating typical and variant pulmonary venous anatomy.

(A) Typical; (B) short common left trunk; (C) long common left trunk;
(D) right middle pulm
onary vein; (E) two right middle pulmonary veins;
(F) right middle pulmonary vein and right upper pulmonary vein.

Figure 3

31
Pulmonary venous anatomy on cardiac CT.

RSPV, right superior pulmonary vein;

RIPV, right inferior pulmonary vein;

LSPV, left superior pulmonary vein;

LIPV, left inferior pulmonary vein;

LA, left atrium;

Figure 4

Delayed image on catheter angiography demonstrating pulmonary veins draining

into the LA.

1, right superior pulmonary vein;

32
2, middle pulmonary vein (anatomic variant);

3, right inferior pulmonary vein;

4, left superior pulmonary vein;

5, left inferior pulmonary vein; LA, left atrium.

Partial anomalous pulmonary venous return (PAPVR) into a systemic

vein produces a left to right shunt. On the right side an anomalous
pulmonary vein may drain into the superior vena cava, azygos vein,
coronary sinus, or inferior vena cava. In left-sided PAPVR left upper
lobe pulmonary veins form a vertical vein that joins the left
brachiocephalic vein or the coronary sinus

Bronchial arteries

• Most commonly, there are 3 bronchial arteries, 2 on the left side

and 1 on the right side arising from the anterolateral aspect of the
descending aorta or from intercostal arteries located within 2 to 3
cm distal to the left subclavian artery.
• They form a rich anastomotic network with the pulmonary arterial
circulation at the level of the lobar or segmental bronchi.
• A substantial portion of bronchial venous blood enters the
pulmonary veins .

PROTOCAL FOR CAROTID ANGIOGRAPHY

INDICATIONS
33
Demonstration of:
 Suspected occlusion of the carotid arteries, their aneurysms,
dissection and preoperatively in the head and neck tumors to
detect the origin of their feeding vessels for the purpose of
ligation.

PATIENT POSITION:
 Head first, supine with arms by the side of the trunk with hands
tucked under the hips.
TOPOGRAM POSITION:
 Lateral; level of the forehead.
MODE OF SCANNING:
 Helical with single breathhold technique.
SCAN ORIENTATION:
 Craniocaudal
• Starting Location: Arch of the aorta.
• End Location: 2-3 cm above the sella .
GANTRY TILT:
 Nil
FILED OF VIEW:
 Just fitting the region of interest.

CONTRAST ADMINISTRATION:
 Intravenous monophasic.

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VOLUME OF CONTRAST:
 100-120mL.
RATE OF INJECTION OF CONTRAST
 4-5ml/sec
SCAN DELAY:
 10-15sec.
SLICE THICKNESS IN RECONSTRUCTION:
 1.0- 1.5mm
SLICE INTERVAL IN RECONSTRUCTION:
 0.5-0.75mm.

RECONSTRUCTION ALGORITHM/ KERNAL:

 Smooth.

3 D-RECONSTRUCTIONS:
 MIP
 VRT(preferably after bone subtraction) COMMENTS:
 Remove all artifacts from the ear, nose and neck. Remove the
dental prostheses as well.
 During positing, the neck should be in neutral position.
 The patient should be instructed to avoid swallowing movements.
 Use of bolus tracking method is preferred to fine out the optimal
scan delay.
 Criteria of good image quality:
• Absence of gross motion and swallowing artifacts.
• Absence of the streak artifacts.

35
 • Good opacification of the carotid arteries( attenuation
values of greater than 100HU) and minimal opacification
of the jugular veins.

CASE STUDY:

CT angiograms (25 ml Iomeprol 400) of the supraaortic, cervical, and intracranial

vessels of a 67-year-old patient with left carotid artery pseudoocclusion. Note the
distribution of calcified plaques along the aortic arch and the common carotid
bifurcation, and an additional 50% stenosis of the left subclavian artery

36
(a). Eccentricity of plaques is commonly found along the carotid bifurcation

(b). The pseudoocclusion of the left internal carotid artery is caused almost
entirely by noncalcified plaques

(c). A high level of luminal detail regarding the internal carotid artery and external
carotid artery branches is evident without venous overlap

PROTOCAL FOR PULMONARY ANGIOGRAPHY

INDICATIONS
Demonstration of:
 Pulmonary thromboembolism, AV malformation, preoperative
evaluation of the pulmonary vasculature for the feeding arteries
and draining veins in case of pulmonary masses, pulmonary
sequestration

PATIENT POSITION:
 Head first, supine with arms elevated above the level of head.
TOPOGRAM POSITION:
 Anteroposterior ; 1inch below the level of the chin to umbilicus.
MODE OF SCANNING:
 Helical with single breath hold technique.
SCAN ORIENTATION:
 Caudocranial
• Starting Location: The domes of the diaphragm.
• End Location: 2cm above the aortic arch .
37
GANTRY TILT:
 Nil
FILED OF VIEW:
 Medial two third of the lung fields.

CONTRAST ADMINISTRATION:
 Intravenous.

VOLUME OF CONTRAST:
 100-150mL.
RATE OF INJECTION OF CONTRAST
 3-4ml/sec
SCAN DELAY:
 Bolus tracking method is preferred for finding the delay or on
average 15-20sec can be used.
SLICE THICKNESS IN RECONSTRUCTION:
 Thinnest available in the scanner (0.5-1mm)
SLICE INTERVAL IN RECONSTRUCTION:
 0.25-0.5mm.

RECONSTRUCTION ALGORITHM/ KERNAL:

 Medium Smooth, Sharp.

3 D-RECONSTRUCTIONS:

 MPR
 MIP
 VRT

38
  Virtual angioscopy, if needed

COMMENTS:
 Bolus tracking for a test bolus 15ml of the contrast is injected at the
rate of 3-4ml/sec; 5mm sections beginning after 4sec of the initial
bolus acquired every 2sec at the level of the main pulmonary artery
for a total of 10images. Time density curve is generated and
appropriate delay with 2-4sec added to the time of peak
enhancement. In normal right sided circulation, this is 15-20 sec.
 FOV in diagnosed cases of AVM and mass lesions can be limited
to the region of interest.
 Criteria of good image quality:
• Absence of motion artifacts and respiratory misregistration.
• High level of arterial opacification greater than 200 HU in
central pulmonary artery with well opacified main lober and
segmental arteries of all lobes.

CASE STUDY:
Purpose Computed Tomography Pulmonary Angiography (CTPA) is a
very frequent examination used to investigate unexplained chest pain in
39
an attempt to detect embolic clots. When present, they appear as filling
defects (dark) in the opacified pulmonary arteries (white).
NAME: D.PRABAKARAN

AGE/SEX: 35/Male
HISTORY: Chest pain

Figure: Pulmonary embolus in right interlobar artery

PROTOCAL FOR CORONARY ANGIOGRAPHY
INDICATIONS
Demonstration of:
 Screening and evaluation of the coronary arteries.

PATIENT POSITION:
 Head first, supine with arms elevated above the level of head.
TOPOGRAM POSITION:
40
  Anteroposterior ; 1inch below the level of the chin to umbilicus.
MODE OF SCANNING:
 Helical with retrospective gating.
SCAN ORIENTATION:
 Craniocaudal
• Starting Location: level of the arch of the
aorta.
• End Location: lower limit of the cardiac
shadow in the topogram GANTRY TILT:
 Nil
FILED OF VIEW:
 Just fitting to the cardiac shadow.

CONTRAST ADMINISTRATION:
 Intravenous.

VOLUME OF CONTRAST:
 100-140mL.
RATE OF INJECTION OF CONTRAST
 4-5ml/sec
SCAN DELAY:
 Test bolus+ 6sec.
SLICE THICKNESS IN RECONSTRUCTION:
 0.75-1mm
SLICE INTERVAL IN RECONSTRUCTION:
 0.4-0.5mm.
41
RECONSTRUCTION ALGORITHM/ KERNAL:

 Medium Smooth, very smooth

RECONSTRUCTION IN CARDIAC PHASE (%R-R interval).

 40-80% at 5%interval

3 D-RECONSTRUCTIONS:

 MPR
 MIP
 VRT
 Virtual angioscopy

COMMENTS:
 3-D mapping is required for optimum visualization of coronary
arteries (combination of MIP and VRT).
 4-D images are routinely reviewed to get the best sequence for a
particular coronary artery.
 The optimal heart rate for cardiac CT is 60-68 beats per minute and
a betablocker may be required to achieve the same. For a lower
heart rate (<50 beats per minute), a higher rotation time may be
used.

42
CASE STUDY:
 Left Anterior Descending Stenosis Proximal left anterior
descending stenosis in a 72-year-old patient, diagnosed by
invasive coronary angiography (ICA)

(A) is correctly depicted by computed tomography angiography (CTA)

with volume-rendered(B) and curved multiplanar reconstruction with
(C) and without (D) model-based iterative reconstruction (MBIR).

 Body mass index was 34 kg/m2, and the radiation dose from CTA
was 0.37 mSv.

43
CASE STUDY:
Normal Coronary Arteries Illustration of normal coronary arteries in a
53-year-old patient (body mass index 17 kg/m2) by CTA with 0.19
mSv. Images without MBIR:

left anterior descending, (B) left circumflex, and (C) right coronary
artery. Images with MBIR: (D) left anterior
descending, (E) left circumflex, and (F) right coronary artery. (G)
Three-dimensional volume-rendered computed tomography
image. (H and I) ICA confirming normal left and right coronary

44
PROTOCAL FOR RENAL ANGIOGRAPHY

INDICATIONS:
Demonstration of:
 Screening and evaluation of the renal masses and their
differential diagnosis.

PATIENT POSITION:
 Head first, supine with arms elevated above the level of head.
TOPOGRAM POSITION:
 Anteroposterior ; Level of the Nipples to highest point on the
Illiac crest.
MODE OF SCANNING:
 Helical with single breath hold technique.
SCAN ORIENTATION:
 Craniocaudal
• Starting Location: Highest point of the iallaic crest.
• End Location: 1cm above highest point on the dome of
diaphragm
GANTRY TILT:
 Nil
FILED OF VIEW:
 Just fitting to the abdominal wall.

CONTRAST ADMINISTRATION:
 Oral,rectal and Intravenous biphasic .

45
VOLUME OF CONTRAST:
 750-1000mL of 1-2% positive contrast orally; 500-700 mL of
1-2% positive contrast Rectally; 60-100mL of contrast
intravenous.
RATE OF INJECTION OF CONTRAST
 2-3ml/sec
SCAN DELAY:
 35-45sec for the nephorgraphic phase and 60-80 sec for
excretory phase.
SLICE THICKNESS IN RECONSTRUCTION:
 3-5mm
SLICE INTERVAL IN RECONSTRUCTION:
 1.5-2.5mm.

RECONSTRUCTION ALGORITHM/ KERNAL:

 Medium Smooth, very smooth

3 D-RECONSTRUCTIONS:
 MPR
 MIP

COMMENTS:.

46
  In this study ,a test bolous scan series is taken prior to the
main scan to find out the optimal time for nephorgraphic and
excretory phase of kidney .
 This is achieved after adminbistring 20ml of intravenous
contrast ans scanning kidney after the delay of 35-45sec.
 In case of the pelvic tumours and additional scan may be
taken in the region of interest at approximately 120-180sec .

Criteria of Good Quality:

Absence of gross motion artefacts and respiratory
misregistration.
Good vascular opacification including renal vein and
inferior vena cava.
Appropriate Nephrograpic and Excretory phase.

CASE STUDY:

A 67 YRS old man with a history of coronary artery

disease,dibetes mellitus type2, hypertension,hyperlipidemai and renal
insufficiency.

The advantages of CT include being able to image patients with

renal artery stents and detecting in stent stenosis.

47
 FUTURE ;1 and 2.

FUTURE: 1 and 2 shows Renal artery stenosis of the patient.

PROTOCAL FOR CONTRAST CEREBRUM

ANGIOGRAPHY:

INDICATIONS:
Detection ,exclusion or follow up of the intracranial space
occupying lesions including tumors ,abscesses, etc

Demonstration of:
 Screening and evaluation of the cerebral arteries.
PATIENT POSITION:

 Head first, supine with arms elevated above the level of head.
48
TOPOGRAM POSITION:

 Lateral: 2-3 cm above the vertex

MODE OF SCANNING:

 Helical with single breath hold technique.

SCAN ORIENTATION:
 Craniocaudal
• Starting Location: Level of the occipital squame
• End Location: Level of the vertex

GANTRY TILT:
 As many degrees as required to make the scanning plane
parallel to the canthomeatal line

FILED OF VIEW:
 Just fitting to the skull including the soft tissue.

CONTRAST ADMINISTRATION:
 intravenous

VOLUME OF CONTRAST:
 60-80 ml

49
RATE OF INJECTION OF CONTRAST
 2-3ml/sec

SCAN DELAY:
 35-45 sec
SLICE THICKNESS IN RECONSTRUCTION:
 3-5mm
SLICE INTERVAL IN RECONSTRUCTION:
 1.5-2.5mm.

RECONSTRUCTION ALGORITHM/ KERNAL:

 Medium Smooth

3 D-RECONSTRUCTIONS:

 MPR
 MIP

COMMENTS:.
The use of head rest is recommended for head positioning .
Spiral scanning is considered if the coronal and sagittal
MPR are needed as for shunt positioning , volumetric measurements
or localization of the lesion .
The slice thickness for reconstruction should be 3-5 mm
with a slice overlap of 2-3 mm

50
 For the posterior fossa and the cranial base,additional scan may
be in the spiral mode,if the MPR are needed with same thickness
with 2-3 mm overlap.

Criteria of good image Quality:

Symmetric position with the orbital plates overlapping with each

other
Absence of the motion artefacts.
Absence of beam hardening
Optimal opacification of the venous sinuses.

CASE STUDY:
Ruptured right internal carotid artery aneurysm.

SUBJECT;
An otherwise healthly 56 yrs old man with no significant
medicallhistory reported enset of Lightheadedness followed by a
“POPPING” sensation in the black of his nick and a
“THUDERCLAP” headache patient went to bed and work up with
intense pain in the head and neck disorientation and mild motor
deficits.
ABOVE:
A pre operative CT scan shows significant subarachnoid
hemorrhage and trace hydrocephalus.

1.ABOVE RIGHT;
51
 Right side CT view of aneurysm.
2.ABOVE LEFT:
3D cerebral angiogram image shows aneurysm on
the right carotid artery.

PROTOCAL FOR CONTRAST PERIPHERAL

ANGIOGRAPHY:

INDICATIONS:
Peripheral stenotic or occluding peripheral artery disease.

52
Demonstration of:
 Screening and evaluation of the peripheral arteries.

PATIENT POSITION:
 Supine with feet first, arms elevated above the head.

TOPOGRAM POSITION:
 Anteroposterior: Xiphisternum.

MODE OF SCANNING:
 Helical
SCAN ORIENTATION:
 Craniocaudal
• Starting Location: Level of the renal arteries
• End Location: Level of the ankles.

GANTRY TILT:
 Nil
FILED OF VIEW:
 Just fitting the region arteries.

CONTRAST ADMINISTRATION:
 intravenous

VOLUME OF CONTRAST:
 120-150 ml Intravenous

53
RATE OF INJECTION OF CONTRAST
 3-4 ml/sec

SCAN DELAY: 20-30 sec

SLICE THICKNESS IN RECONSTRUCTION:

 2-3 mm

SLICE INTERVAL IN RECONSTRUCTION:

 1.0-1.5mm.

RECONSTRUCTION ALGORITHM/ KERNAL:

 Medium Smooth

3 D-RECONSTRUCTIONS:
 MPR
 Thin MIP
VRT with bone subtraction to display the arterial anatomy.

COMMENTS:.
 For the scan delay, bolus tracking method is preferred to find
out the ideal time for optimal opacification of the arteries in
the region of interest.
Include both the lower limbs to get the overall view.

54
 Incase the upper limb angiography is required , the scanning is
done separately in separate sittings.
The patient is placed supine with head first with the limb of
interest in the anatomic position and the contralateral limb elevated
above the head.
The point to remember here is that the intravenous injection
should done in the contralateral limb.
In case the patient is symptomatic in a particular position of
the limb,scanning can then be done in that partical position instead
of the usual position.
The upper limb angiography might need higher mA to overcome
the beam hardening due to the chest.
Creteria of Good Quality:
Absence of beam hardening.
Absence of motion artefacts.
Uniform contrast density in the arteries especially in the region
of interest.

55
CASE STUDY:

In peripheral artery angiography, the 30 cm system on the left

(INNOVA 3100,30 cm ,GE health ,Uppsala,swedan) FUTURE 1:
Is basically used while the 20 cm coronary system
(INNOVA IGS620,20 cm ,GE health care , Uppsala,swedan)
FUTURE 2:
Is too small for peripheral artery angiography.
FOR EX:
The superficial femoral artery (SFA) is the longest vessel and
difficult to visualize in its entirety.

56
\
In figures 1 and 2 two SFA short lesions are shown.

57