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Biphasic CT with Mesenteric CT Angiography in the Evaluation of Acute Mesenteric Ischemia: Initial Experience¹

¹ From the Department of Radiology, University of Manitoba Health Sciences Centre, 820 Sherbrook St, Winnipeg, Manitoba, Canada R3A 1R9. From the 2002 RSNA scientific assembly. Received August 10, 2002; revision requested October 23; final revision received February 14, 2003; accepted March 19. Address correspondence to I.D.C.K. (iain.kirkpatrick@stanford.edu).

View larger version (132K): [in a new window]   Figure 1. CT angiographic phase image of a patient without mesenteric ischemia. Transverse 1.25-mm-thick image in an 84-year-old woman with perforated gastric ulcer found at surgery. Preoperative CT scan demonstrates focal discontinuity of gastric wall (arrow) with a small bubble of adjacent free intraperitoneal air (arrowhead).

View larger version (139K): [in a new window]   Figure 2a. CT and conventional digital subtraction angiograms of a 40-year-old female smoker with abdominal pain and a history of premature claudication. (a) Volume-rendered three-dimensional CT image of abdominal aorta in the lateral projection shows narrowing of the celiac trunk (arrowhead) and occlusion of the proximal SMA (arrow). (b) Anterior correlative lateral conventional aortogram shows SMA occlusion (arrow), with faint opacification of the distal vessel (arrowhead). The celiac trunk is not optimally depicted. (c) Anterior volume-rendered three-dimensional CT image shows that the SMA beyond the occlusion is being supplied by collateral vessels from the celiac artery through the pancreaticoduodenal arcade (straight arrow) and from the IMA through the arc of Riolan (curved arrow). Stenoses of the IMA origin (small arrowhead) and distal aorta (large arrowhead) are also noted. (d) Correlative, anterior conventional aortogram shows faint filling of the SMA (straight arrow) and arc of Riolan (curved arrow). (e) Transverse CT image shows nonspecific inflammatory change about the cecum (arrow), which was the only abnormal bowel finding; however, at surgery there were extensive areas of poorly perfused small and large bowel and poor pulses in all three mesenteric vessels that responded well to aorto-SMA and aortoceliac bypass without need for bowel resection.

View larger version (187K): [in a new window]   Figure 2b. CT and conventional digital subtraction angiograms of a 40-year-old female smoker with abdominal pain and a history of premature claudication. (a) Volume-rendered three-dimensional CT image of abdominal aorta in the lateral projection shows narrowing of the celiac trunk (arrowhead) and occlusion of the proximal SMA (arrow). (b) Anterior correlative lateral conventional aortogram shows SMA occlusion (arrow), with faint opacification of the distal vessel (arrowhead). The celiac trunk is not optimally depicted. (c) Anterior volume-rendered three-dimensional CT image shows that the SMA beyond the occlusion is being supplied by collateral vessels from the celiac artery through the pancreaticoduodenal arcade (straight arrow) and from the IMA through the arc of Riolan (curved arrow). Stenoses of the IMA origin (small arrowhead) and distal aorta (large arrowhead) are also noted. (d) Correlative, anterior conventional aortogram shows faint filling of the SMA (straight arrow) and arc of Riolan (curved arrow). (e) Transverse CT image shows nonspecific inflammatory change about the cecum (arrow), which was the only abnormal bowel finding; however, at surgery there were extensive areas of poorly perfused small and large bowel and poor pulses in all three mesenteric vessels that responded well to aorto-SMA and aortoceliac bypass without need for bowel resection.

View larger version (145K): [in a new window]   Figure 2c. CT and conventional digital subtraction angiograms of a 40-year-old female smoker with abdominal pain and a history of premature claudication. (a) Volume-rendered three-dimensional CT image of abdominal aorta in the lateral projection shows narrowing of the celiac trunk (arrowhead) and occlusion of the proximal SMA (arrow). (b) Anterior correlative lateral conventional aortogram shows SMA occlusion (arrow), with faint opacification of the distal vessel (arrowhead). The celiac trunk is not optimally depicted. (c) Anterior volume-rendered three-dimensional CT image shows that the SMA beyond the occlusion is being supplied by collateral vessels from the celiac artery through the pancreaticoduodenal arcade (straight arrow) and from the IMA through the arc of Riolan (curved arrow). Stenoses of the IMA origin (small arrowhead) and distal aorta (large arrowhead) are also noted. (d) Correlative, anterior conventional aortogram shows faint filling of the SMA (straight arrow) and arc of Riolan (curved arrow). (e) Transverse CT image shows nonspecific inflammatory change about the cecum (arrow), which was the only abnormal bowel finding; however, at surgery there were extensive areas of poorly perfused small and large bowel and poor pulses in all three mesenteric vessels that responded well to aorto-SMA and aortoceliac bypass without need for bowel resection.

View larger version (167K): [in a new window]   Figure 2d. CT and conventional digital subtraction angiograms of a 40-year-old female smoker with abdominal pain and a history of premature claudication. (a) Volume-rendered three-dimensional CT image of abdominal aorta in the lateral projection shows narrowing of the celiac trunk (arrowhead) and occlusion of the proximal SMA (arrow). (b) Anterior correlative lateral conventional aortogram shows SMA occlusion (arrow), with faint opacification of the distal vessel (arrowhead). The celiac trunk is not optimally depicted. (c) Anterior volume-rendered three-dimensional CT image shows that the SMA beyond the occlusion is being supplied by collateral vessels from the celiac artery through the pancreaticoduodenal arcade (straight arrow) and from the IMA through the arc of Riolan (curved arrow). Stenoses of the IMA origin (small arrowhead) and distal aorta (large arrowhead) are also noted. (d) Correlative, anterior conventional aortogram shows faint filling of the SMA (straight arrow) and arc of Riolan (curved arrow). (e) Transverse CT image shows nonspecific inflammatory change about the cecum (arrow), which was the only abnormal bowel finding; however, at surgery there were extensive areas of poorly perfused small and large bowel and poor pulses in all three mesenteric vessels that responded well to aorto-SMA and aortoceliac bypass without need for bowel resection.

View larger version (111K): [in a new window]   Figure 2e. CT and conventional digital subtraction angiograms of a 40-year-old female smoker with abdominal pain and a history of premature claudication. (a) Volume-rendered three-dimensional CT image of abdominal aorta in the lateral projection shows narrowing of the celiac trunk (arrowhead) and occlusion of the proximal SMA (arrow). (b) Anterior correlative lateral conventional aortogram shows SMA occlusion (arrow), with faint opacification of the distal vessel (arrowhead). The celiac trunk is not optimally depicted. (c) Anterior volume-rendered three-dimensional CT image shows that the SMA beyond the occlusion is being supplied by collateral vessels from the celiac artery through the pancreaticoduodenal arcade (straight arrow) and from the IMA through the arc of Riolan (curved arrow). Stenoses of the IMA origin (small arrowhead) and distal aorta (large arrowhead) are also noted. (d) Correlative, anterior conventional aortogram shows faint filling of the SMA (straight arrow) and arc of Riolan (curved arrow). (e) Transverse CT image shows nonspecific inflammatory change about the cecum (arrow), which was the only abnormal bowel finding; however, at surgery there were extensive areas of poorly perfused small and large bowel and poor pulses in all three mesenteric vessels that responded well to aorto-SMA and aortoceliac bypass without need for bowel resection.

View larger version (191K): [in a new window]   Figure 3a. CT and conventional digital subtraction angiograms of a 51-year-old woman with abdominal pain and a history of previous left femoral artery thrombosis. (a) Maximum intensity projection lateral CT image of the aorta shows occlusion of the celiac trunk (arrow). (b) Maximum intensity projection anterior CT image shows filling of the celiac branches through pancreaticoduodenal and dorsal pancreatic collateral vessels (straight arrows). There is a relative paucity of SMA jejunal branch vessels. Note the less opaque but still depicted mesenteric veins (arrowheads) and inferior vena cava (curved arrow), which are potential pitfalls of maximum intensity projection reconstructions if they are mistaken for arteries. (c) Correlative anterior selective SMA angiogram also shows filling of the celiac branches via the same collateral vessels (arrows) and a relative absence of jejunal branches in the left lower quadrant. At surgery, an ischemic segment of jejunum was found in this area and resection was performed. No bowel abnormality was detected with CT.

View larger version (197K): [in a new window]   Figure 3b. CT and conventional digital subtraction angiograms of a 51-year-old woman with abdominal pain and a history of previous left femoral artery thrombosis. (a) Maximum intensity projection lateral CT image of the aorta shows occlusion of the celiac trunk (arrow). (b) Maximum intensity projection anterior CT image shows filling of the celiac branches through pancreaticoduodenal and dorsal pancreatic collateral vessels (straight arrows). There is a relative paucity of SMA jejunal branch vessels. Note the less opaque but still depicted mesenteric veins (arrowheads) and inferior vena cava (curved arrow), which are potential pitfalls of maximum intensity projection reconstructions if they are mistaken for arteries. (c) Correlative anterior selective SMA angiogram also shows filling of the celiac branches via the same collateral vessels (arrows) and a relative absence of jejunal branches in the left lower quadrant. At surgery, an ischemic segment of jejunum was found in this area and resection was performed. No bowel abnormality was detected with CT.

View larger version (180K): [in a new window]   Figure 3c. CT and conventional digital subtraction angiograms of a 51-year-old woman with abdominal pain and a history of previous left femoral artery thrombosis. (a) Maximum intensity projection lateral CT image of the aorta shows occlusion of the celiac trunk (arrow). (b) Maximum intensity projection anterior CT image shows filling of the celiac branches through pancreaticoduodenal and dorsal pancreatic collateral vessels (straight arrows). There is a relative paucity of SMA jejunal branch vessels. Note the less opaque but still depicted mesenteric veins (arrowheads) and inferior vena cava (curved arrow), which are potential pitfalls of maximum intensity projection reconstructions if they are mistaken for arteries. (c) Correlative anterior selective SMA angiogram also shows filling of the celiac branches via the same collateral vessels (arrows) and a relative absence of jejunal branches in the left lower quadrant. At surgery, an ischemic segment of jejunum was found in this area and resection was performed. No bowel abnormality was detected with CT.

View larger version (160K): [in a new window]   Figure 4a. CT findings of a patient with surgically proven arterial embolism causing mesenteric ischemia. (a) Transverse arterial phase CT image of an 88-year-old woman with atrial fibrillation and abdominal pain shows a large embolus lodged in the origin of the SMA (arrow). (b) Transverse arterial phase CT image of an 84-year-old woman with atrial fibrillation and thrombus at echocardiography who presented with abdominal pain. Note relative lack of enhancement of the descending colon (arrowhead) when compared with the ascending colon (arrow). Ischemic segments of both small and large bowel were found at surgery.

View larger version (135K): [in a new window]   Figure 4b. CT findings of a patient with surgically proven arterial embolism causing mesenteric ischemia. (a) Transverse arterial phase CT image of an 88-year-old woman with atrial fibrillation and abdominal pain shows a large embolus lodged in the origin of the SMA (arrow). (b) Transverse arterial phase CT image of an 84-year-old woman with atrial fibrillation and thrombus at echocardiography who presented with abdominal pain. Note relative lack of enhancement of the descending colon (arrowhead) when compared with the ascending colon (arrow). Ischemic segments of both small and large bowel were found at surgery.