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CTA and MRA in Mesenteric Ischemia: Part 1, Role in Diagnosis and Differential Diagnosis

¹ Division of Non-invasive Cardiovascular Imaging, Department of Radiology, University of Virginia Health System, 1215 Lee St., PO Box 800170, Charlottesville, VA 22908.
² Present address: Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.

View larger version (120K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A —76-year-old woman with severe abdominal pain and diarrhea. MDCT angiography (CTA) shows acute embolic occlusion of superior mesenteric artery (SMA) distal to origin of middle colic artery (arrowhead). Pathologic thickening of multiple small-bowel loops of jejunum was present (not shown).

View larger version (149K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B —76-year-old woman with severe abdominal pain and diarrhea. Source image of CTA shows filling defect in SMA (arrowhead) and patent superior mesenteric vein. Patient underwent emergent embolectomy with SMA bypass and small-bowel resection and made full recovery.

View larger version (144K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2A —64-year-old man with syncopal episode and abdominal pain. Patient had history of coronary artery disease after aortocoronary bypass graft and aortobifemoral bypass surgery for aortic occlusive disease. Volume-rendered MDCT angiogram shows aortobifemoral graft as well as severe calcified plaque burden in native vasculature. Note moderate enlargement of ascending branch of inferior mesenteric artery (arrowhead) as well as pancreaticoduodenal arcades (arrows).

View larger version (80K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2B —64-year-old man with syncopal episode and abdominal pain. Patient had history of coronary artery disease after aortocoronary bypass graft and aortobifemoral bypass surgery for aortic occlusive disease. Subvolume maximum intensity projection shows significant vascular wall calcifications in superior mesenteric artery origin (arrowhead) causing highgrade stenosis and acute thrombus seen as a small hypodense filling defect (arrow).

View larger version (92K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A—58-year-old man with history of hypercholesterolemia and nephrolithiasis who presented with severe abdominal pain that began approximately 6 days previously. Axial images of MDCT angiography (A) and gadolinium contrast-enhanced axial T1-weighted image (B) show acute thrombus in superior mesenteric vein (arrowheads) as evidenced by round nonocclusive filling defect.

View larger version (100K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B—58-year-old man with history of hypercholesterolemia and nephrolithiasis who presented with severe abdominal pain that began approximately 6 days previously. Axial images of MDCT angiography (A) and gadolinium contrast-enhanced axial T1-weighted image (B) show acute thrombus in superior mesenteric vein (arrowheads) as evidenced by round nonocclusive filling defect.

View larger version (105K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4A —58-year-old man with acute onset of severe excruciating back and abdominal pain due to type II aortic dissection. Contrast-enhanced MR angiograms show type II dissection with extension of dissection flap (arrow, A) downward below origin of superior mesenteric artery (SMA) and occlusion of right renal artery (not shown). There is an occlusion of ileocolic artery (arrowhead, B).

View larger version (90K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4B —58-year-old man with acute onset of severe excruciating back and abdominal pain due to type II aortic dissection. Contrast-enhanced MR angiograms show type II dissection with extension of dissection flap (arrow, A) downward below origin of superior mesenteric artery (SMA) and occlusion of right renal artery (not shown). There is an occlusion of ileocolic artery (arrowhead, B).

View larger version (75K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4C —58-year-old man with acute onset of severe excruciating back and abdominal pain due to type II aortic dissection. Catheter angiograms in lateral (C) and anteroposterior (D) projections with catheter in anterior false lumen show that dissection ends just below SMA and filling of distal aorta is via nonopacified (from this catheter position) distal aorta. Note also embolus in ileocolic artery (arrowhead, D) of SMA seen on both subvolume maximum intensity projection (B) and catheter angiogram (D).

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4D —58-year-old man with acute onset of severe excruciating back and abdominal pain due to type II aortic dissection. Catheter angiograms in lateral (C) and anteroposterior (D) projections with catheter in anterior false lumen show that dissection ends just below SMA and filling of distal aorta is via nonopacified (from this catheter position) distal aorta. Note also embolus in ileocolic artery (arrowhead, D) of SMA seen on both subvolume maximum intensity projection (B) and catheter angiogram (D).

View larger version (126K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5A —59-year-old man with spontaneous dissection of celiac artery. Contrast-enhanced MR angiogram (A) shows ectasia of celiac artery (arrow), and coronal steadystate free precession image (B) shows dissection flap (arrowhead).

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5B —59-year-old man with spontaneous dissection of celiac artery. Contrast-enhanced MR angiogram (A) shows ectasia of celiac artery (arrow), and coronal steadystate free precession image (B) shows dissection flap (arrowhead).

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A —36-year-old woman with acute onset of abdominal pain and bowel perforation. Axial source image of MDCT angiography shows focal dissection of superior mesenteric artery (SMA) (solid arrowhead). Patient also had free air in peritoneum (arrow) due to bowel perforation as well as air in mesenteric veins (open arrowhead).

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B —36-year-old woman with acute onset of abdominal pain and bowel perforation. Lateral aortogram confirms focal dissection of SMA (arrow).

View larger version (103K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7A —73-year-old woman with 2-year history of postprandial abdominal pain and 50-lb (22.5-kg) weight loss. Contrast-enhanced MR angiogram of abdomen (A) and abdominal aortogram (B) show atherosclerotic occlusion of celiac trunk and superior mesenteric artery. Collateralization is maintained via inferior mesenteric artery (arrowhead).

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7B —73-year-old woman with 2-year history of postprandial abdominal pain and 50-lb (22.5-kg) weight loss. Contrast-enhanced MR angiogram of abdomen (A) and abdominal aortogram (B) show atherosclerotic occlusion of celiac trunk and superior mesenteric artery. Collateralization is maintained via inferior mesenteric artery (arrowhead).

View larger version (135K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8A —60-year-old woman with clinical symptoms of chronic mesenteric ischemia and severe bilateral claudication. Lateral subvolume maximum intensity projection of MDCT angiogram shows occlusion of celiac artery and superior mesenteric artery and high-grade stenosis of inferior mesenteric artery (IMA) (arrow).

View larger version (85K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8B —60-year-old woman with clinical symptoms of chronic mesenteric ischemia and severe bilateral claudication. Volume-rendered image shows that collateral flow to iliac and superior mesenteric arteries was through IMA via Riolan's arch (arrowhead).

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9 —67-year-old man with vasculopathy and history of left hemispheric stroke, chronic claudication, and clinical signs of mesenteric ischemia. Contrast-enhanced MR angiogram shows total occlusion of infrarenal abdominal aorta, high-grade stenosis of celiac artery origin (solid arrow), and segmental superior mesenteric artery stenosis (arrowhead). Inferior mesenteric artery (open arrowhead) was reconstituted via Riolan's arch (arrow).

View larger version (179K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10A —75-year-old man with peripheral vascular and coronary artery disease who was admitted for postprandial abdominal pain and food avoidance. Subvolume maximum intensity projection of MDCT angiogram shows 60% stenosis of proximal superior mesenteric artery caused by eccentric noncalcified plaque.

View larger version (113K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10B —75-year-old man with peripheral vascular and coronary artery disease who was admitted for postprandial abdominal pain and food avoidance. Selective superior mesenteric arteriogram (B) and volume-rendered MDCT angiogram (C) both show high-grade stenosis, which was successfully treated with percutaneous transluminal angioplasty (PTA).

View larger version (128K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 10C —75-year-old man with peripheral vascular and coronary artery disease who was admitted for postprandial abdominal pain and food avoidance. Selective superior mesenteric arteriogram (B) and volume-rendered MDCT angiogram (C) both show high-grade stenosis, which was successfully treated with percutaneous transluminal angioplasty (PTA).

View larger version (89K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 11 —61-year-old woman with history of right nephrectomy and fibromuscular dysplasia of left renal artery that was treated previously with angioplasty. Contrast-enhanced MR angiogram shows beaded appearance typical of fibromuscular dysplasia at origin of superior mesenteric artery (arrow). Patient had no symptoms related to this finding, which was confirmed at catheter angiography (not shown).

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 12 —56-year-old woman with postprandial epigastric pain, weight loss, and abdominal bruit. Patient underwent MDCT angiography and was found to have abdominal aneurysm with both celiac and superior mesenteric artery origin (arrowhead) compression caused by median arcuate ligament of diaphragm. This finding on this maximum-intensity-projection image was consistent with classic median arcuate ligament syndrome.

View larger version (157K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13A —22-year-old woman with history of claudication, hypotension, and postprandial pain who was diagnosed with Takayasu's arteritis. Conventional abdominal angiogram (A) and contrast-enhanced MR angiogram (B) show marked narrowing and occlusion of distal abdominal aorta as well as occlusion of both renal arteries, inferior mesenteric artery (IMA) (arrowhead), and both common iliac arteries. Collaterals reconstitute renal arteries (arrows, B), IMA (arrowhead), and external iliac artery.

View larger version (72K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 13B —22-year-old woman with history of claudication, hypotension, and postprandial pain who was diagnosed with Takayasu's arteritis. Conventional abdominal angiogram (A) and contrast-enhanced MR angiogram (B) show marked narrowing and occlusion of distal abdominal aorta as well as occlusion of both renal arteries, inferior mesenteric artery (IMA) (arrowhead), and both common iliac arteries. Collaterals reconstitute renal arteries (arrows, B), IMA (arrowhead), and external iliac artery.

View larger version (99K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14A —69-year-old woman with Ehlers-Danlos syndrome who presented with postprandial epigastric pain. Volume-rendered MDCT angiograms of abdomen and pelvis (A) and mesenteric artery (B) reveal numerous aneurysms of branches of superior mesenteric artery, thrombosed splenic artery aneurysm (arrowhead, A), and aneurysms of right profunda femoral branches (arrows, A).

View larger version (93K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 14B —69-year-old woman with Ehlers-Danlos syndrome who presented with postprandial epigastric pain. Volume-rendered MDCT angiograms of abdomen and pelvis (A) and mesenteric artery (B) reveal numerous aneurysms of branches of superior mesenteric artery, thrombosed splenic artery aneurysm (arrowhead, A), and aneurysms of right profunda femoral branches (arrows, A).

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15A —41-year-old man with history of antiphospholipid antibody syndrome and retroperitoneal fibrosis who presented to emergency department with 1-week history of low-grade fever, nausea, vomiting, mild diarrhea, and constant postprandial abdominal pain. Oblique sagittal multiplanar reformatted (A) and volume-rendered (B) MDCT angiograms show illdefined soft tissue surrounding abdominal aorta and superior mesenteric artery (SMA) roots (arrowheads, A) and leading to focal stenosis of distal SMA (arrows).

View larger version (162K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 15B —41-year-old man with history of antiphospholipid antibody syndrome and retroperitoneal fibrosis who presented to emergency department with 1-week history of low-grade fever, nausea, vomiting, mild diarrhea, and constant postprandial abdominal pain. Oblique sagittal multiplanar reformatted (A) and volume-rendered (B) MDCT angiograms show illdefined soft tissue surrounding abdominal aorta and superior mesenteric artery (SMA) roots (arrowheads, A) and leading to focal stenosis of distal SMA (arrows).

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