DOI:10.2214/AJR.07.2137
AJR 2007; 189:807-813
© American Roentgen Ray Society
Unsuspected Mesenteric Arterial Abnormality: Comparison of MDCT Axial Sections to Interactive 3D Rendering
Jennifer K. Chen1,
Pamela T. Johnson1,2,
Karen M. Horton1,2 and
Elliot K. Fishman1,2
1 The Johns Hopkins University School of Medicine, Baltimore, MD 21287.
2 Department of Radiology, Johns Hopkins School of Medicine, 601 N Caroline St.,
Room 3251, Baltimore, MD 21287.
Received November 3, 2006;
accepted after revision May 18, 2007.
Supported in part by an Alpha Omega Alpha Carolyn L. Kuckein Student
Research Fellowship.
Address correspondence to P. T. Johnson
(pjohnso5{at}jhmi.edu).
Abstract
OBJECTIVE. The purpose of our study was to determine how frequently
significant mesenteric arterial abnormalities that were identified by
interactive 3D CT with volume rendering and maximum intensity projection were
detected by axial images alone in a series of patients for whom there was no
clinical suspicion of mesenteric vascular disease. Axial CT and 3D
interpretations were compared for lesions involving the celiac and superior
mesenteric arteries or their branches. On a per-patient basis, the axial and
3D interpretations were equivalent in 24% (10/41) of the cases. Axial CT
partially agreed with 3D CT in 10% (4/41), and no mesenteric arterial lesion
was reported on axial CT in 66% (27/41). The 3D CT findings were supported by
other imaging, surgery, clinical findings, or management in 49% (20/41) of the
cases. The mesenteric lesions identified resulted in a change in patient
management in 15% (6/41) of the subjects.
CONCLUSION. Unsuspected mesenteric arterial abnormality may elude
diagnosis when axial MDCT sections are interpreted without 3D renderings.
Keywords: celiac artery • CT • CT angiography • MDCT • superior mesenteric artery • 3D rendering
Introduction
Mesenteric arterial abnormality is relatively uncommon; however, some
conditions can result in significant morbidity and mortality, making early
diagnosis paramount. For example, without timely detection mesenteric ischemia
may lead to intestinal infarction and death. Similarly, mesenteric arterial
aneurysms and dissections can be life-threatening when complicated by rupture
or thromboembolism
[15–5].
The presence of mesenteric arterial abnormality may not always be suspected
clinically because patients often present with vague and nonspecific
complaints such as abdominal or back pain, weight loss, dysphagia, nausea, or
vomiting [1,
4–7].
Some vascular lesions, including stenoses and aneurysms, produce no symptoms
in the early stage
[1–3]
or may mimic nonvascular abnormality.
Investigations comparing CT to conventional arteriography or surgical and
pathologic findings support the utility of 2D and 3D renderings in evaluating
the mesenteric arteries or their branches
[8–11].
However, most of these studies included patients with known or suspected
mesenteric vascular disease (e.g., mesenteric ischemia, pancreatic cancer). In
our CT division, axial sections and interactive 3D renderings are interpreted
and reported separately. We observed that unsuspected mesenteric arterial
lesions identified during 3D rendering are frequently not described on the
axial report. The purpose of this evaluation was to review the records of a
series of patients with significant unsuspected mesenteric arterial
abnormality detected during 3D rendering to determine how frequently the
lesions were identified and reported on review of axial images alone.
Materials and Methods
In our body CT practice, if patients are referred for MDCT with 3D
rendering, axial images are interpreted by one of 12 experienced dedicated
body imaging CT radiologists. Each has at least 5 years of experience in
practice, and more than 50,000 CT examinations are performed annually in our
division. Subsequently, 3D review of these cases is performed interactively by
one highly experienced CT attending physician with 20 years of 3D CT
experience using multiplanar reconstruction (MPR), volume rendering (VR), and
maximum intensity projection (MIP). The 3D report includes any significant
finding identified during interactive 3D rendering. In addition to vascular
abnormalities, findings may include solid organ abnormalities (e.g.,
enlargement, neoplasm, calculus, and infarct), biliary obstruction, bowel
abnormalities (e.g., obstruction, inflammatory bowel disease, and neoplasm),
orthopedic abnormalities, mesenteric disease (e.g., neoplasm, panniculitis),
and even peritoneal disease (e.g., carcinomatosis). Thus, each CT examination
has two separate reports, which are complementary. The 3D CT radiologist
recognized discordance between 3D and axial interpretations when 3D CT
revealed significant mesenteric arterial abnormality in patients without
suspicion for such. This prompted flagging of cases with significant
mesenteric arterial abnormality on 3D rendering for quality assurance
purposes.
This Health Insurance Portability and Accountability Act
(HIPAA)–compliant, retrospective review of these patients' records was
deemed exempt by our institutional review board; informed consent was not
required for review of patient data. The medical records over a 3-year period
from 2003 to 2006 of 111 consecutive patients with unsuspected mesenteric
arterial abnormality identified on 3D CT were evaluated. For each patient, the
indication was recorded from the CT requisition; those with indications that
would prompt evaluation of the mesenteric vasculature were excluded, including
65 subjects with either Loeys-Dietz syndrome, Ehlers-Danlos syndrome,
suspected ischemic bowel, evaluation of arteritis, evaluation of celiac axis
compression, evaluation of splenic and hepatic infarcts, history of celiac
hepatic bypass with graft, or history of splenic aneurysm. In addition, any
patient with a pancreatic mass reported in the CT dictation was excluded
(n = 5) because identification necessitates careful inspection of the
mesenteric arteries and veins.
The dictated reports from the remaining 41 patients' axial and 3D
interpretations were compared for abnormality involving the superior
mesenteric (SMA) or celiac arteries by two coinvestigators who had not
interpreted the CT examinations. Mesenteric vascular abnormality was defined
as any significant lesion(s) of the celiac artery or SMA, including aneurysm,
stenosis (> 50%), thrombosis, embolism, dissection, vasculitis, or
compression (median arcuate ligament syndrome [MALS] or superior mesenteric
artery syndrome [SMAS]). Arterial calcification and dilatation were not
considered significant for the purposes of this study; we recorded arterial
lesions that would prompt imaging follow-up, medical therapy, an
interventional vascular procedure, or surgery. Each patient's medical records
were reviewed to identify any correlative clinical findings, confirmatory
diagnostic tests, or pertinent management.
All CT studies were performed on a 16- or 64-MDCT scanner (Sensation 16 or
Sensation 64, Siemens Medical Solutions) with 0.6- or 0.75-mm detector
thickness, 120 kVp, and 150–250 mAs. Patients received either 320 or 350
mg I/mL of IV contrast material (iodixanol [Visipaque 320] or iohexol
[Omnipaque 350], GE Healthcare), infused at 3–4 mL/s. Each patient
underwent a dual phase acquisition with the arterial phase at 25–30
seconds after injection and the venous phase at 55–60 seconds after
injection. For axial sections, the data set was reconstructed with 3- to 5-mm
section thickness at intervals of 3–5 mm and sent to a PACS workstation
for analysis. All data sets were also reconstructed as 0.75-mm sections at
0.5-mm intervals and transferred to a Leonardo workstation running InSpace
software (Siemens Medical Solutions) to interactively evaluate the arterial
phase volume with MPR, 3D volume rendering, and MIP.
Results
For the 41 subjects included, the MDCT indications were liver evaluation
(n = 9), history of aortic aneurysm (n = 7, five of which
had been repaired), suspected pancreatic mass (n = 7), known
malignancy (n = 5), abdominal pain (n = 4), history of
aortic dissection (n =2), pretransplantation (n = 2),
abdominal pain and history of aortic aneurysm (n = 1), suspected
aortic dissection (n = 1), potential renal donor (n =1),
hematuria (n = 1), and evaluation of gallbladder (n = 1).
The mean age of the subjects was 61 years (age range, 36–83 years), with
95% (39/41) over 40 years.
A total of 49 mesenteric arterial abnormalities were identified at 3D CT,
71% (35/49) involving the celiac artery or branches and 29% (14/49), the SMA.
Abnormalities included MALS (n = 10), stenosis of the celiac artery
(n = 11) or SMA (n = 5), aneurysm of the celiac artery
(n = 9) or SMA (n = 1), celiac branch aneurysms due to
vasculitis (n = 2), thrombus of the SMA (n = 1), celiac
occlusion (n = 1), dissection of the celiac artery (n = 2)
or SMA (n = 3), SMA vasculitis (n = 1), and SMAS (n
= 3) (Table 1). Eight patients
had more than one mesenteric arterial lesion.
On a per-patient basis, the axial and 3D interpretations were equivalent in
24% (10/41) of the cases. Axial CT partially agreed with 3D CT in 10% of
patients (4/41), and no arterial lesion was seen on axial CT in 66% (27/41).
On a per-lesion basis (Table
1), 94% (15/16) of the cases of stenosis not due to MALS detected
by 3D CT were missed by axial CT (Fig.
1A,
1B,
1C). More than half of the
cases of compression to or by the vasculature (six of 10 MALS, two of three
SMAS) were missed on axial sections (Figs.
2 and
3A,
3B,
3C,
3D), as were six of the 12
cases of aneurysm (Figs. 4A,
4B and
5A,
5B,
5C) and four of the five cases
of dissection (Figs. 5A,
5B,
5C and
6A,
6B). Partial agreement was
made for three patients with a 3D diagnosis of MALS. For these patients, the
axial interpretations noted stenosis, collaterals, or both but did not suggest
a diagnosis of ligamentous compression. The remaining case of partial
agreement was an axial interpretation that noted arterial calcification,
whereas the 3D rendering identified SMA stenosis.
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Fig. 1A —78-year-old man with history of infrarenal abdominal aortic
aneurysm. Axial CT image through celiac axis shows narrowing of proximal
celiac axis (arrow). This finding was not described on axial
report.
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Fig. 1B —78-year-old man with history of infrarenal abdominal aortic
aneurysm. Axial CT image at origin of superior mesenteric artery (SMA) shows
narrowing of SMA (arrow). This finding was not described on axial
report.
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Fig. 1C —78-year-old man with history of infrarenal abdominal aortic
aneurysm. Sagittal maximum-intensity-projection 3D CT angiogram shows moderate
stenosis of proximal celiac axis (arrow) with poststenotic dilatation
and stenosis of proximal SMA (arrowhead). These findings were both
described on 3D report. Follow-up CT described celiac stenosis only. Abdominal
aortic aneurysm is also seen.
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Fig. 2 —78-year-old woman with clinical suspicion for pancreatic
mass. Sagittal volume-rendered image shows two focal areas of stenosis
(arrows) involving celiac axis. More proximal stenosis (black
arrow) has hooked appearance that is typical for median arcuate ligament
syndrome; this was confirmed on MRI. No abnormalities were described on axial
report.
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Fig. 3A —41-year-old woman who underwent CT for evaluation as
potential renal donor. Axial CT image at level of renal arteries shows
significant narrowing of space (arrow) between superior mesenteric
artery (SMA) and aorta. This was not noted on axial report.
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Fig. 3B —41-year-old woman who underwent CT for evaluation as
potential renal donor. Axial CT image slightly inferior in relation to
A shows that left renal vein (arrows) is compressed by SMA.
This was not noted on axial report.
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Fig. 3C —41-year-old woman who underwent CT for evaluation as
potential renal donor. Axial CT image through third portion of duodenum
(arrows) shows compression (arrowheads) of duodenum by SMA.
This was not noted on axial report.
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Fig. 3D —41-year-old woman who underwent CT for evaluation as
potential renal donor. Sagittal volume-rendered 3D CT angiogram confirms
decreased space between SMA and aorta. Notice narrow angle at takeoff of SMA.
These findings were described in 3D report, which suggested that this could be
SMA syndrome in proper clinical setting. Clinical findings supported
diagnosis.
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Fig. 4A —46-year-old woman with history of endovascular repair of
abdominal aortic aneurysm. Sagittal volume-rendered 3D CT (B) shows
celiac artery aneurysm, which was described on 3D report but not recognized on
axial section (A).
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Fig. 4B —46-year-old woman with history of endovascular repair of
abdominal aortic aneurysm. Sagittal volume-rendered 3D CT (B) shows
celiac artery aneurysm, which was described on 3D report but not recognized on
axial section (A).
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Fig. 5A —65-year-old man with clinical suspicion for pancreatic mass.
Patient also had undergone left nephrectomy for renal cell carcinoma. Axial CT
image through level of superior mesenteric artery (SMA) shows two discrete
aneurysms of hepatic artery (arrows). These were not described on
axial report.
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Fig. 5B —65-year-old man with clinical suspicion for pancreatic mass.
Patient also had undergone left nephrectomy for renal cell carcinoma. Axial CT
image caudal in relation to A shows dissection of SMA (arrow),
which was not described on axial report.
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Fig. 5C —65-year-old man with clinical suspicion for pancreatic mass.
Patient also had undergone left nephrectomy for renal cell carcinoma. Coronal
volume-rendered 3D CT image shows hepatic artery aneurysms (black
arrows) and SMA dissection (white arrow). These were both
identified with interactive 3D rendering.
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Fig. 6A —83-year-old woman with clinical suspicion for pancreatic
mass. Axial CT image through level of celiac axis shows small focal dissection
(arrow). This finding was not reported on axial dictation.
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Fig. 6B —83-year-old woman with clinical suspicion for pancreatic
mass. Coronal oblique volume-rendered image shows focal dissection flap in
dilated celiac artery. This was described on 3D report. Vascular surgery was
consulted and concluded that this case could be followed and that no immediate
treatment was necessary in this asymptomatic patient.
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Review of the medical records uncovered support for the 3D diagnosis in 49%
of patients (20/41) through follow-up CT (n =13), management
(n =6), MR (n = 1), angiography (n =2), surgery
(n = 3), and clinical findings (n = 6). Of the five subjects
whose lesion(s) identified on 3D CT were subsequently proven at surgery or
angiography, two were not diagnosed on the axial interpretation. However, in
four of the 3D CT stenosis cases with supportive evidence, the follow-up CT or
MRI reported collaterals without stenosis, or only one of two stenoses. In a
fifth case in which 3D CT identified celiac artery and SMA dissections in a
patient with an aortic dissection, angiography nearly 1 year later confirmed
that the dissection extended into the SMA but reported that the true lumen
supplied the celiac artery.
On record review, evidence that did not support the 3D CT findings was
found for two of the 41 patients. In the first case, the 3D CT diagnosis was
severe celiac stenosis, concerning for MALS, in a patient with abdominal pain.
However, no hemodynamically significant stenosis was identified at duplex
sonography; therefore, the diagnosis was dismissed clinically. Review of the
images confirmed that the celiac artery was occluded with collateralization to
the SMA by the gastroduodenal artery, and identification of such a lesion
remains important. For the second discrepant case, a celiac aneurysm on 3D CT
was not reported on hepatic arteriography for chemoembolization. The
arteriogram was not available for review; however, the CT images were
convincing for aneurysmal dilatation of the celiac artery, and the patient had
multiple risk factors for atherosclerosis with a clinical interpretation of
mesenteric atherosclerotic disease.
The mesenteric lesion identified resulted in a change in patient management
in six subjects, including observation, surgery (n =2), blood
pressure management, altered surgical procedure, and steroid therapy for
vasculitis (Table 1). For four
of these six subjects, the finding was identified on the axial sections.
Discussion
The spectrum of mesenteric arterial abnormality evaluated in this study
includes a compilation of relatively uncommon lesions. However, each of these
carries a risk of severe complications. If untreated, mesenteric ischemia can
lead to intestinal infarction and death
[1,
6,
7], and MALS may necessitate
surgical intervention to relieve the ligamentous constriction and any
secondary vascular damage
[12]. Aneurysms of the
mesenteric arteries often do not present until emergent or potentially fatal
complications such as rupture ensue
[1,
2]. Moreover, nonaortic
arterial dissections left untreated may result in intestinal infarction and
arterial rupture and, further, have been identified at necroscopy as an
unsuspected cause of death [4,
5]. Therefore, early and
accurate characterization of mesenteric arterial abnormality is crucial.
MDCT serves as an excellent imaging technique for evaluating the abdominal
vasculature [13,
14]. An alternative
cross-sectional imaging tool, MRI, has been shown to be limited for depicting
small arteries in one study, specifically the right gastric artery and
branches of the right hepatic artery
[15]. However, smaller
effective slice thickness and higher resolution MDCT data sets allow
visualization of small mesenteric artery branches
[14]. Three-dimensional MDCT
reconstructions enable noninvasive viewing of detailed anatomy and complex
relationships. Even before MDCT technology became available, the ability of 2D
and 3D rendering to enhance visualization of vessels coursing perpendicular or
oblique to the axial plane was shown
[16,
17].
Investigations with angiographic confirmation have reported the value of 3D
reconstructions for evaluating normal anatomy and vascular variants of the
SMA, celiac artery, and hepatic artery as well as aneurysms and stenoses of
the SMA and celiac artery [9,
10]. In addition, analyses of
the celiac artery and SMA noted an improvement in branch vessel visualization
when using 3D rendering [13].
Data from the pancreatic cancer literature with surgical correlation
elucidated that 3D or coronal 2D rendering facilitates evaluation of the
mesenteric vessels for encasement
[11,
18,
19].
These articles [11,
18,
19] describe the utility of 3D
renderings when arterial disease is suspected. However, we observed that
interactive 3D rendering reveals unsuspected mesenteric arterial abnormality,
which is frequently missed during axial MDCT interpretation. Accordingly, a
systematic analysis of the CT interpretations in a series of patients was
warranted. This comparison confirmed that significant unsuspected mesenteric
arterial abnormality elucidated during interactive 3D rendering of MDCT
volumes was missed in 66% of the cases using axial sections alone. In our
study, axial CT interpretations missed nearly all cases of arterial stenosis
detected, the majority (60–80%) of the cases of compression and
dissection, and half of the mesenteric aneurysms. The mesenteric lesions
identified affected patient management in 15% (6/41) of cases in accordance
the results of Kirkpatrick et al.
[20], who showed that
mesenteric CT angiography changed patient management in 19% of the cases with
acute mesenteric ischemia. Of these six cases in our series, two were not
detected on axial scans alone. Our findings suggest that the increased imaging
capability of 3D rendering could affect patient care with respect to
mesenteric arterial abnormality; however, a prospective series with a larger
number of subjects is warranted.
Of note, there was a disproportionately large number of patients with
aortic aneurysm, likely owing to the common pathophysiology of atherosclerosis
for many of these lesions. Accordingly, routine multiplanar evaluation of the
mesenteric vessels is recommended for these patients during CT. The large
number of patients with known or suspected liver disease probably reflects the
widespread use of CT to evaluate the liver. Given the variability in clinical
indications for the patients in this study, most of whom were more that 40
years old, these data suggest that 2D or 3D rendering may be warranted in all
subjects over 40 years who undergo abdominal CT, despite the absence of
specific symptoms related to the mesenteric arteries. Current 64-MDCT scanners
yield high-resolution and isotropic or nearly isotropic volumes amenable to 2D
and 3D rendering in all subjects. Furthermore, advances in display hardware
and software have made 3D rendering widely available and readily
accessible.
Our study has a number of limitations. First, the means of identifying
patients through 3D interpretations introduced a selection bias, and clinical
assessment using other imaging techniques that could have confirmed or
contradicted the 3D CT findings was not routinely performed for correlation.
However, in current clinical practice, CT findings are often used to guide
management without the requirement for confirmation by conventional
angiography. The lack of routine correlation was partly the result of a number
of patients having significant comorbid disease such as late-stage malignancy
that preempted further investigation of mesenteric lesions. Also, some
patients chose to continue their follow-up at other institutions. A second
limitation was that axial sections were reconstructed as 3- to 5-mm sections,
whereas the 3D rendering was performed with a volume of data constructed from
0.75-mm overlapping sections. It is possible that review of the thicker slices
was a factor that affected the ability to detect vascular abnormality in
addition to the viewing plane. However, this reconstruction techique is in
keeping with current CT practice because narrow reconstruction sections
yielding thousands of axial sections are not conducive to workflow and are
also typically noisier. Finally, retrospective review of reports is not as
accurate as prospective collection of data. Future prospective investigations
are needed to determine the frequency that 3D and axial CT reveal unsuspected
mesenteric arterial abnormality in the general population now that 64-MDCT
yields high-resolution volumes in all subjects.
In conclusion, we have shown in this study that unsuspected significant
mesenteric arterial abnormality may elude diagnosis when axial MDCT sections
are interpreted without 3D rendering. Our review suggests that routine
multiplanar viewing of the mesenteric arteries is necessary during CT in
patients with a history of aortic aneurysm. Furthermore, inspection of the
mesenteric arterial vasculature using 3D rendering should be considered in all
patients over 40 years who undergo abdominal CT. With 3D rendering now
available on PACS and on the Web, the lack of access to 3D software should be
less of an issue. In the era of isotropic data, perhaps the new standard of
care will be to review all MDCT data sets in 3D mode to exclude any
unsuspected vascular abnormality.
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P. T. Johnson, K. M. Horton, and E. K. Fishman
Nonvascular Mesenteric Disease: Utility of Multidetector CT with 3D Volume Rendering
RadioGraphics,
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Abstract
Introduction
