CHP CT LP MCH VNH
CHP CT LP MCH VNHThs.Bs Phm Thi Hng MC TIUGii phu h mch vnhBt
thng gii phu mch vnh K thut chp ct lp mch vnhMt s bnh l mch vnh
thng gp Gii phu h mch vnh
Mch vnh xut pht t xoang ValsavaNgn phi m. vnh phiNgn tri m vnh
triNgn sau: ngn khng vnh
Smaller branches are generally not visible because of their
small size and the limitations of the scanner with regard to
spatial and temporal resolution.
3
m vnh tri (Left coronary artery-LCA)Nhnh trc xung (Left anterior
descending-LAD)Nhnh cho (Diagonal branches-D1, D2)Nhnh vchNhnh m
(Left Circumflex-LCx)Nhnh b (Marginal branches-M1,M2)m vnh phi
(Right coronary artery-RCA)Nhnh b nhn (Acute marginal
branch-AM)Nhnh nt nh tht (AV node branch)Nhnh sau xung (Posterior
descending artery-PDA)
Mt trc
Mt bn phi
Mt bn trim vnh tri (LCA)i gia bung thot tht phi v nh tri Chia
hai nhnhm m tri (LCx) m trc xung tri (LAD)
On volume rendered images the left atrial appendage needs to be
removed to get a good look on the LCA.1015%: m vnh tri (LCA) cho
thm mt nhnh m trung gian (intermediate branch-IB)
m trc xung tri (LAD)i trong rnh gian tht trc n mm tim Phn
nhnhNhnh cho (Diagonal branches D1, D2) thnh trc tht triNhnh vch
Vch lin tht trc
The diagonal branches come off the LAD and run laterally to
supply the antero-lateral wall of the left ventricle.The first
diagonal branch serves as the boundary between the proximal and mid
portion of the LAD (2).There can be one or more diagonal branches:
D1, D2 , etc.14Nhnh m tri (Left Circumflex-LCx)Nm trong rnh nh tht
Cho nhnh b t (Obtuse marginals -OM1, OM2) thnh bn tht tri
m vnh phi (Right coronary artery-RCA)i trong rnh nh thtPhn nhnh
Nhnh m ng tng tht phiNhnh nt xoang nt xoang nh Nhnh b nhn AM1, AM2
thnh trc tht phiNhnh sau xung thnh di tht tri v vch di
K thut chp ct lp mch vnh
Nhp tim chm v n nh -> Ti u ha nhp tim Gim thi gian ghi hnhTng
phn gii khng gian v thi gianGim nh gi do chuyn ng Gim liu tia
mid diastolic phase or diastasisThe red line refers to the
volume of the heart in a heartbeat. There is no volume change ie
not moving in diastole, and this part is used for CT scan.22Nhp tim
tng tm thu di ra tm trng ngn li H nhp tim v mc ti u ( 130 HUD bo
nguy c bnh mch vnh tng laiThe presence of coronary calcification is
a robust predictor (for a calcium score of >100, the risk ratio
= 1.88) of adverse cardiovascular events
Their conclusions were that patients with low calcium scores had
a low presence of obstructive plaque54
Table 2 Coronary calcium score categories and risks.55
Calcium score = 0
Hp nng
Hp khng ng k ( 1300
Mng x va mch vnh Phn loi Mng x va khng vi haLipid: #40-50 HUX:
#100 HUMng x va hn hp Mng x va vi ha
Lipid: 50 HU X: 100 HU Calci: 300 HU
60
Noncalcifiedplaque (arrow) in the proximal left anterior
descending coronary artery associated with significantluminal
steno-sis in a 65-year-old male patient. Panel A shows a curved
multiplanar reformation (with cross-sections along the vessel in
Panels BD and Panel E is a volume-rendered three-dimensional
reconstruction of CT.61
Tin trin t mng x va cng thnh mng x va mm n nh Khng n nh
Hn hpIt is postulated that the unstable fatty plaques evolve to
mixed fibrofatty and then fibro-calcified and eventually a stable
calcified plaque.63
Mng x va mm
Cholestrol - khng n nh
Khng n nh, v
V mng x va
= Huyt khi lng mchThe chemical compounds released by the
ruptured plaques produce a blood clot, that stops the normal flow
of blood to the heart ie heart attack.64Remodeling (ti cu trc) Thnh
mch phnh ra ngoi Lng mch thay i khng ng k
Khng nh hng huyt ng Nguy c v mng x va NMCT =========
67Mng x va khng n nh
Figure 2.A maximal intensity projection image shows low-density
intimal atheroma surrounding a small area of intimal contrast
(arrow). A Hounsfield unit measurement just proximal to the
diagonal bifurcation is consistent with either a fatty plaque or
thrombus.69Stent mch vnh
nh gi lng stent ph thuc vo loi v ng knh ca stent
Sach ct mach vanh, chuong stent.
Fig. 13.1 Overview of differentcoronary stents using ex-vivo CT.
Stent lumen visibility and artifacts differgreatly for the
currentlyavailable coronary artery stents. This is mainly due to
differencesin material, strut size, and design. The visibility of
the lumen of the Magicstent (asterisk), which is made of magnesium
(plus less than 5% of zirconium, yttrium, and rare earth metals
each), is far superior to thatof tantalum-coated stents (strut
thickness of 58 and 84 mm) with pronounced artificial lumen
narrowing (arrowheads). Modifiedand usedwith permission from Maintz
et al. Eur Radiol 200970nh gi Cng ha chm tia Gim m trong stent nh
gi booming (m) Hp gi to Ti to 0,5 v 0,8Sharp Kernel rng ca s >
1000 (trung bnh, 1500) v trung tm t 400 n 800 (trung bnh, 650)
Beam hardening refers to a shift in the X-ray spectrum to higher
energy photons caused by absorption of lower energy photons within
very dense structures such as metallic material. It may lead to a
virtual loss of CT density in surrounding soft tissue (i.e., it may
look darker than it should and black streaks may occur).
Blooming artifact: the average density of the two will be
displayed. As CT density values of metal are extremely high, those
average values will always be way above those of body tissue and in
the window-level set-tings used in CT angiography will rather
resemble those of the stent struts. Thus the better spatial
resolution gets, which means the smaller the voxels are, the fewer
partial volume effects will be seen. However, even state-of-the-art
high-end CT scanners do not provide a spatial resolution equivalent
to current stent strut size (0.070.15 mm). One of the most
bothersome effects of blooming is artificial lumen narrowing. The
in-stent lumen is systematically underestimated in CT: artificial
narrowing ranges from 20% to 100% depending on stent material.
71
Within the stent, beam hardening artifacts depend on the
individual stent structure and may look like repeated dark
spotsinside the stent lumen (arrows in Panel C). They preclude
rule-out of in-stent restenosis in this 56-year-old male patient,
which thus hadto be excluded by conventional coronary angiography.
The corresponding angiogram in Panel D shows only mild focal
waisting (arrow) but no relevant stenosis72
Fig. 13.3 Illustration of the effectof slice thickness on
visibility of in-stent lumina. Curved multiplanar reformations of a
3.0-mm stentin the right coronary artery using a slice thickness of
0.6-mm (Panel A) and 1.0 mm (Panel B). The improved resolution
shows greater detail, but also increases noise (Panel A), whereas
there is pronounced blooming and reduced lumen visibility with
thicker slices (Panel B). Both datasets were reconstructed at a
slice increment equal to two thirds of the slice thickness (0.4 and
0.7 mm) with an intermediatesharp reconstruction kernel and are
displayed with identical window-level settings (1500/300)73
Ti to thng thngTi to cho stent Stent Ph ht mng x va Hp trong
stent Huyt khi Tng sinh ni mc Qu bung/ bung khng GyGp gc Tc
nhnh
CTA and evaluation of the stent consists of determining whether
the stent was completely deployed across a plaque and whether there
is a stenosisin the lumen of the stent. The lumen and density in
the stent should be similar to that of adjacent artery. Areas of
low density in the stent indi-cate either subintimal hyperplasia or
thrombus.76
Overlapping stents may have a similar appearance to an
underexpandedstent. Signicantly increasing the window width on the
workstation in therange of 1,5003,000 may prove helpful.
The clue that the stent is fractured instead of there being a
second stentis that the stent fragment (6 mm).77
Huyt khi trong stent FIGURE 4.2. (AC) Volume rendering, cMPR,
and stretched LADLIMA: Occluded sequential stents in the proximal
to mid-LAD. Thelower arrow in Figure 4.2A and B show a transition
zone between the distal stent and the LAD, indicating an
occlusion
Low density alone in the lumen of a stent is not diagnostic of
an occludedstent. Extensive subintimal hyperplasia may mimic an
occlusion. Addi-tional ndings such as a distal short low-density
transition zone or lackof contrast opacication of the distal artery
are needed to conclude that thestent is occluded78
FIGURE 4.7. (A and B) cMPR and stretched, RCA: Widely patent
overlapping stentsin the proximal to mid-RCA (short arrow).
High-grade critical obstruction in the distalRCA (long arrow). (C)
Axial slice demonstrating high-grade critical obstruction in
thedistal RCA (arrow).79M bc cu mch vnhTM hin MLIMA RIMA m v mc ni
m quay m thng v di
http://pubs.rsna.org/doi/full/10.1148/rg.254045151Coronary
Artery Bypass Grafts: Assessment with Multidetector CT in the Early
and Late Postoperative Settings
http://www.appliedradiology.com/articles/ct-angiography-for-coronary-artery-bypass-graft-surgeryCT
angiography for coronary artery bypass graft surgery - See more at:
http://www.appliedradiology.com/articles/ct-angiography-for-coronary-artery-bypass-graft-surgery#sthash.bfIHuXkK.dpuf
80M bc cu mch vnh
Mch ghp c kch thc ln hn v t b nh hng bi nh gi chuyn ng hn so vi
ng mch vnhnh gi ch ni xa c chnh xc thp hn Clip phu thut c th hn ch
vic nh gi cc phn on ng mch ghp TM hin D bc tch, t co tht D hnh thnh
mng x vaThng thong #50% sau 15 nm Khu trc tip/ connector vo m
chFree graftSVG-RCA/PDA/distal LADSVG-LAD/Dia/LCX/OM Y graft
Ni bn-bn hoc tn-bn
82
m v trongt hnh thnh mng x va hn SVG Thng thong >90% sau 10 nm
LIMAIn situ:LIMA-LAD/Dia/OM RIMAIn situ: RCA/LAD/Dia/LCX/OM Free
graftY graft
Fig. 12.7 62-year-old male patient who was operated on 15 years
earlier with fivevenous bypass grafts. Because of an occlusion
ofthe left anterior descending artery and typical angina pectoris
(Canadian class III) the left internal mammary artery
(skeletonized, LIMA)prolonged with the right gastroepiploic artery
(free graft) was used to revascularize the left anterior descending
artery 3 years ago. CTwas now performed because of atypical angina
pectoris and showed the vein grafts (Panel A) and the LIMA (Panel
B) to be patent with-out significantstenosis85m quayD co mch Free
graft Y graft
Trng kho stm v trong: t m di n m thng v: n phn trn bng
nh gi CABG Xut phtThn Ch ni Mch vnh sau ch ni
(A and B) Volume rendering: Surgical Y graft of the left
internal mammary artery (LIMA) and a radial artery. (C)
cMPR:LIMA-radial artery anastomosis (A). (D) cMPR: upper arrow:
LIMA; middle arrow: radial artery anastomosis; lower arrow: distal
LIMALAD anastomosis.88Bin chng sau phu thut bc cu mch vnh Sm
(1thng) Huyt khi , tcSVG: Tng sinh ni mc mng x va IMA: Khng hnh
thnh mng x va, tc thng ti mch vnh sau ch ni Phnh mch Phnh tht: sau
5 nm, x va m Gi phnh: sm hn, nhim trng hay p lc, ch ni
Subtotal occlusion in the mid-body of the VGOM (arrow). (B and
C) cMPR, stretch cMPR: SVGOM, mid-body graft subtotal occlusion
(proximal arrow).90
Figure 17.Curved multiplanar reformation image shows a radial
artery graft with postoperative vasospasm. Note that the more
proximal aspect of the graft (black arrow) is narrower than the
distal aspect (white arrow).92Bt thng mch vnh
Khng ph bin #1% dn s Nguy c thiu mu c tim, t t CT gip pht hin sm
CCT coronary angiography is very useful in evaluating the origin
and course of anomalous coronary arteries (37,38). In addition, CCT
can easily determine the 3-dimensional relationship of anomalous
coronary arteries with the aorta and pulmonary arterial trunk.
Also, it can detect aneurysms on coronary vessels, arteriovenous
fistulae, and myocardial bridges
93Bt thng mch vnh
Bt thng ch xut pht, ng i v tn cngXc nh mi quan h 3 chiu ca ng
mch vnh bt thng vi cc ng mch ch v ng mch phi Phnh ng mch vnh, d ng
tnh mch, v cu c timCCT coronary angiography is very useful in
evaluating the origin and course of anomalous coronary arteries
(37,38). In addition, CCT can easily determine the 3-dimensional
relationship of anomalous coronary arteries with the aorta and
pulmonary arterial trunk. Also, it can detect aneurysms on coronary
vessels, arteriovenous fistulae, and myocardial bridges
94
Left Anterior Descending (LAD)Left Circumflex (LCX)LMAGii phu
bnh thng Right coronary artery (RCA)
on gian ng mch Xut pht ring ca LAD v LCX (khng c LMA)
LADLCX RCA c thay th bng LCX
Anomalous Left Coronary Artery From the Pulmonary Artery
(ALCAPA)ALCAPAOn the left images of a patient with an anomalous
origin of the LCA from the pulmonary artery, also known as
ALCAPA.ALCAPA results in the left ventricular myocardium being
perfused by relatively desaturated blood under low pressure,
leading to myocardial ischemia.ALCAPA is a rare, congenital cardiac
anomaly accounting for approximately 0.25-0.5% of all congenital
heart diseases.Approximately 85% of patients present with clinical
symptoms of CHF within the first 1-2 months of life.
99Cu c tim
Mt phn ca ng mch vnh i trong c timb p trong tm thu, ti mu trong
tm trng Triu chng lm sng? Stress test ng mch vnh bnh thng trn lp
thng tm mcR ng mch vnh Thng ni tin mao mch gia nhnh mch vnh vi bung
tim/mch muXut pht t RCA/LCA/RCA+LCADn lu v tht (P), nh (P), m phi,
xoang vnh, nh (T), tht (T), tmc trn Shunt (T)-(P)
Normal coronary arteries terminate in broom-like arborizations,
which penetrate the myocardium.CAF is defined as a direct
precapillary connection between a branch of a coronary artery and
the lumen of a cardiac chamber, the coronary sinus or superior vena
cava, or a pulmonary artery or pulmonary vein close to the heart
(10).Congenital fistulous connections between the coronary system
and a cardiac chamber appear to represent persistence of embryonic
intratrabecular spaces and sinusoids. They are the most common
congenital coronary anomalies affecting hemodynamic parameters
(11).CAF arises from the right coronary artery (RCA) in
approximately 50% of patients, the left coronary artery (LCA) in
approximately 42% of patients, and both the RCA and LCA in
approximately 5% of patients (12).The majority of symptomatic CAFs
originate from the RCA, but asymptomatic CAFs demonstrate a greater
prevalence of origin from the LCA (13). More than 90% of the
fistulas drain into the venous circulation. Low-pressure structures
are the most common sites of drainage of the CAF (14). The most
common drainage sites in order of decreasing frequency are the
right ventricle (41%) (Figs 1,2), right atrium (26%) (Fig 3),
pulmonary artery (17%) (Figs 46), coronary sinus (7%) (Fig 7), left
atrium (5%), left ventricle (3%), and superior vena cava (1%)
(15)
101R ng mch vnh Dn cc nhnh mch mu Dn bung tim ng m gia ng v tnh
mch m ch ngc nhDn thn m phi
http://pubs.rsna.org/doi/full/10.1148/rg.293085120
FIGURE 2.9. (A) Axial. The left main coronary artery and great
cardiac vein are dilated. LM, left main coronary artery; GCV, great
cardiacvein. (B) Coronal. Dilated LM, left main coronary artery.
(C) Volume rendered. AV stula (arrow).
Normal coronary arteries terminate in broom-like arborizations,
which penetrate the myocardium.CAF is defined as a direct
precapillary connection between a branch of a coronary artery and
the lumen of a cardiac chamber, the coronary sinus or superior vena
cava, or a pulmonary artery or pulmonary vein close to the heart
(10).Congenital fistulous connections between the coronary system
and a cardiac chamber appear to represent persistence of embryonic
intratrabecular spaces and sinusoids. They are the most common
congenital coronary anomalies affecting hemodynamic parameters
(11).CAF arises from the right coronary artery (RCA) in
approximately 50% of patients, the left coronary artery (LCA) in
approximately 42% of patients, and both the RCA and LCA in
approximately 5% of patients (12).The majority of symptomatic CAFs
originate from the RCA, but asymptomatic CAFs demonstrate a greater
prevalence of origin from the LCA (13). More than 90% of the
fistulas drain into the venous circulation. Low-pressure structures
are the most common sites of drainage of the CAF (14). The most
common drainage sites in order of decreasing frequency are the
right ventricle (41%) (Figs 1,2), right atrium (26%) (Fig 3),
pulmonary artery (17%) (Figs 46), coronary sinus (7%) (Fig 7), left
atrium (5%), left ventricle (3%), and superior vena cava (1%)
(15)
102
Figure 7a.CAF draining into the coronary sinus in a 66-year-old
man with dilated cardiomyopathy.(ag)Axial MIP(ad)(displayed from
superior[a]to inferior[d]), coronal oblique MIP(e), and
volume-rendered(f, g)CT images show a tortuous and elongated RCA
with a fistulous communication (arrow inacandeg) to the coronary
sinus (arrow ind).(hj)Angiographic images show the fistulous
connection between the RCA (arrow inhandi) and the coronary sinus
(arrow inj).103Phnh ng mch vnhnh ngha> 1.5 ln ng knh, 50% chiu
di mch mu Dn mch vnh Bnh sinh X vaBm sinh Nhim trng Kawasaki: Nht
Bn http://pubs.rsna.org/doi/full/10.1148/rg.297095048Coronary
artery aneurysms are de-fined as coronary artery segments
that(a)have a diameter that exceeds the diameter of normal adjacent
coronary segments or the diameter of the patients largest coronary
vessel by 1.5 times and(b)involve less than 50% of the total length
of the vessel
In Western countries, atherosclerotic aneurysms are most common
(50%), followed by congenital (17%) and infectious causes (10%);
and in Japan, Kawasaki disease represents the predominant cause of
coronary artery aneurysm(14,16,17). The pathogenesis for coronary
artery aneurysms is usually related to the underlying cause (Table
2), but an essential prerequisite to aneurysm formation is the
presence of an abnormal tunica media in the vessel wall (erosion,
ulceration, or hemorrhage in the tunica media), with resultant
enlargement and remodeling of an arterial segment, as clearly
demonstrated in the atherosclerotic model (25,2730).104
Figure 4a. Morphologic classification of coronary artery
aneurysms.(a, b)Drawing(a)and double-oblique maximum intensity
projection image(b)of an atherosclerotic fusiform aneurysm (arrow)
in a 65-year-old man. In this type of aneurysm, the length(L)of the
dilated portion of the coronary artery is more than its transverse
diameter(T).(c, d)Conversely, in saccular aneurysms, as the
drawing(c)shows, the length(L)of the dilated portion is less than
its transverse diameter(T). This type of aneurysm is commonly seen
as a poststenotic dilatation, but in this 55-year-old man, the CT
coronal multiplanar reconstruction of the left main
trunk(d)demonstrates a giant saccular atherosclerotic aneurysm (*)
in the left main trunk. Note the calcified (black arrow) and
noncalcified (white arrow) plaques. Significant coronary artery
disease was noted in the midportion of the left anterior descending
coronary artery (not shown).106
Figure 4c. Morphologic classification of coronary artery
aneurysms.(a, b)Drawing(a)and double-oblique maximum intensity
projection image(b)of an atherosclerotic fusiform aneurysm (arrow)
in a 65-year-old man. In this type of aneurysm, the length(L)of the
dilated portion of the coronary artery is more than its transverse
diameter(T).(c, d)Conversely, in saccular aneurysms, as the
drawing(c)shows, the length(L)of the dilated portion is less than
its transverse diameter(T). This type of aneurysm is commonly seen
as a poststenotic dilatation, but in this 55-year-old man, the CT
coronal multiplanar reconstruction of the left main
trunk(d)demonstrates a giant saccular atherosclerotic aneurysm (*)
in the left main trunk. Note the calcified (black arrow) and
noncalcified (white arrow) plaques. Significant coronary artery
disease was noted in the midportion of the left anterior descending
coronary artery (not shown).107
(d)of coronary artery ectasia in a 62-year-old man with multiple
cardiac risk factors. Ectasia is seen in the RCA, its
posterolateral branch, and the left anterior descending coronary
artery (arrows). Note normal diameters (arrowheads) of the
coronaries; dilatation of the coronary arteries extends for more
than 50% of the vessel length. Most likely cause is atherosclerotic
disease.n= normal.108Bc tch ng mch vnh T pht Giai on trc sanh X va
ng mch Bnh m lin kt V cnSau can thip mch vnh qua da
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2570766/http://www.medscape.com/viewarticle/490976_2http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1995048/http://www.slideshare.net/ncscadsurvivor/scad109
Fig. 1 Multidetector computed tomographic angiography reveals
the dissection of the proximal segment of the right coronary artery
(RCA) (arrows)110
National Heart, Lung and Blood Institute (NHLBI) classification
system for coronary artery dissection types. See text for complete
description. Types A and B are generally clinically benign, whereas
types C through F portend significant morbidity and mortality if
untreated111
chest painlung cancer
lung nodulepericardial effusion
left sided chest pain
left sided chest painarea with no blood vesselspneumothorax
always evaluate with lung windowsThank youTi liu tham kho
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