‫بسم هللا الرحمن الرحيم‬

AL RIBAT UNIVERSITY
FACULTY OF RADIOLOGY AND NUCLEAR
MEDICINE

CT Angiography

‫األشعه المقطعيه لألورده والشرايين‬

Research for have B.S.C

Name/ Adil Tawfig AbdAllha Mohammed

Supervisor/ Shaza Mahgob

CHAPTER ONE
 Introduction
Computed tomography (CT) is a simple and robust method for evaluating the
peripheral arterial system and for diagnosing peripheral arterial disease. Advances in
technology and variability in patient physiology make contrast administration
challenging, however. This article will review patient preparation for CT angiography
(CTA) of the lower extremities, as well as optimal scanner settings, contrast
administration, and visualization techniques.

What is CT angiography?
A CT (computerised tomography) scanner uses X-rays and a computer to make
pictures of the inside of your body. It is similar to a plain X-ray however it takes lots
of pictures of a section (cross sections) of your body instead of just one.
CT angiography uses CT and a special contrast dye to look at blood vessels in your
brain, neck, heart, lungs, kidneys and legs.
The CT scanner has a round opening in the centre and a flat bed for you to lie on.
While you are lying on the bed, it will slowly move you into the opening where the
pictures are taken. The movement is controlled by the CT staff.

Benefits of CT angiography
 Used for diagnosis to show very detailed pictures of inside your head, neck,
body, legs and arms.
 Can be used during surgery to look at blood vessels while they are being
repaired.
 Although CT scans use radiation, no radiation is left in your body after the scan is
finished.
 Painless, accurate and fast.
 Risks of CT angiography
Your doctor knows the risks of CT angiography and will advise you whether the
benefits outweigh any possible risk.
Angiograms are not usually recommended in early pregnancy, or for people with
known kidney disease but may occasionally be necessary.
Possible risks include:

 Small amount of radiation. The amount of radiation you are exposed to

depends on the number of pictures taken and the part of the body being examined.
 Extremely small chance you could develop cancer in the long term from the
radiation.
 An allergic reaction from the dye. You may have nausea (feeling sick),
sneezing, vomiting, itching, hives and dizziness. More serious reactions can occur,
but are very rare.
 Infection, bleeding or injury at the site of an injection.
If you have any allergies, tell the CT staff or radiology doctor.
If you are at all concerned regarding the risks, talk to your doctor before the
examination.

Tell your doctor before the scan

 If you are or may be pregnant.
 If you have any allergies and medical conditions, including asthma, diabetes,
heart disease, kidney disease or thyroid problems.
 Any medications you are taking.

Just before the scan

 You may be given a gown to wear.
 You may be asked to remove any metal objects.
CHAPTER TWO
What Is It Used For?
Doctors order CT scans for a long list of reasons:

 CT scans can detect bone and joint problems, like complex bone fractures and
tumors.
 If you have a condition like cancer, heart disease, emphysema, or liver masses, CT
scans can spot it or help doctors see any changes.
 They show internal injuries and bleeding, such as those caused by a car accident.
 They can help locate a tumor, blood clot, excess fluid, or infection.
 Doctors use them to guide treatment plans and procedures, such as biopsies,
surgeries, and radiation therapy.
 Doctors can compare CT scans to find out if certain treatments are working. For
example, scans of a tumor over time can show whether it’s responding
to chemotherapy or radiation.

What Is a CT Scan with Contrast?

In a CT scan, dense substances like bones are easy to see. But soft tissues don’t show up as
well. They may look faint in the image. To help them appear clearly, you may need a special
dye called a contrast material. They block the X-rays and appear white on the scan,
highlighting blood vessels, organs, or other structures.
Contrast materials are usually made of iodine or barium sulfate. You might receive these
drugs in one or more of three ways:

 Injection: The drugs are injected directly into a vein. This is done to help your blood
vessels, urinary tract, liver, or gallbladder stand out in the image.
 Orally: Drinking a liquid with the contrast material can enhance scans of your
digestive tract, the pathway of food through your body.
 Enema: If your intestines are being scanned, the contrast material can be inserted in
your rectum.

After the CT scan, you’ll need to drink plenty of fluids to help your kidneys remove the
contrast material from your body.
CHAPTER THREE
How should I prepare?
You should wear comfortable, loose-fitting clothing to your exam. You may need
to wear a gown during the procedure
Metal objects, including jewelry, eyeglasses, dentures and hairpins, may affect
the CT images. Leave them at home or remove them prior to your exam. You
may also be asked to remove hearing aids and removable dental work. Women
will be asked to remove bras containing metal underwire. You may be asked to
remove any piercings, if possible.
You will be asked not to eat or drink anything for a few hours beforehand,
if contrast material will be used in your exam. You should inform your physician
of all medications you are taking and if you have any allergies. If you have a
known allergy to contrast material, your doctor may prescribe medications
(usually a steroid) to reduce the risk of an allergic reaction. To avoid unnecessary
delays, contact your doctor before the exact time of your exam.
Also inform your doctor of any recent illnesses or other medical conditions and
whether you have a history of heart disease, asthma, diabetes, kidney disease or
thyroid problems. Any of these conditions may increase the risk of an adverse
effect.
Women should always inform their physician and the CT technologist if there is
any possibility that they may be pregnant. See the  CT Safety During
Pregnancy  page for more information.
If you are breastfeeding at the time of the exam, ask your doctor how to
proceed. It may help to pump breast milk ahead of time and keep it on hand for
use until contrast material has cleared from your body, about 24 hours after the
test. However, the most recent American College of Radiology (ACR) Manual on
Contrast Media reports that studies show the amount of contrast absorbed by
the infant during breastfeeding is extremely low. For further information please
consult the  ACR Manual on Contrast Mediaand its references.

What does the equipment look like?

The CT scanner is typically a large, donut-shaped machine with a short tunnel in
the center. You will lie on a narrow examination table that slides in and out of
this short tunnel. Rotating around you, the x-ray tube and electronic x-ray
detectors are located opposite each other in a ring, called a gantry. The
computer workstation that processes the imaging information is located in a
separate control room. This is where the technologist operates the scanner and
monitors your exam in direct visual contact. The technologist will be able to hear
and talk to you using a speaker and microphone.

How does the procedure work?

There are many similarities between conventional x-ray imaging and CT
scanning. During conventional x-ray imaging, a single x-ray beam source sends
x-rays through the body. A detector plate captures the x-rays that come out of
the body. Based on the amount of x-rays blocked by the body organs, the image
will appear in different shades of gray. For example, bones appear white on the
x-ray while air is relatively black.
For CT scans, multiple x-ray beam sources and sets of x-ray detectors spin
around the body at high speed. The x-ray beam sources send multiple small
high-energy x-ray beams through the body. The detectors capture those x-rays
that come out of the body. During the examination, you will lie on a table that
moves through the CT scanner so that the x-ray beams can examine different
areas of the body. Then, a fast computer will take the information gathered from
the scanner to produce images of the body. The computer processes a large
volume of CT scan data to create two or three-dimensional images of the body.
Radiologists will analyze these images using sophisticated computer programs
and high-quality monitors to detect diseases in the body.
When a contrast material is introduced to the bloodstream during the
procedure, it clearly defines the blood vessels being examined by making them
appear bright white.

Who interprets the results and how do I get them?

A radiologist, a doctor specially trained to supervise and interpret radiology
exams, will analyze the images. The radiologist will send an official report to the
doctor who ordered the exam.
Follow-up exams may be needed. If so, your doctor will explain why. Sometimes
a follow-up exam is done because a potential abnormality needs further
evaluation with additional views or a special imaging technique. A follow-up
exam may also be done to see if there has been any change in an abnormality
over time. Follow-up exams are sometimes the best way to see if treatment is
working or if an abnormality is stable or has changed.
How is the procedure performed?
Prior to, or on the day of the procedure, you may be asked to complete a questionnaire
to ensure your safety during this procedure. A nurse or technologist will insert
an intravenous (IV) catheter into a vein, usually in your arm or hand. Rarely, a small
amount of blood is withdrawn through the catheter or finger stick to test kidney
function.
The technologist begins by positioning you on the CT exam table, usually lying flat on
your back. Straps and pillows may be used to help you maintain the correct position
and remain still during the exam.
An automatic injection pump connected to the IV will inject contrast material at a
specified rate. In some cases, especially in children and patients with fragile and small
veins, the contrast may be hand-injected using a syringe. During scanning, the table is
positioned at the start point of imaging and will then move through the opening of the
machine as the actual CT scanning is performed. A single scan takes approximately one
to two minutes, but multiple scans may be required.
During CT angiography of the heart, electrocardiogram (ECG) leads (sticky patches) will
be placed on your chest to synchronize CT scanning with your heartbeats. If your heart
beats too fast, it may be temporarily slowed down with medication to obtain clear
images of the heart. If you receive heart rate control medication, you will be closely
monitored during and after the procedure.
You may be asked to hold your breath during the scanning. Any motion, including
breathing and body movements, can lead to artifacts on the images. This loss of image
quality can resemble the blurring seen on a photograph taken of a moving object.
Occasionally, sedation is required for children to keep them still during scanning. Your
doctor will help determine if sedation is needed and, if so, will arrange it. Preparation
for sedation may include no eating and drinking for several hours before the exam to
prevent complications. Also, an extended close observation following the scan may be
required until the medication used for sedation wears off.
When the exam is complete, you will be asked to wait until the technologist verifies that
the images are of high enough quality for accurate interpretation.
Following the exam, the technologist will remove the intravenous catheter and place a
bandage over the needle puncture site.
The entire CT angiography exam may be over within a few seconds. However, the actual
time in the scanner room may be longer, as the technologist will have to appropriately
position you on the table, verify placement of the IV line, do preliminary imaging, and
set up the scanner and contrast injection pump settings based on the part of the body
being imaged.
CT angiography is rarely performed in children as they are more sensitive to radiation
than adults. For children and for adults of reproductive age, radiologists administer low
radiation dose CT scans with dose reduction measures.

What will I experience during and after the

procedure?
CT exams are generally painless, fast and easy. With multidetector CT, the
amount of time that the patient needs to lie still is reduced.
Though the scan is painless, you may have some discomfort from remaining still
for several minutes or from placement of an IV. If you have a hard time staying
still, are very nervous, anxious or in pain, you may find a CT exam stressful. The
technologist or nurse, under the direction of a doctor, may offer you some
medication to help you tolerate the CT exam.
If an intravenous contrast material is used, you will feel a pin prick when the
needle is inserted into your vein. You may feel warm or flushed while the
contrast is injected. You also may have a metallic taste in your mouth. This will
pass. You may feel a need to urinate. However, this is a contrast effect and
subsides quickly.
When you enter the CT scanner, you may see special light lines projected onto
your body. These lines are used to ensure that you are properly positioned. With
modern CT scanners, you may hear slight buzzing, clicking and whirring sounds.
These occur as the CT scanner's internal parts, not usually visible to you, revolve
around you during the imaging process.
You will be alone in the exam room during the CT scan, unless there are special
circumstances. For example, sometimes a parent wearing a lead shield may stay
in the room with their child. However, the technologist will always be able to see,
hear and speak with you through a built-in intercom system.
After a CT exam, the technologist will remove the intravenous line used to inject
the contrast material. The tiny hole made by the needle will be covered with a
small dressing. You can return to your normal activities.
CHAPTER FOUR
Abstract
CT has been gaining widespread acceptance in clinical practice since its invention in the 1970s.
However, cardiac imaging with the use of conventional CT has been limited by the fact that cardiac
motion interferes with conventional CT reconstruction algorithms and leads to loss of morphological
details. Although techniques were developed in the late 1970s or early 1980s to reduce image
degradation due to heart motion [1,2], cardiac imaging has been dominated by invasive coronary
angiography. However, this changed with the development of multislice CT scanners. The main
applications of multislice CT in cardiac imaging are demonstrated in the detection of coronary
calcium deposits, assessment of lumen stenosis or occlusion and prediction of disease outcomes.
Calcium deposition can be quantified non-invasively at a very early stage by electron beam CT
(EBCT) using the Agatston method [3]. EBCT revolutionised cardiac imaging by combining high
temporal resolution (50–100 ms) with prospective electrocardiographic triggering so that images free
of artefacts could be acquired with this technique. The main clinical application of EBCT is in the
detection and evaluation of calcification in the coronary arteries (calcium scoring), which is
considered to be an indicator of coronary artery disease (CAD). EBCT has significant value in
determining calcium scores, which are associated with the degree and severity of CAD, and thus
assists in predicting the probability of future cardiac events [4]. The main limitation of EBCT is its
inferior spatial resolution (z-axis resolution), which is between 1.5 and 3.0 mm. This restricts its
diagnostic value in accurately evaluating the severity of CAD. After the arrival of multislice CT
scanners in the late 1990s, the use of EBCT became rare. It was eventually replaced by multislice CT
from 2003 onwards.
As an alternative to invasive coronary angiography, coronary CT angiography (CCTA) has been
increasingly used for the investigation of suspected CAD, and rapid technological developments have
led to improved spatial and temporal resolution. The early generations of 4- and 16-slice CT scanners
represented a technological revolution in cardiac imaging [5-9], although the diagnostic accuracy in
terms of sensitivity was low for grading native coronary disease. Specificity for exclusion of CAD
(negative predictive value) was good, and this generation of technology also proved useful for the
evaluation of coronary anomalies and bypass graft patency. Improved spatial resolution with 16-slice
CT plays an important role in the reliable detection and characterisation of coronary plaques and
cardiac wall changes (such as remodelling of the coronary wall due to atherosclerotic plaques).
However, the image quality is compromised in patients with a high heart rate, stents or severely
calcified arteries [7,8]. In 2004, all major CT manufacturers introduced the next generation of CT
scanners with 32, 40 and 64 simultaneously acquired slices, which brought about a further leap in
volume coverage speed. With gantry rotation times down to 330 ms for 64-slice CT, temporal
resolution for cardiac electrocardiography (ECG)-gated imaging was again markedly improved.
Improvement of image quality has also been reported in the visualisation of all coronary artery
branches, with high sensitivity and specificity achieved [10-12]. In patients with high heart rates,
multisegment reconstruction algorithms were reported to provide diagnostic images by offering
optimal temporal resolution, thus mitigating motion artefacts [13,14].
Dual-source CT was designed to further improve temporal resolution to 83 ms, thus increasing image
quality by reducing motion artefacts. Studies have shown a significant improvement with the use of
CCTA in the assessment of patients with a high heart rate when dual-source CT (DSCT) is used [15-
18]. The development of wide-area detector CT enables greater coverage per gantry rotation [19-21].
Expansion of multislice CT systems from a prototype 256-slice to a 320-slice system has allowed for
acquisition of whole-heart coverage in one gantry rotation. Tables 1 and and22 list the number of
detector rows, number of simultaneously acquired slices, maximum gantry rotation speed, effective
maximum temporal resolution, method of dual-energy imaging and other special features for each of
the manufacturers for their scanners of 64 slices and above.
a
Conjugate cone-beam back projection uses sets of counteropposed projections to provide 128 distinct projection
measurements per rotation for an axial and a helical acquisition mode to significantly improve z-resolution. Axial
reconstruction provides up to 128 reconstructed slices for 1 rotation.
b
Dynamic z-focal spot technique is used to double the sampling in the slice direction, resulting in 256 simultaneous slices.
c
z-sharp technology doubles the X-ray projections reaching each detector segment, resulting in a full 128-slice acquisition.
Temporal resolution can be down to 75 ms for Syngo HeartView CT.
d
Dual-source cardio acquistion modes: z-flying focal spot technique is used to acquire 128 slices. Syngo HeartView Flash
(Siemens Healthcare) provides 75 ms temporal resolution independent of the heart rate (≤37.5 ms using two-segment
reconstruction, except Flash Spiral).
e
Dual source Flash Spiral modes for increased scan speed ≥400 mm s –1, resulting in temporal resolution of 75 ms.
f
Dual-source, dual-energy acquisition modes with the parallel utilisation of two sources with different kilovolt settings and
selective photon shield, resulting in improved differentiation.
CHAPTER FIVE
Conclusion

CT has become a simple and robust method for assessing the peripheral arterial
system and diagnosing peripheral arterial disease. Optimization of contrast
administration is increasingly challenging as scanner speeds increase. New ways to
evaluate each patient's circulatory physiology and compensate for it when
administering contrast material are needed.
Advances in scanner speed are unlikely to reduce the volume of contrast used
during examination of the peripheral vascular system but will improve image
resolution. Finally, additional detector rows create additional data to analyze. We
must continue to find more effective and automated ways to manipulate and process
such large data sets.
REFERENCE

1/ A/ https://appliedradiology.com/articles/ct-angiography-of-the-lower-extremities

B/ https://healthywa.wa.gov.au/Articles/A_E/CT-angiography#:~:text=Risks%20of%20CT
%20angiography&text=Small%20amount%20of%20radiation.,allergic%20reaction%20from%20the
%20dy

2/ https://www.webmd.com/cancer/what-is-a-ct-scan

3/https://www.radiologyinfo.org/en/info.cfm?pg=angioct#:~:text=CT%20angiography%20uses%20a
%20CT,a%20vein%20of%20the%20arm.

4/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3479873/

5/ https://appliedradiology.com/articles/ct-angiography-of-the-lower-extremities