George G. Hartnell

Coronary artery ectasia. Its prevalence and clinical significance in 4993 patients.

To assess the clinical significance of coronary artery ectasia 4993 consecutive coronary arteriograms were reviewed to identify patients with this condition and to allow the assessment of their progress. Coronary ectasia was a relatively uncommon finding (overall incidence 1.4%). It was not related to the development of aortic aneurysms and did not affect the outcome, results of coronary artery surgery, or symptoms.

Guidelines for Patient Radiation Dose Management

Michael S. Stecker, MD, Stephen Balter, PhD, Richard B. Towbin, MD, Donald L. Miller, MD, Eliseo Vano, PhD,Gabriel Bartal, MD, J. Fritz Angle, MD, Christine P. Chao, MD, Alan M. Cohen, MD, Robert G. Dixon, MD,Kathleen Gross, MSN, RN-BC, CRN, George G. Hartnell, MD, Beth Schueler, PhD, John D. Statler, MD,Thierry de Baere, MD, and John F. Cardella, MD, for the SIR Safety and Health Committee and the CIRSEStandards of Practice Committee

Imaging of aortic aneurysms and dissection: CT and MRI.

There are numerous approaches to the diagnosis of aortic aneurysms and aortic dissection. Echocardiography, computed tomography (CT), and magnetic resonance imaging (MRI) have enthusiastic proponents promoting each technique, which to some extent obscures the real value of each technique. This review examines the role of these techniques in the diagnosis of aortic disease, with special reference to the most recent published literature and an emphasis on the use of CT and MRI. For most patients with chronic aortic disease, MRI is the most appropriate investigation. In acute situations, CT scanning is usually the most useful technique, with echocardiography added for those with ascending aortic disease or cardiac complications.

Transcatheter arterial chemoembolization of liver tumors: effects of embolization protocol on injectable volume of chemotherapy and subsequent arterial patency.

AbstractThe purpose of this study was to determine whether transcatheter arterial chemoembolization (TACE) protocol affects the total volume of chemotherapy injected into the liver as well as subsequent arterial patency. A total of 160 patients with primary or secondary liver cancer were treated with 3 different chemoembolization protocols at a single institution. Data were analyzed retrospectively. Group 1 (n = 36) consisted of slurry of chemotherapy, oil and polyvinyl alcohol particles (PVA), group 2 (n = 91), chemotherapy and oil followed by PVA, and group 3 (n = 33), chemotherapy and oil followed by Gelfoam pledgets. The total volume of chemotherapy injected into the liver was recorded. Arterial patency was determined during subsequent chemoembolizations. The mean percentage of total intended chemotherapy dose administered was 54.6% for group 1, 75.3% for group 2, and 80.6% for group 3. Arterial patency at follow-up angiography was 56% for group 1, 74% for group 2, and 81% for group 3. The slurry protocol (group 1) significantly reduced arterial patency and injectable volume of chemotherapy during TACE.

Percutaneous femoral artery puncture: practice and anatomy

In a survey of the superficial landmarks used to select the site of puncture of the femoral artery for angiography, the inguinal skin crease was most popular, preferred by 39.2% of angiographers. The maximal femoral pulse irrespective of the position of the skin crease was the next most popular landmark (24.7%). Bony landmarks were least popular (13.0%). The majority (73.7%) of those using the skin crease punctured at the same level or distal to it. The relationship of these superficial landmarks to the common femoral artery (CFA) and its bifurcation were investigated. The inguinal skin crease was distal to the bifurcation of the CFA in 71.9% of limbs (mean, 0.61 cm). The maximal femoral pulse was over the CFA in 92.7% of limbs, and the CFA was projected over the medial aspect of the femoral head in 77.9% of limbs. The use of the inguinal skin crease is a popular though unreliable guide for puncture of the CFA. Use of the maximal femoral pulse will enable more constant puncture of the CFA.

Myocardial bridging of the coronary arteries.

Of 1102 consecutive coronary angiograms 16 (1.4%) were found to have systolic narrowing typical of myocardial bridging on the left anterior coronary artery or its branches. Four cases of bridging had otherwise normal coronary arteriograms, four were associated with left ventricular hypertrophy (three in cases of aortic valve disease and one case of hypertrophic cardiomyopathy) and eight were found in association with fixed coronary artery stenoses. Bridging was seen more commonly than expected on normal angiograms. When bridging was associated with left ventricular hypertrophy it affected a longer segment and caused more severe compression. When bridging was found in patients with coronary artery disease, it was not associated with atheroma at its site. Evidence for a pathogenic role of myocardial bridging in ischaemic heart disease is discussed.

Spiral CT evaluation of coronary artery bypass graft patency

Spiral CT (SCT) differs from conventional CT in that the entire heart can be rapidly imaged in the axial plane following the peripheral infusion of small quantities of contrast material. As contrast material travels through coronary artery bypass graft segments, good image detail is achieved, allowing visualization of entire coronary artery graft segments during a single injection. The patency of 43 coronary artery bypass grafts in 14 patients on contrast enhanced SCT, with timing tailored to patient-specific transit times, was compared with that obtained by selective graft angiography. With use of 5 or 8 mm/s table feed and 24 s volumetric acquisitions, SCT established graft patency with 85.7% sensitivity and 100% specificity compared to angiographic examination (96.4% sensitivity and 100% specificity). The mean time between angiography and SCT was 2.1 days, with 86% of SCT studies done within 24 h after angiography. The utilization of dynamic scanning to establish the patient-specific time delay prior to initiation of SCT proved crucial in improving the quality and reliability of SCT bypass graft patency assessment. The paired McNemar test indicates no significant difference between angiography and SCT in establishing patency rates.

Coil embolization of pulmonary arteriovenous malformations

Pulmonary arteriovenous malformations (PAVMs) are uncommon lesions that can be treated by surgery or interventional radiology. Forty-four PAVMs in 11 patients were occluded by transcatheter coil embolization with only one symptomatic complication, deep venous thrombosis, attributable to the procedure. There was a significant improvement in symptoms and a reduction in pulmonary AV shunting in the 9 patients in whom embolization of all visible discrete lesions was successfully completed. Coil embolization is an effective alternative to other methods of treating PAVMs.

Mri of Right Atrial Pseudomass: Is It Really a Diagnostic Problem?

Objective To determine whether the high proportion of patients reported to have prominence of normal right atrial structures by MRI may lead to inappropriate diagnosis of intracardiac tumors. Materials and Methods One hundred forty-nine subjects were examined by spin-echo MRI: patients with cardiac (no. 40), pericardial (no. 30), or thoracic aortic disease (no. 40) and mediastinal tumor (no. 15), and normal volunteers (no. 24). Imaging was reviewed to determine the frequency of a prominent crista terminalis/Chiari network and the likelihood of misdiagnosis of cardiac tumor. Results Prominent intraatrial structures were seen in 59% of subjects, a single prominent nodule in 36%, an intraatrial strand in 13%, and both in 10%. In no case were these findings originally or on review thought to represent a pathological mass or was it felt likely that they could reasonably be misinterpreted as such. Conclusion Normal structures within the right atrium, such as the crista terminalis and Chiari network, may be seen more commonly with MRI than with other imaging modalities. An appreciation of the frequency with which these findings are seen should prevent inappropriate misdiagnosis of pathological masses when none is present.

Magnetic resonance angiography demonstration of congenital heart disease in adults

OBJECTIVE There are limitations when using spin-echo MR imaging to evaluate congenital heart disease (CHD). These include limited ability to detect small shunts, long acquisition times, in-plane or slow flow signal and limited ability to represent complicated three-dimensional (3D) anatomy. However, MR angiography can image flow direction and disturbances, assess function and easily represents 3D anatomy. This may be valuable when evaluating adults with CHD. PATIENTS AND METHODS Fifty consecutive adult patients were referred for MR evaluation of possible or known CHD using time-of-flight MR angiography. Cine, breathhold and presaturation cine MR angiography were acquired as appropriate, with 3D (MIP) reconstruction of all extracardiac anomalies. RESULTS Forty-nine patients had a diagnostic examination (one was unsatisfactory because of arrhythmia). Correlation with alternative imaging (TTE = 36, TOE = 13, cardiac catheter = 16) or surgery was available in 39 patients (MR angiography correct in 36 patients). MRA demonstrated or excluded all confirmed congenital valve (12/12), aortic (9/9), and venous (7/7) anomalies. Thirty-five patients were evaluated for shunts. MR angiography detected 31/33 confirmed shunts (shunts present in 26 patients, sensitivity 94%, specificity 95%). Although not used in all cases, spin-echo was unreliable in demonstrating shunts as signal loss in the region of the secundum septum frequently mimicked atrial septal defects (reducing accuracy for excluding intracardiac shunts, specificity 58%). CONCLUSION MR angiography accurately defines intra- and extra-cardiac anatomy and is superior to spin-echo in detecting or excluding shunts. MR angiography safely and accurately demonstrates many aspects of CHD in adults.