DAVID SUTTON PICTURES Only for study purpose

1. 15
DAVID SUTTON

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. • Fig. 15.1 (A,B) Ultrasound. Large 9-cm AAA
containing thrombus.

4. • Fig. 15.2 Infected right axillo-femoral and
femoro-femoral cross-over Dacron grafts on
technetium- diverticulum on technetium
labelled red cell scan.

5. • Fig. 15.3 Gastrointestinal bleeding into
descending colon from a diverticulum on
technetium labelled HMPAO white cell scan.

6. • Fig. 15.4 CT. (A) Large 8.5-cm. AAA. (B) AAA
containing thrombus

7. • Fig. 15.5 AAA on coronal planar
reconstruction.

8. • Fig. 15.6 CT. (A) Inflammatory AAA with
calcification in its wall. (B) Leaking AAA with
retroperitoneal haematoma. (C) Leaking AAA
with active retroperitoneal bleeding.

9. • Fig. 15.7 CT. (A) AAA with contained leak into
left psoas muscle. (B) Infected aortic
bifemoral Dacron graft with gas-fluid level in
the sac of the aneurysm

10. • Fig. 15.8 CT. Right popliteal artery aneurysm
on axial slice (A) and 3D MIP (B) and SSD (C)
reconstructed images.

11. • Fig. 15.9 CT. Large 9.5-cm ascending thoracic
aortic aneurysm.

12. • Fig. 15.10 CT. Type A dissecting aneurysm of
ascending and descending thoracic aorta.

13. • Fig. 15.11 (A-C) CT. Type B aortic dissection of
descending thoracic and abdominal aorta and
iliac arteries.

14. • Fig. 15.12 CT. Type B aortic dissection in
abdominal aorta and left common iliac artery
on coronal planar reconstruction.

15. • Fig. 15.13 (A) 3D spiral CT scan showing
fibromuscular hyperplasia of right renal artery
with poststenotic aneurysm at the bifurcation. (B)
Computer-extracted 3D color study of aortic
aneurysm compressing the left main bronchus,
which is shown in green. (Courtesy of Dr A. Al
Katoubi.)

16. • Fig. 15.14 (A) Spiral CT. 3D reconstruction showing abdominal
aortic aneurysm. The inferior vena cava and hepatic veins are also
well shown. (B) Spiral CT. 3D surface shaded study of prosthesis
replacing aortic aneurym. AP view of double aorta-iliac graft in situ
after transfemoral insertion. (Courtesy of Dr. A. L. Kutoubi.)

17. • Fig. 15.14 (A) Spiral CT. 3D reconstruction showing
abdominal aortic aneurysm. The inferior vena cava and
hepatic veins are also well shown. (B) Spiral CT. 3D surface
shaded study of prosthesis replacing aortic aneurym. AP
view of double aorta-iliac graft in situ after transfemoral
insertion. (Courtesy of Dr. A. L. Kutoubi.)

18. • Fig. 15.15 MRA. Normal femoral, popliteal and tibial
arteries.

19. • Fig. 15.16 MRA. Normal renal arteries and
accessory artery to lower pole of right kidney.

20. • Fig. 15.17 MRA. Aneurysm of thoracic aortic
arch.

21. • Fig. 15.18 MRA. Aneurysm of lower
abdominal aorta.

22. • Fig. 15.19 (A, B) Normal right superficial
femoral artery with stenosis (arrow) in right
popliteal artery on carbon dioxide DSA.

23. • Fig. 15.20 DSA. Spasm (arrow) in right
external iliac artery produced by the right
catheter in a child.

24. • Fig. 15.21 DSA. Occlusion in right common
iliac artery produced by a guide-wire
dissection during cardiac catheterisation.

25. • Fig. 15.22 Intravenous DSA image showing
aortic thrombosis.

26. • Fig. 15.23 Intravenous DSA
image showing femoral false
aneurysm following cardiac
catheterisation.

27. • Fig. 15.24 Technique of percutaneous catheter
insertion using the Selding-Sutton needle. (A) Needle
inserted into artery. (B) Guide passed through needle
into artery (C) Needle withdrawn leaving guide wire in
artery. (D) Catheter passed over guide into artery. (E)
Guide withdrawn leaving catheter in artery.

28. • Fig. 15.25 MRA. Coarctation of the descending
thoracic aorta distal to the left subclavian artery
(arrow) with hypertrophied collateral vessels in
the chest wall.

29. • Fig. 15.26: (A). Abdominal
coarctation with
involvement of superior
mesenteric origin. There is
collateral circulation
through the artery of
Drummond from left colic
branch of the inferior
mesenteric to middle
colic branch of superior
mesenteric. Owing to the
increased flow, aneurysm
have developed at both
ends of collateral.
(Courtesy of Dr. R. Eban)(B
and C) DSA and 2 D time
of flight MRI showing
lower abdominal aortic
stenosis.

30. • Fig. 15.26: (A). Abdominal coarctation with involvement of superior
mesenteric origin. There is collateral circulation through the artery
of Drummond from left colic branch of the inferior mesenteric to
middle colic branch of superior mesenteric. Owing to the increased
flow, aneurysm have developed at both ends of collateral. (Courtesy
of Dr. R. Eban)(B and C) DSA and 2 D time of flight MRI showing
lower abdominal aortic stenosis.

31. • Fig. 15.27 Mycotic aneurysm of left common
iliac artery in a patient with salmonella
septicaemia.

32. • Fig. 15.28 (A) Chest film showing aortic
knuckle (arrow) apparently displaced
downward by a supra-aortic mass. (B,C)
Angiograms showing that this is due to an
aneurysm of the arch and innominate artery.

33. • Fig. 15.29 (A) MRA. AAA and left common
iliac artery stenosis. (B) DSA. Right popliteal
artery aneurysm.

34. • Fig. 15.30 DSA. (A,B) Bilateral common femoral
and right deep femoral artery aneurysms and
occlusion of right superficial femoral artery. (C)
Aorto-bi-iliac Dacron graft with false aneurysm at
distal anastomosis of right limb and occlusion of
right external iliac artery.

36. • Fig. 15.32 DSA studies. (A) Traumatic false
aneurysm of the arch following RTA. (B,C)
Ruptured innominate artery following RTA

37. • Fig. 15.33 Types of dissecting aneurysms (see
text).

38. • Fig. 15.34 Axial MRI section of thorax shows a
dissecting aneurysm. In the ascending aorta both
lumens are patent and separated by an intimal flap (F).
In the descending aorta the false lumen contains
thrombus (T). (Courtesy of Dr Peter Wilde and Bristol
MRI Centre

39. • Fig. 15.35 DSA. (A-C) Type B dissecting aneurysm
of descending thoracic and abdominal aorta
with filling of false lumen in aortic arch and left
common iliac artery and occlusion of left renal
artery.

40. • Fig. 15.35 DSA. (A-C) Type B dissecting aneurysm
of descending thoracic and abdominal aorta
with filling of false lumen in aortic arch and left
common iliac artery and occlusion of left renal
artery.

41. • Fig. 15.36 Polyarteritis nodosa showing
multiple micoaneurysms.

42. • Fig. 15.37 Aneurysm of the pancreaticoduodenal
arcade (arrow) secondary to acute pancreatitis
(subtraction film).

43. • Fig. 15.38 (A) CT of a large mediastinal mass
presenting in a young woman. (B) Transaxillary
aortogram confirms giant poststenotic aneurysm
and previously unrecognised mild coarctation.

44. • Fig. 15.39 (A) Aorto-bifemoral Dacron graft with occlusion of left limb and false aneurysm at
distal anastomosis of right limb (MRA). (B) Occlusion of right common and external iliac
arteries and patent left to right femoro-femoral Dacron crossover graft (MRA). (C) Occlusion
of right external iliac and common femoral artery foll owing the use of a device to seal the
arterial puncture site after a cardiac catheter (DSA)

45. • Fig. 15.40 (A) Localised defect in the popliteal artery due to a
popliteal cyst. (B) DSA. Coeliac artery stenosis (top arrow) and
superior mesenteric artery occlusion (lower arrow).

46. • Fig. 15.41 (A) Occlusion of coeliac and superior mesenteric
arteries. Separate origin of splenic artery. Artery of
Drummond arising from inferior mesenteric. (B) Artery of
Drummond supplies the superior mesenteric origin and
then the hepatic artery through pancreatic arcades.

47. • Fig. 15.42 (A) Renal artery stenosis due to
atheroma. (B) DSA. Renal artery stenosis due to
fibromuscular dysphasia.

48. • Fig. 15.43 Subelavian stenosis with
poststenotic aneurysm formation. (A)
Saccular. (B) Fusiform aneurysm.

49. • Fig. 15.44 Subclavian thrombosis (arrow).

50. • Fig. 15.45 MRA. (A,B) Right subclavian artery
aneurysm with arms down, but occlusion due
to compression in the thoracic outlet with
arms up.

51. • Fig. 15.46 DSA. (A,B) Left subclavian artery
steal syndrome.

52. • Fig. 15.47 DSA. Digital artery occlusions due
to thoracic outlet syndrome.

53. Fig. 15.48 Buerger's
disease. Femoral
arteriography showed
normal smooth-walled
femoral and popliteal
arteries, but occlusion of
the calf vessels with
collaterals.

54. • Fig. 15.49 Fibromuscular hyperplasia of the
brachial artery in a woman of 50 years
presenting with digital ischaemia.

56. • Fig. 15.52 (A) Plain film.
(B) DSA. Occlusion of left
popliteal artery due to
dislocation of left knee.

57. • Fig. 15.53 (A) CT. (B,C) DSA. Pulmonary emboli
with right deep femoral and left popliteal
artery paradoxical emboli.

58. • Fig. 15.54 (A) DSA. (B) CT. Left common iliac
and inferior mesenteric artery emboli
(arrows).

59. • Fig. 15.55 (A) Embolus of the aortic bifurcation
with clot defect extending into the left common
iliac. DSA study. (B) Embolus of the superior
mesenteric artery.

60. • Fig. 15.56 (A,B) Arteriogram. High-flow
angiomatous malformation in right kidney.

61. • Fig. 15.57 Angioma of the pelvis, presenting as vulval
swelling. Aneurysmal dilatation of draining vein.

62. • Fig. 15.58 Angioma of the small bowel with high-volume shunting into
the portal system in a woman of 24 years with repeated attacks of
melena. In the previous 10 years she had had four barium enemas and
five barium follow-throughs with negative findings. Large angiomas like
this are unusual in the bowel, small areas of dysplasia being more
common.

63. • Fig. 15.59 (A,B) DSA. (C) Proton-density MRI.
High-flow angiomatous malformation in right
buttock (arrows).

64. • Fig. 15.59 (A,B) DSA. (C) Proton-density MRI.
High-flow angiomatous malformation in right
buttock (arrows).

65. • Fig. 15.60 Mesenteric-portal fistula (arrowed) shown by selective superior
mesenteric injection. There is rapid filling of dilated superior mesenteric
and portal veins. The lesion followed a crush injury to the abdomen.

66. • Fig. 15.61 Giant renal arteriovenous fistula, possibly due to
rupture of an aneurysm associated with fibromuscular
hyperplasia. The patient presented with heart failure and a
pulsating mass clinically thought to be pelvic because of ptosed
kidney. (A) Arterial phase. (B) Venous phase showing a dilated
inferior vena cava.

67. • Fig. 15.62 Aortocaval
fistula following
spontaneous rupture of
an abdominal aortic
aneurysm. The superior
mesenteric is displaced
by the aneurysm
containing mural
thrombus (white arrow).
The fistula into the
inferior vena cava is
marked by the black
arrow. The curved arrow
suggests an intimal flap
in the aneurysm. (From
Gregson et al (1983) by
permission of the editor
of Clinical Radiology.)

68. • Fig. 15.63 DSA. Active bleeding (arrow) into
the small intestine due to lymphoma.

69. • Fig. 15.64 DSA. Active bleeding (arrow) into
the descending colon from a diverticulum.

70. • Fig. 15.65 (A,B) DSA. Vascular encasement of
gastroduodenal artery and hepatic portal
vein by a carcinoma in the head of the
pancreas.

71. • Fig. 15.66 Renal carcinoma showing
pathological vessels.

72. • Fig. 15.67 DSA. Renal artery stenosis in a
kidney transplant.

73. • Fig. 15.68 (A) Selective hepatic arteriogram. A
large vascular tumour is shown in the lower part
of the right lobe of the liver. Histology: primary
hepatoma. (B) Selective hepatic angiogram shows
solitary vascular deposit from colonic carcinoma.

74. • Fig. 15.69 (A) Vascular lesion simulating tumour
in the liver. Haemangioma. (B) Note absence of
drainage veins or arteriovenous shunting and
persistence of contrast medium in the late phase.

75. • Fig. 15.70 Angiogram showing a large vascular
mass with a smaller mass in the lower part of the
right lobe.

76. • Fig. 15.71 DSA. Small hepatocellular
carcinoma in the right lobe of the liver kin
hemochromatosis.

77. • Fig. 15.72 DSA. Large tumour in the liver in a
child due to focal nodular
• hyperplasia.

78. • Fig. 15.73 Pancreatic cystadenoma showing
florid pathological circulation in the head of the
pancreas.

79. • Fig. 15.74 DSA. Insulinoma in the head of the
pancreas.

80. • Fig. 15.75 Carotid body tumour (A) Lateral
projection. (B) A.P. projection.

81. • Fig. 15.76
Haemangiopericytom
a. Patient presented
with a lump in the
right thigh. The
vascular tumour was
highly malignant and
metastasised rapidly.

82. • Fig. 15.77 (A) Arteriogram showing 75-90% stenoses in the right
external iliac artery and occlusion of the right superficial femoral
artery before angioplasty. (B) Balloon catheter in the external iliac
artery during the angioplasty. (C) Angiographic result in the external
iliac artery after angioplasty.

83. • Fig. 15.78 (A) Arteriogram showing 75% stenosis in
right superficial femoral artery before angioplasty. (B)
Angiographic result (arrows) with intimal clefts after
angiography.

84. • Fig. 15.79 (A) A suitable lesion for PTA-
arteriogram showing 75% stenosis in the
distal left superficial femoral artery. (B)
Arteriogram after angioplasty.

85. • Fig. 15.80 (A)
Arleiiugiam ~bowing
a shod 2 CHI
occlusion in the right
popliteal artery,
below the distal
anastomosis of a
femoro popliteal vein
graft. (B) Arteriogram
after angioplasty.

86. • Fig. 15.81 (A) Arteriogram showing short occlusion in right tibioperoneal
trunk before angioplasty. (B) Balloon catheter in tibioperoneal trunk
during angioplasty. (C) Angiographic result after angioplasty.

87. • Fig. 15.82 (A) Arteriogram showing 75%
stenosis in left subclavian artery before
angioplasty. (B) Angiographic result with
filling of internal mammary artery after
angioplasty.

88. • Fig. 15.83 (A) Arteriogram showing 75%
osteal stenosis (arrow) in right renal artery
before angioplasty. (B) Angiographic result
after and insertion of a vascular stent.

89. • Fig. 15.84 (A) Arteriogram showing a short 4 cm
occlusion in the right common iliac artery. (B)
Arteriogram after insertion of Wallstens in both
common iliac arteries.

90. • Fig. 15.85 (A) Traumatic AV fistula (arrow)
between right common iliac artery and left
common iliac vein produced by lumbar disc
surgery on MRA. (B) Angiographic result after
insertion of a covered stent (arrows).

91. • Fig. 15.86 CT showing coronal planar
reconstruction of AAA.

92. • Fig. 15.87 (A) Arteriogram showing infrarenal
AAA suitable for EVAR. (B,C) Angiographic
result after insertion of aortobiiliac stent.

93. • Fig. 15.88 (A) Arteriogram showing fusiform
aneurysm of descending thoracic aorta. (B)
Angiographic result after insertion of straight
aortic stent.

94. • Fig. 15.89 Type 1 endoleak after early EVAR
on CT (A) and arteriogram (B).

96. • Fig. 15.91 (A) Phlebogram showing gastric varices
during a TIPS with vascular stent in the liver. (B)
Phlebographic result after embolisation with metal
coils. (C) Phlebographic result after successful TIPS.
Guide has passed through the hepatic vein and liver to
reach (arrows) a portal vein.

97. • Fig. 15.91 (A) Phlebogram showing gastric varices
during a TIPS with vascular stent in the liver. (B)
Phlebographic result after embolisation with metal
coils. (C) Phlebographic result after successful TIPS.
Guide has passed through the hepatic vein and liver to
reach (arrows) a portal vein.

98. • Fig. 15.92 Venograms showing complete occlusion of the superior
vena cava due to thrombus (A) before thrombolysis and (B) a
pulse spray catheter in the superior cava during the lysis with tissue
plasminogan activator. (C) Angiographic result in the superior vena
cava and brachiocephalic veins after thrombolysis and the insertion
of a Wallstent.

99. • Fig. 15.93 (A) Renal arteriogram showing a large
renal cell carcinoma. (B) After embolisation of
the right kidney with absolute ethyl alcohol,
gelatin sponge fragments, and spiral metal coils.

100. • Fig. 15.94 Nasopharyngeal angiofibroma. (A)
Before embolisation. (B) After embolisation.

101. • Fig. 15.95 (A,B) Arteriogram showing
hypervascular multifocal hepatocellular
carcinoma in the liver. (C) Lipiodol and
doxorubicin in the liver after
chemoembolisation.

102. • Fig. 15.96 (A,B) Arteriograms showing an
arteriovenous fistula between the left deep
femoral artery and vein with false aneurysm
formation due to a stab wound. (C,D) After
embolisatin with the balloons.

103. • Fig. 15.97 (A) Arteriogram showing false
aneurysm of anterior branch of right hepatic
artery at the site of the hepatojejunostomy.
(B) Angiographic result after embolisation

104. • Fig. 15.98 (A) Arteriogram showing splenic
artery aneurysm. (B) Angiographic result
after embolisation with metal coils. (C)
Embolisation coils proximal and distal to the
neck of the aneurysm.

105. • Fig. 15.99 Colour and spectral Doppler of the
origin of the internal carotid artery. The colour
Doppler shows a high-velocity jet at the site of an
hypoechoic plaque with aliasing of the colour
Doppler information; the spectral display also
shows aliasing of the Doppler signal, a rough
estimate of the peak velocity can be obtained by
adding the two systolic components together:
260 + 212 = 472 cm/s.

106. • Fig. 15.100 The carotid bifurcation showing (A)
higher diastolic flow in the internal carotid artery
compared with (B) the external carotid artery;
the normal region of reversed flow in the bulb is
also seen (*). In addition, the external carotid
waveform shows fluctuations (arrows) induced by
tapping the superficial temporal artery. A branch
artery can also be seen arising from the external
carotid artery.

107. • Fig. 15.101 The common femoral artery
waveform at rest (A) and after moderate
exercise (B).

108. • Fig. 15.102 Transverse view of the right carotid
bifurcation using power Doppler ultrasound. It is
not possible to distinguish the direction, or
velocity of flow in the two branches of the artery
from the more superficial internal jugular vein.

109. Fig. 15.103 Transcranial colour Doppler images of the circle
of Willis before (A) and after (B) an injection of the echo-
enhancing agent Levovist. Before the Levovist injection only
the middle cerebral artery is seen; after the injection all the
major components of the circle of Willis are visible.

111. • Fig. 15.105 (A) Type 1 plaque showing a thin
rim over the surface of a predominantly
hypoechoic plaque. (B) Type 4 plaque showing
a predominantly echogenic plaque with a
smooth surface. (C) An ulcerated plaque

112. • Fig. 15.106 Power Doppler image of a critical
ICA stenosis showing the narrow residual
lumen.

113. • Fig. 15.107 Transverse view of a carotid
bifurcation with an hypoechoic carotid body
tumor splaying the two major branches.

114. • Fig. 15.108 A dissection of the common
carotid artery, showing the thrombosed
channel posteriorly (*) and the tapered
stenosis anteriorly.

115. • Fig. 15.109 (A) The normal appearance of the
intimal line with an IMT of 0.5 mm. (B) A
thickened intimal line in a patient with an I MT
of 1.4 mm.

116. • Fig. 15.110 Colour Doppler image of the neck
showing the common carotid artery (orange)
with the vertebral artery between the lateral
processes of the cervical spine. The blue of
the vertebral artery shows that it is flowing in
the opposite direction to the carotid; this is
confirmed by the spectral display.

117. • Fig. 15.111 A high-grade stenosis of the
common femoral artery showing aliasing and
a peak velocity in excess of 3.4 m/s (A),
compared with a prestenosis velocity of 0.66
m/s (B), producing a velocity ratio of more
than 5 : 1 indicating a severe stenosis.

118. • Fig. 15.112 An in situ vein graft showing a
stenosis on colour Doppler ultrasound with a
peak velocity of 2.8 m/s (A), compared with a
prestenosis velocity of 0.6 m/s (B), producing
a velocity ratio of 4.6:1 consistent with a
severe stenosis.

119. • Fig. 15.113 Image of an upper segment of a
femotopopliteal graft showing damped flow
of low velocity (27 cm/s), which is strongly
suggestive of a graft at risk of failure.

120. • Fig. 15.114 A false aneurysm of the common
femoral artery following arteriography. Colour
Doppler ultrasound shows the blood in the false
aneurysm and the spectral trace shows the
characteristic to and fro flow of blood in and out
of the aneurysm during the cardiac cycle.

122. • Fig. 15.116 A TIPS in a patient with portal
hypertension. Spectral Doppler ultrasound
shows evidence of a degree of stenosis with
flow in excess of 2 m/s.

125. • Fig. 15.119 An aneurysm of the hepatic artery
in a transplant patient, colour Doppler showed
arterial flow within the lumen.

126. • Fig. 15.120 (A) Normal hepatic vein spectral
display showing variation in flow during the
cardiac cycle. (B) The cardiac variations reflect the
pressure changes in the right atrium during the
cardiac cycle. 1 = Forward flow into the atrium
during diastolic relaxation; 2 = reverse flow
during tricuspid valve closure and ventricular
systole; 3 = forward flow as tricuspid valve opens;
4 = reverse flow during atrial systole.

127. • Fig. 15.121 Colour Doppler image of the liver
in a patient with Budd-Chiari syndrome.
Instead of the normal regular pattern of
hepatic veins, there is a complex network of
abnormal collaterals.

128. • Fig. 15.122 Intraparenchymal Doppler
examination of a patient with renal arte
stenosis shows a damp waveform with a
prolongs acceleration time of 0.18 s.

129. • Fig. 15.124 Transverse colour Doppler view of
the bladder showing a pair of normal ureteric
jets.

130. Fig. 15.125 (A) A film from an intravenous urography examination in
a patient who sustained right renal trauma in a road traffic
accident: there is only minimal excretion of contrast from the lower
fragment. (B) Spectral Doppler ultrasound shows both arterial and
venous flow in this fragment.

131. • Fig. 15.123 Intrarenal Doppler image of a
patient with acute renal failure shows no
significant diastolic flow R.I. = 1 .0. This
pattern may also be seen in patients with
renal vein thrombosis.

132. • Fig. 15.126 (A) Colour and spectral Doppler from
a transplant kidney with a moderately elevated RI
of 0.79. (B) The effect of transducer pressure over
the transplant with a decrease in diastolic flow to
zero.

133. • Fig. 15.127 Transverse colour Doppler image
of the lower abdominal aorta showing the
inferior mesenteric artery lying to the left of
the aorta (orange), the inferior mesentericvein
is seen further laterally (blue).

134. • Fig. 15.128 (A) A caval filter inserted for
recurrent pulmonary emboli. (B) Colour
Doppler ultrasound confirms the patency of
the cava at the level of the filter. The change in
colour from red to blue reflects the relative
change in the direction of flow in relation to
the transducer as the blood flows through the
sector.

135. • Fig. 15.129 Reformatting of post-processed data
in order to straighten out a curved structure - in
this case a normal renal artery. (A) Raw data
image. (B) Reformatted 3D CE-MRA image.

136. • Fig. 15.130 3D CE-MRA image showing a left
subclavian stenosis (arrow).

137. • Fig. 15.131 Coronal maximum intensity projection
(MIP) image of a two-dimensional time-for-flight MR
angiogram showing normal bilateral neck arteries. c,
common carotid artery; e, external carotid artery; i,
internalcarotid artery; v, vertebral artery.

138. • Fig. 15.132 Lateral MIP image of a two-
dimensional time-of-flight MRA targeted to
show the right neck arteries (same key as in
Fig. 15.131.

139. • Fig. 15.133 Peripheral 3D CE-MRA performed in
sections with tracking of the contrast bolus using set
prescribed table movements, with slight overlap, to
demonstrate the aortic bifurcation and peripheral
vessels including the run-off. The final image is a
composite to show the whole study. (Courtesy of
Philips Medical Systems.)

140. • Fig. 15.134 Bilateral carotid arteries with a left common
carotid stenosis (arrow) with no venous enhancement on a
3D CE-MRA image using elliptical centric view ordering of
the data (see Ch. 59). (Courtesy of IGE Medical Systems.)

141. • Fig. 15.135 Chronic descending aortic dissection
on (A) sagittal and (B) transverse gated T2-
weighted spin echo (TE 2b ms.). Note the signal
from the slow-flowing blood in the false lumen
(curved arrow), and the itimal flap (straight
arrows).

142. • Fig. 15.136 (A) Moderate degree of aneurysmal dilatation of the
ascending aorta extending into the proximal part of the
innominate artery on contiguous parasagittal T 1 - weighted spin
echo (SE 750/15) image. (B) A sagittal-oblique phase contrast
gradient echo (GE 750/7/40°) sequence in the same patient through
the outflow tract shows a jet of signal void in the left ventricle
(arrowed) consistent with aortic regurgitation.

143. • Fig. 15.137 Flask-shaped dilatation (a) of the aortic
root and ascending aorta characteristic of Marfan's
syndrome, on coronal oblique ECG-gated (A) T,-
weighted spin-echo and (B) phase constrast gradient
echo image.

144. • Fig. 15.138 Chronic aortic dissection on: (A) a set of four transverse tine gradient refocused (TE 28 ms) MR
angiograms through the upper abdomen at the same anatomic level; (B) flow velocity maps derived from the
angiograms in part (A) and (C) a plot of the maximum flow rates in the true and false lumens at different times
in the cardiac cycle, showing reversal of blood flow in the false lumen (o, true lumen; t, false lumen) (Same
patient as in part A, i mages have been taken at 100 ms intervals from the R-wave of the patient's ECG
(indicated by the number on each image). There is a high signal within the false lumen (straight arrow) of the
aorta (a) and inferior vena cava (i). Note signal loss in the true lumen (curved open arrow) and superior
mesenteric artery (curved closed arrow) during systole due to high flow rates, with a return of signal at 530 ms
as the flow rate reduces. In part B, flow direction and velocity can be derived. Antegrade flow appears as light
grey, absence of flow as mid-grey (similar to background), and retrograde flow as dark grey. The true lumen
(curved arrow) shows antegrade flow during systole, whereas false lumen (straight arrow) shows initial
antegrade flow with flow reversed at 330 ms (see part C). Flow in the inferior vena cave (i) is consistently
caudocranial. (Reproduced with permission from Mitchell et al 1988).

145. • Fig. 15.138 Chronic aortic dissection on: (A) a set of four transverse tine gradient refocused (TE 28 ms)
MR angiograms through the upper abdomen at the same anatomic level; (B) flow velocity maps derived
from the angiograms in part (A) and (C) a plot of the maximum flow rates in the true and false lumens at
different times in the cardiac cycle, showing reversal of blood flow in the false lumen (o, true lumen; t,
false lumen) (Same patient as in part A, i mages have been taken at 100 ms intervals from the R-wave of
the patient's ECG (indicated by the number on each image). There is a high signal within the false lumen
(straight arrow) of the aorta (a) and inferior vena cava (i). Note signal loss in the true lumen (curved
open arrow) and superior mesenteric artery (curved closed arrow) during systole due to high flow rates,
with a return of signal at 530 ms as the flow rate reduces. In part B, flow direction and velocity can be
derived. Antegrade flow appears as light grey, absence of flow as mid-grey (similar to background), and
retrograde flow as dark grey. The true lumen (curved arrow) shows antegrade flow during systole,
whereas false lumen (straight arrow) shows initial antegrade flow with flow reversed at 330 ms (see part
C). Flow in the inferior vena cave (i) is consistently caudocranial. (Reproduced with permission from
Mitchell et al 1988).

146. Fig. 15.139 Post-ductal coarctation of the aorta showing
a narrowed diaphragm (arrowed) on (A) sagittal
oblique and (B) coronal-oblique intermediate-weighted
ECG-gated spin echo (SE 1000/21) scans. Note the
dilated collateral vessels supplying the descending
aorta (d) beyond the coarctation.

147. • Fig. 15.140 Coarctation of the aorta, arrowed, previously repaired.
(A) Oblique gated T 1 -weighted spin echo scan (TE 26 ms). (B) A
set of six tine gradient refocused echo (TE 12 ms) MR angiograms
at the same anatomic level, spaced at 100 ms intervals from 15 ms
from the R-wave of the ECG. At peak flow rates during systole there
is some signal reduction at the repaired coarctation site (arrowed),
indicating turbulence. Velocity maps (not shown) were performed
at this site, giving a peak velocity (v) of 2 m/s (pressure gradient =
4v2 , making a calculated gradient of 16 mmHg). This compared
favourably with the value of 20 mmHg obtained from Doppler
ultrasound.

148. • Fig. 15.140 Coarctation of the aorta, arrowed, previously repaired. (A) Oblique
gated T 1 -weighted spin echo scan (TE 26 ms). (B) A set of six tine gradient
refocused echo (TE 12 ms) MR angiograms at the same anatomic level, spaced at
100 ms intervals from 15 ms from the R-wave of the ECG. At peak flow rates during
systole there is some signal reduction at the repaired coarctation site (arrowed),
indicating turbulence. Velocity maps (not shown) were performed at this site,
giving a peak velocity (v) of 2 m/s (pressure gradient = 4v2 , making a calculated
gradient of 16 mmHg). This compared favourably with the value of 20 mmHg
obtained from Doppler ultrasound.

149. • Fig. 15.141 Coarctation of the
aorta (arrow) on a 3D CE-MRA
image in the sagittal-oblique
plane.

150. • Fig. 15.142 Congenital branch pulmonary artery stenosis in a 11-
year-old child with corrected Fallot's tetralogy and persistent
pulmonary artery hypertension. (A) Oblique-coronal gated T 1
weighted spin echo (TE 26 ms) image (B,C) Gradient-refocused echo
(TE 12 ms) MR angiograms at the same anatomic level. (B) End-
diastole. (C) In systole, showing signal loss, due to turbulence, in the
right pulmonary artery (curved arrow). a, right-sided aortic arch; o,
outflow tract of the left ventricle; p, right and left pulmonary
arteries; pa, main pulmonary artery; ra, right atrium; s, left-sided
superior vena cava; t, trachea; straight arrow in part B, position of
the pulmonary valve.

151. • Fig. 15.143 Normal thoracic and upper
abdominal vessels on a 3D CEMRA in the
coronal plane.

152. Fig. 15.144 Posterior view of a surface-rendered
reformatted image of a CE-MRA study showing normal
thoracic vessels. d = descending aorta; p = pulmonary
artery; I = left atrium (Courtesy of GE Medical Systems).

153. • Fig. 15.145 Clear cell renal carcinoma (arrow)
with dilatation and tumour infiltration of the left
renal vein (v) on coronal (A) T,-weighted spin-
echo and (B) 3D CE-MRA studies.

154. • Fig. 15.146 Bilateral renal artery stenosis
(arrows) on a coronal 3D CE-MRA image.

155. • Fig. 15.147 Bilateral fibromuscular dysplasia
(arrows) in a 39-year-old woman on (A), 3D
CE-MRA confirmed on subsequent (B)
conventional arteriography.

156. • Fig. 15.148 Normal renal arteries, including a left
accessory vessel (arrow), on a CE-MRA image
showing scarring to the left kidney (Courtesy of
GE Medical Systems).

157. • Fig. 15.149 Right iliac stenosis on a peripheral 3D CE-MRA study showing: (A)
reference image; (B) postcontrast study during the arterial phase; (C) subtraction
of A and B; (D) 3D surface-rendered image; (E) intraluminal navigator images.
(Courtesy of Philip Medical Systems.)