15

DAVID SUTTON

DAVID SUTTON PICTURES

DR. Muhammad Bin Zulfiqar PGR-FCPS III SIMS/SHL

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

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

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

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

• Fig. 15.5 AAA on coronal planar reconstruction.

• 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.

• 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

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

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

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

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

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

• 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.)

• 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.)

• 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.)

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

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

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

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

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

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

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

• Fig. 15.22 Intravenous DSA image showing aortic thrombosis.

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

• 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.

• 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.

• 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.

• 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.

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

• 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.

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

• 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.

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

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

• 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

• 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.

• 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.

• Fig. 15.36 Polyarteritis nodosa showing multiple micoaneurysms.

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

• 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.

• 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)

• 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).

• 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.

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

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

• Fig. 15.44 Subclavian thrombosis (arrow).

• 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.

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

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

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

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

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

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

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

• 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.

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

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

• 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.

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

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

• 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.

• 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.

• 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.)

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

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

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

• Fig. 15.66 Renal carcinoma showing pathological vessels.

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

• 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.

• 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.

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

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

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

• hyperplasia.

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

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

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

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

• 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.

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

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

• 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.

• 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.

• 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.

• 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.

• 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.

• 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).

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

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

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

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

• 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.

• 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.

• 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.

• 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.

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

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

• 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.

• 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

• 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.

• 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.

• 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.

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

• 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.

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.

• 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

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

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

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

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

• 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.

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

• 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.

• 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.

• 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.

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

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.

• 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.

• 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.

• 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).

• 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.

• 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.

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

• 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.

• 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.

• 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.)

• 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.)

• 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).

• 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.

• 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.

• 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).

• 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).

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.

• 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.

• 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.

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

• 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.

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

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).

• 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.

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

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

• 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).

• 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.)