Aortic imaging with CMR

Dr. Saul Myerson

Clinical Lecturer in Cardiovascular Medicine
For www.scmr.org 02/2007

This presentation posted for members of scmr as an educational guide – it represents the
views and practices of the author, and not necessarily those of SCMR.

University of Oxford Centre for Clinical Magnetic Resonance Research

(OCMR)
 Overview

• Background

• Basic imaging techniques

• Specific application to common disease

states
 Background

• Many advantages that CMR brings :

– Free choice of imaging planes
– Range of imaging techniques – anatomical, cine,
angiography, flow
– 3D imaging with angiography

• CMR is the gold standard for aortic imaging

• Other techniques (TEE, CT) do have

strengths, esp. in the acute setting
 Basic approaches
• Start with standard imaging stack in 3 planes:
– Transverse
– Coronal
– Oblique sagittal, parallel to asc & desc aorta

• Aim for reasonable long-axis view of aortic arch/descending

aorta (the ‘candy-stick’ view)
– Gives good representation of anatomy
– May need other views for measuring diameter/flow
• Use transverse/other images piloted from long axis view for
better visualisation/measurement
• Should usually include the aortic root & valve too
• Hints:
• Make good use of Cine imaging
• Be creative in your choice of image plane
• You don’t always need to image the entire aorta in one plane
 Oblique sagittal slices

Can sometimes achieve good long-axis view of aorta if lucky –

otherwise may need to adjust above views using coronal
views to guide, or utilise 3-point-planning
Cine images in aortic long axis
• May need 3- point
planning to achieve

• Good identification of
aortic wall and motion

• Excellent representation of
course of the aorta without
mental re-construction

• Not good for diameter

measurement however, but
is good for planning trans-
aorta image slices
 Oblique coronal image

Sometimes useful for depicting anatomy:

* *

Dilated & tortuous descending aorta with intra-mural haematoma (*)

 LV outflow tract
Need to assess: general anatomy, dilation, shape
diameters (sinus, asc aorta, arch ± aortic annulus)
- use transverse views from this one
aortic valve function
Specific applications
• Dilated aorta
• Dissection
• Coarctation
• Cervical arch
 Dilated aorta

• Important to take full advantage of CMR and use trans-

aortic planes for true diameters
• Several points are required (sinuses, asc Ao, mid arch,
mid-desc Ao…)
• For dilated Ao roots, it is important to document any AR
 Dilated aorta (3) - angiography
• MR angiography can be especially useful for complex dilated aortas, and the
exact anatomy can be visualised.
• Surface-rendered angiograms are good, but can miss smaller vessels and
stenoses can be overestimated.

Dilated aortic arch with small calibre entry and exit vessel. Note left subclavian
arises from dilated section, and requires re-implantation at surgery
 Dissection (1)

• Cine imaging often v. helpful

– Motion of dissection flap

– High signal from surrounding flowing blood

– Low signal from flap ± adjacent slow flow (in false

lumen)

• Needs to be perpendicular to the plane of

dissection for good visualisation of the flap
Dissection (2) - example

Type B aortic dissection

in long-axis plane
Dissection (3)
Shows correct piloting of long-axis plane from
transverse image – perpendicular to dissection flap
a) Coronal LVOT view of repaired ascending aortic
dissection (with short inter-positional graft) – some
turbulence seen but dissection flap not seen
b) Angulated slightly further to reveal suspicious
turbulence but still not clear
c) Further imaging in correct plane reveals clear
dissection flap above the inter-positional graft
 Dissection (4)
– importance of correct imaging plane

a) Coronal LVOT view of repaired ascending aortic dissection (with short

inter-positional graft - arrowed). Some turbulence seen but dissection flap
not seen
b) Angulated slightly further to reveal suspicious turbulence but still not clear
c) Further imaging in correct plane reveals clear dissection flap (arrowed)
above the inter-positional graft

a b c
 Dissection (5)

True lumen
False lumen

Pleural effusion

• The dissection flap usually spirals from the root around the
lesser curve of the arch
• The true lumen is often smaller and commonly medial
• The dissection may extend into branch vessels
 Coarctation (1)
• Aim for a longitudinal plane through the
coarctation site
• Ideally obtain in-plane flow in this plane - can be
tricky to obtain, and in severe or complete
coarctation, impossible
Coarctation (2) – angiography

• Very severe or complete

coarctation is aided by
MR angiography.

• Collateral vessels can

also be seen well. Note
the aneurysm in the
collateral vessel (close to
the aorta) in this patient

• Be careful not to
overestimate the tightness
of the coarctation by poor
threshold setting
 Coarctation (3) - tips

• Beware metal clip artefacts

post-repair – can cause image
drop-out and appear as more
severe/recurrent coarctation

• Do image the aortic valve ±

flow - the aortopathy persists
even after coarctation repair
and 50% of coarctations have
a bicuspid valve and
Metal artefact from clips
suggesting tight re-
coarctation. Catheter data
showed no significant
stenosis
 Cervical aortic arch

High-coursing aortic arch (behind clavicle). Can be narrowed, or (as in this

case) of normal calibre. May be due to persistence of 3rd branchial arch in
fetal development, or failure of 4th branchial arch to migrate downwards
 Conclusions

• Aortic imaging is straightforward if you think

about what you’re trying to visualise

• Make good use of cine, flow and contrast

angiography

• Don’t forget about the aortic valve