Aortic Angiography Research Articles

Iterative reconstruction in single-source dual-energy CT angiography: feasibility of low and ultra-low volume contrast medium protocols.

To evaluate the feasibility of using contrast medium (CM) of low and ultra-low volumes and injection rates in aortic CT angiography (CTA) through the joint application of single-source dual-energy CT (ssDECT) and adaptive statistical iterative reconstruction (ASIR). 120 patients with known or suspected aortic dissection underwent aortic CTA and were equally divided into 3 groups. Conventional 120-kVp scan with a CM volume of 70 ml and an injection rate of 5 ml s-1 was performed on Group A. Groups B and C underwent ssDECT scan with CM volumes of 0.6 and 0.4 ml kg-1, respectively. 40% and 50% ASIR algorithms were applied for Groups B and C, respectively. A five-point grading scheme was utilized to subjectively evaluate the image quality, and the CT value and contrast-to-noise ratio were recorded as objective measures. The radiation dose was also evaluated. Groups B and C had equivalent subjective scores and CT values as Group A, whereas they had higher or equivalent contrast-to-noise ratios. Group B had 40.1% and 30% reductions on CM volume and injection rate, respectively, than Group A. Group C further resulted in 19.2% and 22% lesser CM volume and injection rate than Group B. The average effective radiation doses for the study groups were 22.5-24.5% lower than the control group. With the aid of ASIR and ssDECT for aortic CTA, it is feasible to adopt low and ultra-low CM volumes and injection rates while obtaining good quality images. Advances in knowledge: Low and ultra-low CM volumes and injection rates are feasible in CTA through the joint application of ssDECT and ASIR.

Different impact of aortic regurgitation assessed by aortic root angiography after transcatheter aortic valve implantation according to baseline left ventricular ejection fraction and N-terminal pro-B-type natriuretic peptide.

Transcatheter aortic valve implantation (TAVI) is an alternative therapeutic option for severe aortic stenosis. Aortic regurgitation (AR) is commonly observed after TAVI and increases the mortality rate. We hypothesized that the influence of significant AR, defined as that more severe than mild AR, on survival rate after TAVI might differ according to the baseline left ventricular ejection fraction (LVEF) and N-terminal pro-B-type natriuretic peptide (NT-pro BNP) level. We categorized 856 patients who underwent transfemoral TAVI into 2 groups according to their baseline LVEF (<40 and ≥40%) and NT-pro BNP levels (≤5000 and >5000pg/mL). Significant AR was observed in 92 patients (11%). Among patients with significant AR, the proportion of patients with CoreValve/EvolutR implantation was higher than that of patients with SAPIEN XT/3 implantation. Kaplan-Meier curves and the log-rank test showed that significant AR was not associated with 1-year mortality in patients with LVEF ≥40% and those with NT-pro BNP level ≤5000pg/mL. On the other hand, it was significantly associated with a higher 1-year mortality in patients with LVEF <40% (p=0.003) and those with NT-pro BNP level >5000pg/mL (p=0.011). Similarly, multivariate Cox regression analysis showed that the presence of AR was significantly associated with a higher 1-year mortality in patients with LVEF <40% [p=0.005, hazard ratio (HR)=3.626] and NT-pro BNP level >5000pg/mL (p=0.004, HR=3.221). However, AR was not significantly associated with a higher 1-year mortality in patients with LVEF ≥40% and NT-pro BNP level ≤5000pg/mL. Thus, the impact of significant AR on mortality after TAVI seems to be considerable in patients with reduced LVEF or high NT-pro BNP levels, but not those with preserved LVEF or low NT-pro BNP levels, suggesting that the influence of AR differs depending on the baseline LVEF and NT-pro BNP level.

Variations of renal arteries on 64 slice Multidetector Computed Tomography

IntroductionThe incidence of accessory renal arteries is very high. Multidetector Computed Tomography (MDCT) is a minimally invasive alternative to conventional angiography in preoperative evaluation. The aim of this study was to document the incidence of accessory renal arteries and the level of origin of main renal arteries from abdominal aorta. MethodsThe study was conducted on one hundred patients in whom aortofemoropopliteal or aortic CT angiography was done for various indications at a tertiary care center in North India. CT angiography was performed on 64 slice MDCT scanner. The reconstructed images were analyzed using vessel analysis software. ResultsAccessory renal arteries were present in 36% cases with unilateral anomaly in 30% cases and bilateral in 6% cases. The dominant side of renal artery variations was the right side. All the accessory arteries took origin from the aorta and 52.8% of these supplied the inferior pole of the kidney. In 99% cases the origin of main renal artery was between upper border of L1 vertebra and lower border of L2 vertebra. The most common site of origin was at the level of intervertebral disc between L1 and L2. DiscussionThe incidence of multiple renal arteries is much higher than predicted by various studies. Comprehensive anatomic depiction of the renal arterial pattern aids in determining the technical feasibility of surgical and endourological interventions. It helps to avoid postoperative complications.

Additional value of venous phase added to aortic CT angiography in patients with aortic aneurysm

PurposeTo compare diagnostic performance of unenhanced and CTA images (Image set 1) to that of combined unenhanced, CTA, and venous-phase images (Image set 2) for incidentalomas in patients with aortic aneurysm. MethodsPreoperative CT Images of consecutive 240 patients were reviewed by two observers for incidentalomas. Diagnostic performance was assessed. ResultsSensitivity was higher in Image set 2 than Image set 1 in observer 1 and overall (P=0.03 and 0.00). AUCs for both observers were higher in Image set 2 than Image set 1 (P=0.03 and 0.01). ConclusionAddition of venous-phase to CTA significantly improved diagnostic performance of incidentalomas.

Non-gated high-pitch computed tomography aortic angiography: Myocardial perfusion defects in patients with suspected aortic dissection

ObjectivesTo investigate the diagnostic value of first-pass myocardial perfusion defects visualised in non-gated high-pitch computed tomography angiography (CTA) in patients admitted to the emergency department (ED) for suspected aortic dissection. MethodsWe recruited 174 ED patients who underwent high-pitch CTA of the aorta because of suspected aortic dissection. We divided these patients into two groups (diseased and control groups) based on whether their clinical data fulfilled the third universal definition of acute myocardial infarction (AMI), specifically an increase in cardiac troponin (cTn) with at least one of the following: (a) symptoms of ischemia; (b) new ST-segment-T wave (ST-T) changes or new left bundle branch block (LBBB); (c) development of pathological Q wave; (d) new loss of viable myocardium or new regional wall motion abnormality; or (e) identification of an intracoronary thrombus by angiography or autopsy. Twenty-two patients with a clinical diagnosis of AMI were placed in the diseased group. Myocardial perfusion defects were evaluated qualitatively and quantitatively on the late arterial phase obtained 50 s post-threshold. ResultsOf the 22 patients with a final diagnosis of AMI, visually identifiable perfusion defects were observed in 12 patients. The sensitivity, specificity, negative predictive value, and positive predictive value of any perfusion defect for predicting AMI were 54.6%, 94.7%, 93.5%, and 60.0%, respectively. Quantitative analysis indicated that CT attenuation was significantly lower within perfusion defects than within the normal myocardium (67.6 ± 29.5 HU vs. 92.2 ± 19.7 HU; p < 0.001). ConclusionsIn patients with acute chest pain, the presence of myocardial perfusion defect observed on nongated high-pitch CTA of the aorta can be used to identify individuals with AMI with high specificity, but low sensitivity.

Importance of variants in cerebrovascular anatomy for potential retrograde embolization in cryptogenic stroke.

To test the hypothesis that variants in cerebrovascular anatomy will affect the number of patients demonstrating a plausible retrograde embolization mechanism from plaques in the descending aorta (DAo). Thirty-five patients (aged 63 ± 17years) with cryptogenic stroke underwent 4D flow MRI for the assessment of aortic 3D blood flow and MR angiography for the evaluation of circle of Willis, posterior circulation, and aortic arch architecture. In patients with proven DAo plaque, retrograde embolization was considered a potential mechanism if retrograde flow extended from the DAo to a supra-aortic vessel supplying the cerebral infarct territory. Retrograde embolization with matching cerebral infarct territory was detected in six (17%) patients. Circle of Willis and aortic arch variant anatomy was found in 60% of patients, leading to reclassification of retrograde embolization risk as present in three (9%) additional patients, for a total 26% of cryptogenic stroke patients. 4D flow MRI demonstrated 26% concordance with infarct location on imaging with retrograde diastolic flow into the feeding vessels of the affected cerebral area, identifying a potential etiology for cryptogenic stroke. Our findings further demonstrate the importance of cerebrovascular anatomy when determining concordance of retrograde flow pathways with vascular stroke territory from DAo plaques. • Retrograde embolization from descending aortic plaques constitutes a plausible etiology in cryptogenic stroke. • Common variants of cerebrovascular anatomy are important in determining retrograde embolization mechanism. • Variant cerebrovascular anatomy can link retrograde flow pathways with vascular stroke territory.

TCTAP A-009 The Pattern of Myocardial Perfusion Defects in Patients with Acute Coronary Syndrome Detected by Non-gated High-pitch CT Angiography of Aorta at Emergency Department

We intended to investigate the pattern of myocardial perfusion defects (PDs) in cases of acute coronary syndrome visualized by non-gated high-pitch Contrast-enhanced computed tomography angiography (CTA) in patients admitted to emergency department (ED) for suspected aortic dissection. From April

Echocardiographic diagnosis of rare pathological patterns of sinus of Valsalva aneurysm.

ObjectiveTo evaluate the value and improve the diagnostic accuracy of echocardiography in the diagnosis of a sinus of Valsalva aneurysm (SVA) with rare pathological patterns.MethodsEchocardiographic features and surgical findings from 270 Chinese patients with SVA treated in the last 18 years (1995–2013) at the Union Hospital were compared retrospectively; 22 of 270 cases had rare patterns.ResultsThe patients with SVA, a rare origin, a rare extending position, or a rare course accounted for 3.4%, 7.4%, and 0.4% of the 270 cases, respectively. The three most common aneurysmal complications of the patients with rare patterns were severe aortic regurgitation (16), obstruction of the ventricular outflow tract or valvular orifice (3), and conduction disturbance (3). The origin, course, extending position and rupture status of the SVAs determined by echocardiography were entirely consistent with surgical findings in 81.8% of the 22 cases. With the exception of one failed diagnosis of an aneurysmal wall dissection and one misdiagnosis of a descending aortic dissection, the echocardiographic results of SVA complications and associated cardiovascular lesions were also confirmed.ConclusionWe could accurately diagnose SVAs with rare pathological patterns by echocardiographic identification of distinguishing features. However, for several conditions, we could not accurately identify the origin or course of the aneurysm or define its relationship to adjacent structures using conventional echocardiography alone. Therefore, we recommend combining conventional echocardiography with different imaging techniques, such as transesophageal echocardiography, three-dimensional echocardiography, computed tomography angiography, and aortic angiography.

Reducing Iodine Contrast Volume in CT Angiography of the Abdominal Aorta Using Integrated Tube Potential Selection and Weight-Based Method Without Compromising Image Quality.

The purpose of this study is to determine whether image quality was maintained when a weight-based protocol incorporating tube potential selection was used to select lower iodine contrast volumes for aortic CT angiography (CTA). Patients with potentially decreased renal function underwent CTA performed with the iodinated contrast volume determined using a table incorporating different tube potentials and patient weights. The image quality of CTA examinations performed with a reduced iodine volume (hereafter known as "low-iodine CTA examinations"), internal control CTA examinations (i.e., prior examinations), and size-matched control CTA examinations was evaluated in separate reading sessions conducted by three vascular radiologists who were blinded as to the contrast volume and tube potential used. Side-by-side unblinded comparison of the examinations was also performed. Aortic attenuation and the contrast-to-noise ratio were measured. Comparisons were performed using the Wilcoxon signed rank test. Fifty low-iodine CTA examinations, 36 internal control CTA examinations, and 50 size-matched control CTA examinations were performed. Contrast volumes were 63% lower when the protocol based on tube potential and patient weight was used (mean contrast volume, 49 mL for low-iodine CTA vs 133 mL for internal control CTA and 138 mL for size-matched control CTA). The mean volume CT dose index was 15.1 mGy for low-iodine CTA versus 18.8 mGy for internal control CTA (p < 0.001), and 15.3 mGy for low-iodine CTA versus 17.1 mGy for size-matched control CTA (p = 0.11). Of the image quality and diagnostic confidence evaluations for low-iodine CTA examinations, over 97% had acceptable image quality and diagnostic confidence for blinded (50/50) and unblinded (35/36) comparisons. Aortic attenuation was similar between groups (p = 0.13-0.71). A weight-based protocol that incorporates tube potential selection allows the use of substantially lower volumes of iodinated contrast material in aortic CTA while maintaining acceptable image quality.

Initial Experience of the Application of Automated Tube Potential Selection Technique in High-pitch Dual-source CT Angiography of Whole Aorta Using Third-generation Dual-source CT Scanner.

Objective To evaluate the application of automated tube potential selection technique in high-pitch dual-source CT aortic angiography on a third-generation dual-source CT scanner. Methods Whole aorta angiography were indiated in 59 patients,who were divided into 2 groups using a simple random method:in group 1 there were 31 patients who underwent the examination with automated tube potential selection using a vascular setting with a preferred image quality of 288 mA/100 kV;in group 2 there were 28 patients who underwent the examination with a tube voltage of 100 kV and automated tube current modulation using a reference tube current of 288 mA. Both groups were scanned on a third generation dual-source CT device operated in dual-source high-pitch ECG-gating mode with a pitch of 3.0,collimation of 2×192×0.6 mm,and a rotation time of 0.25 s. Iterative reconstruction algorithm was used. For group 1,the volume and flow of contrast medium and chasing saline were adapted to the tube voltage. For group 2,a contrast material bolus of 45 ml with a flow of 4.5 ml/s followed by a 50 ml saline chaser at 5 ml/s was used. CTA scan was automatically started using a bolus tracking technique at the level of the original part of aorta after a trigger threshold of 100 HU was reached. The start delay was set to 6 s in both groups. Effective dose (ED),signal to noise ratio (SNR),contrast to noise ratio (CNR),and subjective diagnostic quality of both groups were evaluated. Results The mean ED were 21.3% lower (t=-3.099,P=0.000) in group 1 [(2.48±0.80) mSv] than in group 2 [(3.15±0.86) mSv]. Two groups showed no significant difference in attenuation,SD,SNR,or CNR at all evaluational parts of aorta (ascending aorta,aortic arch,diaphragmatic aorta,or iliac bifurcation)(all P>0.05). There was no significant difference in subjective diagnostic quality values of two groups [(1.41±0.50) scores vs. (1.39±0.50) scores;W=828.5,P=0.837]. Conclusion Compared with automated tube current modulation,the automated tube potential selection technique in aorta CT angiography on a third-generation dual-source CT can dramatically reduce radiation dose without affecting image quality.

Initial experience with the 3.3 Fr Mongoose® pigtail catheter for aortic angiography during patent ductus arteriosus closure in small patients.

Background:Smaller femoral arterial sheaths may be associated with fewer vascular complications. The 3.3 Fr Mongoose® Pediavascular pigtail catheter is a catheter that allows higher flow rates, potentially resulting in improved angiographic quality. We reviewed our experience with this small catheter during patent ductus arteriosus (PDA) closure.Materials and Methods:Review of patients ≤20 kg in whom the Mongoose® catheter was used during PDA closure from 12/13 to 4/15. Angiographic efficacy and procedural details were compared to ten 4 Fr catheter cases. Comparisons were performed using Mann–Whitney U-test; P < 0.05 was statistically significant.Results:Twelve (9 female) patients were catheterized with a 3.3 Fr Mongoose®. Median weight 10.5 kg (range 6.4–18.2), height 81 cm (range 37–111), and body surface area (BSA) 0.47 m2 (range 0.33–0.75) were similar to ten patients (3 females) in the 4 Fr control group (P = NS); median weight 9.9 kg (range 6–16.8), height 80 cm (range 64–102), and BSA 0.46 m2 (range 0.31–0.74). Angiographic quality was subjectively adequate with both with no difference in the median pixel density between the two techniques (3.3 Fr: 76.7 [range 33.5–90] and 4 Fr: [70; 38–102]; P = NS). Contrast used was similar between the groups (3.3 Fr: median 4.2 ml/kg and 4 Fr: 4.9 ml/kg; P = NS). Median radiation dose was similar in the two groups (3.3 Fr: 28.1 mGy [range 17.2–38] and 4 Fr: 38 mGy [range 20.4–58.5]; P = NS). All ducts were closed at latest follow-up (P = NS). No complications were encountered.Conclusions:The 3.3 Fr Mongoose® allowed similar angiography to the 4 Fr pigtail catheter, allowing safe and effective transcatheter PDA closure in small children.

Celiac trunk and hepatic artery variants: A retrospective preliminary MSCT report among Egyptian patients

ObjectiveTo evaluate the feasibility of MSCT angiography of the celiac trunk and hepatic artery variants with a non-tailored protocol among Egyptian patients. Patients and methods1285 Egyptian patients were retrospectively analyzed in our Radiology Department – Ain Shams University came for triphasic CT or CT aortic angiography. The celiac trunk origin and its main branches mainly the common hepatic artery were identified. The incidence of different celiac and hepatic artery anomalies was calculated depending on Uflacker’s and Michel’s classifications. ResultsAbout 90.5% of the patients showed normal trifurcation pattern of the celiac trunk (Uflacker type I) with the commonest variant was gastro-splenic trunk (Uflacker type V) with 4.3% incidence. The bifurcation pattern was representing 7.7% of cases. Regarding the hepatic artery, 74.3% of the cases showed normal origin of the hepatic arteries (Michel type I) with the commonest anomaly was Michel type III with 12.5% incidence. Some cases are discovered not previously described by either Uflacker’s or Michel’s classifications. ConclusionIn our preliminary reports, Good imaging quality of MSCT angiography has proved effectiveness in depicting different celiac trunk and hepatic artery variants. This is important pre-interventional or pre-surgical to decrease the complications and the morbidity rates.

Use of low tube voltage and low contrast agent concentration yields good image quality for aortic CT angiography

To evaluate the impact of a "double-low" imaging protocol (low tube voltage and low contrast agent concentration) on image quality and radiation dose for aortic computed tomography (CT) angiography (CTA). This was a prospective study of 72 patients undergoing aortic CTA. They were randomised to the double-low and conventional CT (control) groups (n=36/group). Axial imaging was performed in the study group, and control patients were scanned with the conventional protocol. Double-low parameters were: 80-100kV, 200mAs, 128×0.625 collimation, 1-mm section thickness, 0.5-mm increments, 300mm field of view (FOV), iohexol (300mg iodine/ml, 1-1.5ml/kg, injected at 4-5ml/s). Control CT parameters were: 120kV, 200-300mAs, iopamidol (370mg iodine/ml; 1-1.5ml/kg, injected at 4-5ml/s); the remaining parameters were the same as in the double-low group. Image noise and quality scores of the double-low and control groups were 15.05±1.53 versus 14.67±1.53 and 3.52±0.51 versus 3.44±0.5 (both p>0.05), respectively. Radiation dose was 56% lower in the double-low group compared to control patients (6.76±1.08 versus 15.48±1.01mSv, p<0.001). Iodine intake per-capita in the double-low group was 18% lower compared to the control group (300.25±7.2 versus 367.86±5.54 mgI/kg, p<0.001). The "double-low" technique for aortic CTA significantly reduced the doses of radiation and iodine contrast agent, while maintaining good image quality.

Application of Amplatzer vascular Plug II in pediatric coronary artery fistula patients treated with transcat-heter closure

Objective To investigate the feasibility and safety of transcatheter closure of coronary artery fistula (CAF) with Amplatzer vascular PlugⅡ(AVPⅡ) in pediatric patients. Methods Between June 2012 and October 2015, 5 children aged 0.9 to 7.0 years old and weighted 10 to 21 kg with CAF were admitted to the Department of Pediatric Cardiology in Shandong Provincial Hospital Affiliated to Shandong University.Aortic root angiography was used first to confirm the origin, shape, branches, drainage and the diameter of the orifice of CAF by deploying the pigtail catheter.The AVPⅡwas retrogradely deployed into targeted artery through guiding catheter and aortic angiography was performed before releasing the plug. Results All the 5 children underwent transcatheter closure by AVPⅡsuccessfully.Two cases were involved with right coronary-right ventricular fistula, 1 case of left anterior descending coronary-right ventricular fistula (residual fistula after surgical repair), and 1 case of left circumflex coronary-left atrial fistula.Four children had a single fistula, and 1 case had double fistulas.The diameter of the orifice ranged from 2.00 to 5.96 mm, and the selected occluders from 8 to 14 mm.The ratio of diameter of occluder to fistula orifice ranged from 2.3 to 3.4.All the patients were followed up for 4 to 44 months.Two patients developed instant minor and modera-te aortic regurgitation.No other complications such as thrombosis, embolization, residual shunt, arrhythmia, coronary dissection or perforation occurred. Conclusions Transcatheter closure of CAF by AVPⅡin pediatric patients is feasible and safe.Aortic regurgitation should be noted, especially during the procedure. Key words: Coronary artery fistula; Transcatheter closure; Plug; Arotic regurgitation

54. Radiofrequency perforation of pulmonary valve and PDA stenting in a preterm neonate

Transcatheter radiofrequency perforation of the pulmonary valve and PDA stenting is considered as a modality for pulmonary atresia and intact ventricular septum with mildly hypoplastic tripartate right ventricle. We present a preterm neonate who has undergone this procedure. we assume that transcatheter radiofrequency perforation of pulmonary valve and PDA stenting is a safer approach for pulmonary atresia with intact ventricular septum in preterm newborns, than surgical approach.We present 5 days old, preterm (36 weeks gestation) baby girl, with 2.2 kg. She was reffered to our centre with the diagnosis of pulmonary atresia with intact ventricular septum, mildly hypoplastic tripartate right ventricle. Right ventricle angiography showed tripartate right ventricle with no sinusoids. She underwent successful radiofrequency perforation of pulmonary valve followed by balloon dilatation. At the same time prograde PDA stenting was done. Repeat right ventricle angiography showed good right ventricular outflow tract forward flow, and descending aorta angiography showed good PDA flow supplying both pulmonary arteries. The baby was extubated on same day, and prosoglandin E1 was discontinued immediately after the procedure.The baby mainatined saturation more than 80% on room air. The baby was discharged after 2 days. Our case is pecular because to our knowledge this is the lowest weight for wich radiofrequency perforation and PDA stenting is done as well as being preterm.

Clinical application of AMPLATZER Vascular Plug Ⅱ in transcatheter closure of congenital coronary artery fistula in children

To evaluate the feasibility of applying AMPLATZER Vascular Plug Ⅱ (AVP Ⅱ) in transcatheter closure of congenital coronary artery fistula in children. Transcatheter closure procedure applying AVP Ⅱ was carried out in 7 patients (3 males and 4 females, age 1.2-12.0 years) with congenital coronary artery fistula between May 2014 and September 2015 in Pediatric Cardiology Department of Guangdong Cardiovascular Institute. Selective coronary artery angiography and aortic root angiography were performed after the release of the device to evaluate the immediate therapeutic effect. Echocardiography and electrocardiography were performed at 1 day, 1 month, 3 months, 6 months, 1 year post procedure and repeated once a year during the follow-up period. Transcatheter deployment of the device was successfully accomplished in all patients. The narrowest diameter of the fistula was (8.6±2.8) mm (4.0-12.5 mm), and the size of the deployed device ranged from 10.0 to 16.0 mm. Immediate selective coronary artery angiography revealed no residual shunt in 5 patients and trivial residual shunt in 2 patients. During a mean follow-up period of 2.7 (1.0-16.0) months, echocardiography showed that 3 patients remained no residual shunt, while 2 patients had trivial residual shunt, 2 patients developed small residual shunt. Cardiac murmur disappeared post procedure in all patients. Electrocardiography showed no ST-T changes. No migration or detachment of the device was found. AVP Ⅱ is a safe and effective choice in transcatheter closure of congenital coronary artery fistula in children.

Computed tomography angiography of aorta subjected to external wrapping.

BackgroundExternal wrapping is a surgical technique used in patients with dilated ascending aorta. To date, there is no available data describing the radiographic features of the aorta subjected to external wrapping using a straight corrugated Dacron vascular prosthesis. The aim of this study was to find distinctive radiographic features of an externally constricted aorta.MethodsPreoperative and early postoperative (7th postoperative day) CT angiography images of ten patients who underwent wrapping procedures were assessed and compared. The images were analyzed in order to find characteristic features of CT angiography images of the ascending aorta subjected to external wrapping.ResultsThe CT-angiography images showed that the aortic wall deformed significantly (the wall plicated) after the wrapping procedure in one patient, whose aortic diameter was decreased by 47 %. The remaining nine patients did not have significant aortic wall deformations. All patients presented with a periaortic mass. This was a collection of blood clots and pericardial fluid that filled the empty space in the pericardium following a decrease in the diameter of the ascending aorta. A very thin (<1 mm) crescent-shaped uncontrasted layer was noticed between the aorta and the periaortic area in all patients. This, in turn, was an empty space between the aorta and the corrugated vascular prosthesis.ConclusionsThe CT-angiography images of the aorta subjected to external wrapping may have unique features that are not observed after other operations on the ascending aorta. The knowledge about the details of this surgical procedure helps to correctly assess these images.

Usefulness of triphasic CT aortic angiography in acute and surveillance: Our experience in the assessment of acute aortic dissection and endoleak

IntroductionComputed tomography angiography (CTA) has been widely used in the diagnostic evaluation of many aortic diseases, but no standardized techniques actually exist for aortic CTA. The aim of this study was to describe the usefulness of triphasic CTA in aortic assessment in both non-traumatic emergency and surveillance conditions. MethodsWe performed non ECG-gated CTA examinations with a 64-slice CT scanner using a triphasic protocol consisting of an unenhanced acquisition, and two (early and delayed) contrastographic phases with a delay of 25–30 s and 100–120 s respectively after the injection of contrast medium. Were retrospectively selected adult patients with imaging findings of acute aortic dissection (AAD) or endoleak (EL) from November 2012 to November 2014. ResultsAAD was detected in 36 (67%) patients: 23 type A-AADs, and 13 type B-AADs. The presence of EL was observed in 18 (33%) patients: 1 type Ia, 5 types IIa, 2 types IIb, 1 type IIIa and 9 types IIIb. DiscussionTriphasic CTA is useful to provide correct and prompt diagnosis of AAD in emergency, allowing the evaluation of type and atypical forms of AAD, and the identification of possible branch-vessel involvement and complications. During surveillance, triphasic CTA assures accurate and complete assessment of all known and unknown ELs and it is essential for first follow-up examination. ConclusionTriphasic CTA represents a reliable imaging tool for aortic assessment in both non-traumatic emergency and surveillance after endovascular aneurysm repair. Modified protocol could be employed in selected patients and tailored in their known disease.

Hemodynamic Assessment of AorticRegurgitation After TranscatheterAortic Valve Replacement: The Diastolic Pressure-Time Index.

Assessment of aortic regurgitation (AR) immediately after transcatheter aortic valve replacement (TAVR) is essential to guide further intervention in cases of relevant AR. It was the aim of this study to identify a simple and reproducible hemodynamic parameter for the assessment of AR. Relevant AR after TAVR is present in up to 21% of cases and might be associated with adverse long-term outcomes. Three hundred sixty-two consecutive patients who were treated with TAVR for symptomatic aortic valve stenosis were analyzed. AR was assessed by aortic root angiography according to the Sellers classification. For hemodynamic evaluation, the diastolic pressure-time (DPT) index was calculated after TAVR: the area between the aortic and left ventricular pressure-time curves was measured during diastole and divided by the duration of diastole to calculate the DPT index. The DPT index was finally adjusted for the respective systolic blood pressure: DPTindexadj=(DPT index/systolic blood pressure)×100. Patients with angiographically nonrelevant AR (grade<2) had higher DPT indexadj (30.7 ± 6.8) compared with those with relevant AR (grade≥2) (26.2 ± 5.8) (p< 0.05). Patients with DPT indexadj≤27.9 had significantly higher 1-year mortality risk in comparison with those with DPT indexadj >27.9: 41.4% versus 13.5% (hazard ratio: 3.8; 95% confidence interval: 2.4 to 5.9; p [log rank-test]< 0.001). In multivariate regression analysis, DPT indexadj≤27.9 was the strongest independent predictor of 1-year mortality (hazard ratio: 2.5; 95% confidence interval: 1.8 to 3.7; p< 0.001). DPT indexadj is a simple, investigator-independent parameter that should be considered to differentiatebetween relevant and nonrelevant AR after TAVR.

Acute aortic dissection presenting as painless paraplegia: a case report

BackgroundAcute aortic dissection is an extreme emergency that is generally manifested by violent chest pain irradiating to a patient’s back and abdomen. Paraplegia due to spinal cord ischemia and infarction as a presenting manifestation of aortic dissection has been found in 2 to 5 % of patients. However, painless paraplegia is exceedingly rare and limited to a few case reports in the literature. We describe a new case with this unusual presentation of aortic dissection and here we emphasize that this condition must be considered in all patients with painless paraplegia.Case presentationA 70-year-old Arab man with no previous known medical or surgical conditions was hospitalized for brutal heaviness of his lower limbs associated to urinary retention. A neurological examination revealed flaccid paraplegia without sensory disorder. His blood pressure and his pulse were in normal ranges. He was afebrile. His peripheral pulses were not checked. Laboratory investigations eliminated multiple organ failure. Spinal magnetic resonance imaging realized in emergency was normal. He had a cardiopulmonary arrest 1 day after his hospitalization. His autopsy report concluded a type A aortic dissection with an intimal tear at his aortic isthmus with intrapericardial rupture and extension to his intercostal and lumbar arteries.ConclusionsAcute aortic dissection is an extreme emergency that can lead to death unless there is an early diagnosis. It must be considered in any patient with paraplegia even painless. Clinical examination has a major role to play in diagnosing this condition. Apart from the neurological examination, palpation of peripheral pulses and blood pressure measurements in all four limbs is of paramount importance. Then further investigations must be carried out consisting of aortic angiography by computed tomography or by magnetic resonance imaging.