Computed Tomography Aortography Research Articles

Dual-layer spectral computed tomography aortography using a seventy-five-percent-reduced iodine dose protocol and multiparameter spectral imaging: comparison with conventional computed tomography imaging.

Computed tomography angiography (CTA) is the recommended diagnostic and follow-up imaging modality for acute aortic dissection (AD). However, the high-contrast medium burden associated with repeated CT aortography follow-ups remains a significant concern. This prospective study aimed to assess whether an ultra-low contrast dose (75% cutoff) aortic CTA protocol on dual-layer spectral CT could achieve comparable image quality with the full dose protocol. We also investigated the image quality of the virtual noncontrast (VNC) images derived from the ultra-low dose protocol. This study included 37 consecutive patients who were referred to aortic CTA from May 2022 to August 2022. The enrolled patients underwent full-dose contrast CTA and ultra-low dose (reduced to 25% of conventional) contrast CTA on dual-layer spectral CT in 1 day. Virtual monochromatic images (VMIs) were reconstructed with 40 and 70 keV. The VNC images were reconstructed for both protocols. Objective image quality evaluation, recorded as signal-to-noise ratios (SNRs) and contrast-to-noise ratios (CNRs), was compared between the groups using 1-way analysis of variance and post hoc analysis with Bonferroni correction. Subjective image quality was also compared between the groups. Finally, VNC images derived from the low-dose (VNClow) and full-dose (VNCfull) protocols were compared to the true noncontrast (TNC) images. Neither CNR nor SNR was lower for the 40-keV images reconstructed from the ultra-low dose group compared to the conventional images. Both were significantly higher than those of the 70-keV images. Regarding subjective image quality, vessel enhancement was not significantly different between the 40-keV VMI and full-dose images [ascending aorta (AAO): 4.37±0.46 vs. 4.57±0.48, P=0.096; brachiocephalic arteries: 4.34±0.45 vs. 4.51±0.49, P=0.152; abdominal aortic side branch: 4.42±0.48 vs. 4.51±0.49, P=0.480]. The VNClow images were similar to the TNC images but significantly different from the VNCfull images (P<0.001). Ultra-low contrast aortic CTA with a 75%-reduced iodine dose using dual-layer spectral CT and the derived VNC achieved image quality comparable to that of conventional CTA and TNC images.

Intravascular ultrasound imaging in evaluation of aortic stiffness: A proof-of-concept study.

Aortic stiffness is a well-known cardio-vascular risk factor. For years, different methods have been studied in the assessment of aortic elastic properties and large arterial stiffness for risk stratification. Herein is an assessment of the role of intravascular ultrasound (IVUS) imaging for the evaluation of aortic elastic properties. Intravascular ultrasound imaging of the aorta was performed in 12 patients with transthoracic echocardiography (TTE) and computed tomography (CT) evidence for enlargement of the ascending aorta - diameter ≥ 40.0 mm. Mechanical properties of the aorta were derived from the measured diameters and intra-aortic pressure. Paired samples T-test analyses were performed to determine differences between measurements derived by TTE, CT and IVUS. Mean values of the calculated elastic properties via IVUS of the ascending aorta were as follows: compliance 0.021 ± 0.02; strain 205 ± 4.3; aortic stiffness index 4.3 ± 0.75; elastic modulus 0.31 ± 0.05. On paired T-test analysis maximum ascending aortic diameter measured by CT aortography and IVUS did not differ significantly (t = -0.19, p = 0.985), but a significant difference between IVUS measurements and TTE derived diameters was found (t = 13.118, p = 0.034). On average, IVUS diameters were 2.3 mm larger than the results acquired by TTE (95% confidence interval: 14.21-17.13). Intravascular ultrasound examination of the ascending aorta provided larger diameters than the ones collected by means of TTE. However, IVUS measurements did not differ significantly from diameters derived by CT aortography.

Avoiding the re-do sternotomy: treatment of an ascending aortic pseudoaneurysm using a percutaneous Amplatzer PFO closure device.

Ascending aortic pseudoaneurysms are a common phenomenon requiring surgical intervention but can pose high surgical risks in medically complex patients. We report a novel approach to percutaneous closure of ascending aortic pseudoaneurysms using an Amplatzer PFO closure device. We present the case of a 65-year-old male with haemoptysis on a background of multiple cardiac surgeries and chronic kidney disease. Serial computerised tomography scans of the thoracic aorta demonstrated an enlarging ascending aortic pseudoaneurysm. Percutaneous closure was considered the safest treatment option. With angiography, the pseudoaneurysm was defined and a 25mm Amplatzer PFO closure device was deployed. Repeat Computed Tomography aortography performed 43days later confirmed stable device position and resolution of the pseudoaneurysm. The patient was clinically stable at this follow-up point. The off-label use of the Amplatzer PFO device may provide a viable alternative treatment for ascending aortic pseudoaneurysms in medically complex patients to reduce morbidity and mortality.

The role of computed tomography in the diagnosis of malperfusion syndrome in acute aortic dissection (literature review)

Timely diagnosis and treatment of patients with acute aortic dissection continues to be one of the most important and discussed problems in emergency medicine. Due to accurate diagnosis and an effective surgical approach, the results of interventions for acute aortic dissection have improved, at least in specialized centers. However, for patients suffering from malperfusion against the background of acute dissection, the prognosis in some cases remains unfavorable. The cause of malperfusion can be stenosis or occlusion of the main branches of the aorta, which can be detected using computed tomography aortography (CT-AG). Today, it is the method of choice in the diagnosis of not only acute aortic dissection, but also its complications, including malperfusion ones. The purpose of this article is to analyze the capabilities of CT-AG in detecting various types of stenosis arising in the transition of dissection to the main branches of the aorta, as well as the actual manifestations of malperfusion in organs and tissues in acute aortic dissection, according to various authors.

Trends in computed tomography aortography and acute aortic syndrome in an emergency department within Aotearoa New Zealand.

Acute aortic syndrome (AAS) comprises a triad of life-threatening aortic conditions that are difficult to diagnose because of their non-specific clinical presentations. Contrast-enhanced computed tomography aortography (CTA) has a high sensitivity and specificity for these conditions. However, under- and over-investigation of patients with suspected AAS using CTA carries significant risk. The aim of the present study was to evaluate the diagnostic imaging practices of CTA use for patients presenting to an ED with suspected AAS. All atraumatic thoracic CTAs performed on patients aged ≥15 years old with suspected AAS who presented to Auckland City Hospital between 2009 and 2019 were included. Outcomes of interest were the annual ED and population incidences of AAS, and the rate of CTAs performed. A total of 1646 CTAs were included. There were 135 (8.2%) cases of at least one AAS diagnosis and 220 (13.4%) cases where an alternative diagnosis was made. The population-adjusted number of AAS diagnoses remained relatively stable over the study period, with a mean annual AAS incidence of 19.6 (95% confidence interval 9.9-33.7) per 100 000 patients, and 3.2 (95% confidence interval 1.6-5.4) per 100 000 population. The number of ED presentations increased during the study period, along with the population-adjusted rate of CTAs performed, from approximately 150 per 100 000 patients (2009) to 350 per 100 000 patients (2019). Thoracic CTA use for investigating suspected AAS in our ED has recently increased. However, the annual incidence of AAS did not increase over the same period, but was higher than reported in overseas institutions.

Utilization of Intra-Arterial Contrast for Computed Tomography Aortography in a Swine Model

Utilization of Intra-Arterial Contrast for Computed Tomography Aortography in a Swine Model

An Interesting Case of Takayasu’s Arteritis with an Atypical Presentation in an Adolescent Asian Girl

Introduction: Takayasu arteritis (TA) is a chronic non-specific inflammatory disease mainly affecting the medium and large arteries and is a common cause of renovascular hypertension among young Asian females. The initial symptoms and signs vary due to the heterogeneity of affected vessels. Case Presentation: Here we reporting a case of a rare disease in a 15 years old female presenting with abdominal distension, swelling over feet, facial puffiness lasting 1 month after which she was transferred to our hospital for further treatment. Blood Pressure showed significant discrepancy in upper limb and lower limb. Her laboratory results showed an elevated C-reactive protein and D-dimer. Also Color Doppler ultrasound and Computed Tomography Aortography (CTA) leading to diagnosis of TA, after which we started the patient on medical treatment and cardiological intervention. Vasculitis-induced renovascular secondary hypertension resulted in myocardial dysfunction, which recovered with treatment of hypertension and TA. Delayed diagnosis and lack of specific treatment could explain the extent and the clinical severity of the disease at time of hospital admission. Conclusion: Takayasu arteritis is a relatively rare disease with various clinical manifestations, such as ascities, anasarca as in our case. Currently, there are multiple diagnostic tools and treatment options available, and more under investigation. Early, appropriate diagnosis and initiation of proper therapy could avoid further progression and reduce complications of the disease. Hence early diagnosis and treatment is warranted

Flow density of computed tomography aortography for predicting early unfavorable aortic remodeling after TEVAR in type IIIb aortic dissection

ObjectivePatients diagnosed of DeBakey type III aortic dissection with partial thrombosis of false lumen (FL) have a higher mortality rate. However, IIIb dissections with full patent FL tend to exhibit a partially thrombosed FL quickly after thoracic endovascular aortic repair (TEVAR); thus, we investigated survival and aortic remodeling in this population. MethodsWe reviewed computed tomography aortograms (CTAs) of 123 patients with TEVAR-treated IIIb aortic dissections from July 2006 to June 2015; contrast density of CTAs represented intraluminal flow. Patients were selected to fit in 2 groups of FL in term of FL contrast density: low flow (LF) group (non-opacification in the midway of FL) and high flow (HF) group (full patent FL). ResultsSurgical mortality was 10.3% in the HF group and 4.5% in the LF group (n = 61; LF = 22; HF = 39). 3 patients in the HF group suffered from lethal aortic rupture in 10 days postoperatively. The HF group showed significant increase in maximal diameter, and had larger thoracic (+4.00 ± 2.68 vs −1.16 ± 3.42 mm, P < .001) aortic diameter expansion from preoperation to one week postoperation. Both groups exhibited significant favorable thoracic TL expansion and maximal aortic diameter shrinkage in postoperative one week to one year. However, HF group displayed less thoracic aortic FL regression (−70.9 ± 83.5 vs −113.9 ± 95.0 cm3, P = .1) and TL expansion (+14.5 ± 27.2 vs +36.8 ± 28.3 cm3, P = .008) when compared to LF group. ConclusionsPreoperative HF in the FL has an unfavorable effect on thoracic aortic diameter in one week post-TEVAR. This might increase the risk of aortic rupture.

A Successful Repair of Pseudocoarctation With Associated Aortic Arch Aneurysm in an Eight-Month-Old Infant.

Pseudocoarctation of the aorta is an uncommon congenital entity characterized by juxtaductal elongation and tortuosity of the aortic arch. It is known to be associated with aneurysm formation. Our patient is a 7.7-month-female infant followed prenatally by magnetic resonance imaging that detected this anomaly. Subsequently, postnatal preoperative computed tomography angiography was confirmatory. The operation comprised resection of the aneurysmal portion of the aorta and extended end-to-end reconstruction, without prosthesis usage. The left subclavian artery was reimplanted into the left carotid artery. The postoperative course was uneventful. Computed tomography aortography and transthoracic echocardiography demonstrated no residual stenosis at six months of follow-up.

Clinical utility of intraprocedural three‐dimensional integrated image guided transcatheter aortic valve implantation using novel automated computed tomography software: A single‐center preliminary experience

Novel automated computed tomography (CT) software (Valve ASSIST 2) has been developed for transcatheter aortic valve implantation (TAVI), which not only provides three-dimensional (3D) reconstruction of multidetector (MD) CT images, but also enables intraprocedural real-time fusion of fluoroscopic and MDCT images. We aimed to clarify the reproducibility and accuracy of this software in the aortic annulus assessment and verify the potential of intraprocedural integrated MDCT imaging for TAVI. We examined 50 patients with severe aortic stenosis undergoing transfemoral TAVI. Aortic annulus measurements were performed using 3mensio and the novel planning software. For intraprocedural imaging, preoperative CT dataset was overlaid onto fluoroscopy with the fusion software. The two images were aligned using the aortic root anatomy visible on both modalities. Novel planning software provided excellent reproducibility for the measurement of aortic annulus area (intraobserver intraclass correlation coefficients [ICC] 0.959, interobserver ICC 0.941), and perimeter (intraobserver ICC 0.915, interobserver ICC 0.912). Excellent correlation was found between novel planning software and 3mensio (ICC 0.952 for aortic annulus area, and 0.923 for perimeter). Intraprocedural fusion image of CT aortography and fluoroscopic aortic root aortography generated by this novel software identified coronary orifices and the distribution of aortic valve calcification during the device positioning. Fusion image displayed coronary orifices after device implantation. Novel planning software showed excellent reproducibility and accuracy in the assessment of aortic root anatomy. Furthermore, the integrated 3D fusion image might have a potential as an intraprocedural imaging modality to contribute to the development of a safer TAVI procedure.

Discriminatory Value of the Ascending Aorta Diameter in Suspected Acute Type A Aortic Dissection.

The objective was to determine if ascending aorta (AscAo) diameters measured by noncontrast computed tomography (CT) allow for meaningful discrimination between patients with and without type A aortic dissection (TAAD), ideally with 100% sensitivity. This study was a retrospective analysis of cases of TAAD, as well as controls, undergoing evaluation for TAAD with CT aortography, presenting to 21 emergency departments within an integrated health system between 2007 and 2015. AscAo diameters were determined using axial noncontrast CT images at the level of the right main pulmonary artery by two readers. AscAo diameters were additionally normalized for age, sex, and body surface area (assessed by a Z-score, which is the number of standard deviations between the observed and expected AscAo diameters). Overall model discrimination was assessed using the area under the receiver operating characteristic curve (AUC). Comparative discrimination was assessed using both the change in AUC (∆AUC) and the continuous net reclassification index (NRI). A total of 230 cases of TAAD and 325 controls were included in the study. The median ages for cases and controls were 65 and 62 years, and the median AscAo diameters were 50 and 35 mm, respectively. The raw and normalized AscAo diameters demonstrated similarly excellent discrimination (AUCs of 0.96 vs. 0.97, respectively; ∆AUC = 0.01, p = 0.09) and an NRI of 0.30 (95% confidence interval [CI] = 0.13-0.47), both indicating small incremental improvements in classification with the use of the normalized AscAo measures. A raw AscAo diameter of 34 mm and a normalized Z-score of 1.84 both yielded 100% sensitivity for TAAD, with respective specificities of 35% (95% CI = 29.6%-40.2%) and 67% (95% CI = 61.7%-72.2%). Nearly all patients with TAAD appear to have enlarged AscAo diameters as measured by noncontrast CT, whereas most patients with suspected but absent TAAD have relatively normal AscAo diameters. Both raw and normalized AscAo measures provided relatively comparable discriminatory value. If validated, these data may be useful in adjudicating risk among patients with suspected TAAD in whom a criterion standard test is unavailable, nondiagnostic, or contraindicated.

Influence of Proximal Aortic Neck Diameter on Durability of Aneurysm Sealing and Overall Survival in Patients Undergoing Endovascular Aneurysm Repair. Real World Data from the Gore Global Registry for Endovascular Aortic Treatment (GREAT)

Aortic neck diameter is an independent anatomical feature that is poorly understood, yet potentially linked to proximal seal failure and adverse outcome following standard EVAR. The aim of this study was to assess whether large proximal aortic neck (LAN) diameter is associated with adverse outcome using prospectively collected individual patient data from The Global Registry for Endovascular Aortic Treatment (GREAT). A total of 3166 consecutive patients, from 78 global centres, receiving Gore Excluder stent grafts for infrarenal abdominal aortic aneurysm repair between 2011 and 2017 were included. Patient demographics, biometrics, operative details, and clinical outcome were analysed. Patients were divided into two groups: normal baseline proximal aortic neck (NAN) diameter (<25 mm on computed tomography aortography), and LAN (≥25 mm). Clinical follow up (including imaging) was available for 76.5% of patients 5 years post-intervention. Primary endpoints analysed were Type IA endoleak and any aortic re-intervention up to 5 years post-procedure. A composite endpoint of Type IA endoleak, re-intervention, aortic rupture, or aortic related mortality was also assessed. A total of 1977 (62.4%) patients were classified NAN and 1189 (37.6%) were LAN. Immediate technical success was achieved in 3164 out of 3166 (>99.9%) of cases. Freedom from Type IA endoleak was achieved in 99.3% at 1 year and 97.3% at 5 years (lower in LAN vs. NAN: 96.8% [CI 93.7–98.4] vs. 98.6% [CI 94.5–99.6], p = .007). Freedom from aortic re-intervention was 93.7% at 1 year and 83.2% at 5 years (78.6% [CI 66.0–87.0] LAN vs. 86.0% [CI 81.8–89.3] NAN, p = .11). Freedom from primary composite endpoint was 95.9% at 1 year and 84.9% at 5 years (81.3% [CI 69.2–89.0] LAN vs. 87.0% [CI 81.6–91.0] NAN, p = .066). Five year survival was lower in the LAN group; 64.6% (CI 50.1–75.7) vs. 76.5% (CI 70.7–81.3), p = .03). LAN is associated with delayed Type IA endoleak occurrence and lower overall survival.

Editor's Choice – Influence of Proximal Aortic Neck Diameter on Durability of Aneurysm Sealing and Overall Survival in Patients Undergoing Endovascular Aneurysm Repair. Real World Data from the Gore Global Registry for Endovascular Aortic Treatment (GREAT)

Aortic neck diameter is an independent anatomical feature that is poorly understood, yet potentially linked to proximal seal failure and adverse outcome following standard EVAR. The aim of this study was to assess whether large proximal aortic neck (LAN) diameter is associated with adverse outcome using prospectively collected individual patient data from The Global Registry for Endovascular Aortic Treatment (GREAT). A total of 3166 consecutive patients, from 78 global centres, receiving Gore Excluder stent grafts for infrarenal abdominal aortic aneurysm repair between 2011 and 2017 were included. Patient demographics, biometrics, operative details, and clinical outcome were analysed. Patients were divided into two groups: normal baseline proximal aortic neck (NAN) diameter (<25mm on computed tomography aortography), and LAN (≥25mm). Clinical follow up (including imaging) was available for 76.5% of patients 5 years post-intervention. Primary endpoints analysed were Type IA endoleak and any aortic re-intervention up to 5 years post-procedure. A composite endpoint of Type IA endoleak, re-intervention, aortic rupture, or aortic related mortality was also assessed. A total of 1977 (62.4%) patients were classified NAN and 1189 (37.6%) were LAN. Immediate technical success was achieved in 3164 out of 3166 (>99.9%) of cases. Freedom from Type IA endoleak was achieved in 99.3% at 1 year and 97.3% at 5 years (lower in LAN vs. NAN: 96.8% [CI 93.7-98.4] vs. 98.6% [CI 94.5-99.6], p=.007). Freedom from aortic re-intervention was 93.7% at 1 year and 83.2% at 5 years (78.6% [CI 66.0-87.0] LAN vs. 86.0% [CI 81.8-89.3] NAN, p=.11). Freedom from primary composite endpoint was 95.9% at 1 year and 84.9% at 5 years (81.3% [CI 69.2-89.0] LAN vs. 87.0% [CI 81.6-91.0] NAN, p=.066). Five year survival was lower in the LAN group; 64.6% (CI 50.1-75.7) vs. 76.5% (CI 70.7-81.3), p=.03). LAN is associated with delayed Type IA endoleak occurrence and lower overall survival.

Assessment of the Coronary Artery in High-Pitch, Dual-Source CT Aortography Without ECG Synchronization

Background: The high pitch, dual source computed tomography (CT) provides motion-free aortic imaging. Objectives: To evaluate the image quality of coronary artery using dual-source CT aortography without electrocardiogram (ECG) synchronization. Patients and Methods: One hundred fifty patients (87 men; mean age; 63.7 ± 13.0 years, mean heart rate; 64.7 ± 6.6 beats/min) with suspected or known aortic disease underwent non-ECG gated, high-pitch, dual-source CT aortography. No beta blocker or nitroglycerin was administered for the patients. The image quality of each coronary artery segment and its ostium was graded on a three-point scale (excellent, moderate, and non-diagnostic image quality). Results: Most patients (88.7%) showed diagnostic image quality in the ostia of the left main and right coronary artery. Among 1894 coronary arterial segments, 870 (45.9%) segments were rated as excellent image quality, 507 segments (26.8%) were rated as moderate image quality, and 517 segments (27.3%) were rated as non-diagnostic image quality. In the per-vessel analysis, non-diagnostic image qualities were often found in right coronary artery (44.0%) and left circumflex artery distribution (36.0%). In contrast, non-diagnostic image qualities were less frequently found in left main (0.67%) and left anterior descending distributions (9.9%). Conclusion: Non-ECG gated, high-pitch, dual-source CT can be useful to evaluate the coronary ostial involvement in patients with ascending aortic dissection. The left main and left anterior descending coronary arteries exhibit relatively good diagnostic image qualities compared with left circumflex and right coronary arteries.

Effects of anatomical characteristics as factors in abdominal aortic aneurysm rupture: CT aortography analysis.

The aim of this study was to analyze the anatomical characteristics of patients with ruptured abdominal aortic aneurysms (AAAs) using computed tomography (CT) aortography in order to determine the risk factors for rupture.We retrospectively reviewed the CT aortography findings and medical records of patients with ruptured AAAs who underwent CT aortography between February 2002 and December 2014. Age, sex, blood pressure at the time of rupture, treatment methods used for the ruptured AAAs, and treatment outcomes were analyzed. Statistical analyses were performed to determine the association between the maximum aneurysm diameter, which is considered the standard predictor of aneurysm rupture, and anatomical characteristics such as proximal neck diameter, angle between the suprarenal aorta and the aneurysm neck (α angle), angle between the aneurysm neck and aneurysm sac (β angle), and angles between the abdominal aorta and both iliac arteries.Data were reviewed for a total of 36 patients. The mean maximum diameter of AAAs was 76.84 ± 21.08 mm. Multivariate analysis adjusted for age and sex indicated statistical correlations between the α and β angles and maximum aneurysm diameter and between the β angle and iliac artery involvement.Our results suggest that the tortuosity of the aorta tends to be associated with the diameter of AAAs and iliac artery involvement. Investigation of the anatomical characteristics of individual patients using CT aortography is expected to aid in predicting the risk of AAA rupture.

Impact on outcomes by measuring tortuosity with reporting standards for thoracic endovascular aortic repair

In this study, we assessed the association between the tortuosity of the thoracic aorta as measured by the reporting standards for thoracic endovascular aortic repair (TEVAR), described by the Society for Vascular Surgery, and midterm outcomes after TEVAR for atherosclerotic aneurysms. We analyzed 77 consecutive patients who underwent TEVAR for atherosclerotic aneurysms from November 2006 through May 2013 in a single institution. The preoperative aortic tortuosity index (TI) was calculated by computed tomography aortography, and patients were divided into low-tortuosity (TI ≤ 1.29) and high-tortuosity (TI > 1.29) groups. The relationships between TI and the occurrence of endoleaks, complications, and survival were analyzed. The mean follow-up period was 29± 26months. During this period, endoleaks occurred in 19 patients. Patients in the high-tortuosity group were at greater risk for endoleaks (odds ratio, 9.95; 95% confidence interval, 2.06-48.1; P= .004) and stroke (odds ratio, 13.2; 95% confidence interval, 1.03-169; P= .047) than those in the low-tortuosity group. The overall survival at 1, 3, and 5years was 73%, 69%, and 63%, respectively, for the high-tortuosity group and 92%, 92%, and 86%, respectively, for the low tortuosity group. Our findings demonstrated that high tortuosity of the thoracic aorta is associated with higher rates of endoleaks and lower survival in patients undergoing TEVAR for atherosclerotic aneurysms. Patients with aneurysms in a highly tortuous aorta may therefore need greater attention in preoperative planning, perioperative procedures, and follow-up examinations.

Don't get in a flap!: A case report of progression through the spectrum of an acute aortic syndrome

To present a single case that clearly demonstrates the progression through the whole spectrum of an acute aortic syndrome, from a solitary penetrating aortic ulcer (PAU) through to multiple PAUs with intra-mural haematoma (IMH) progression. The index images show that despite the clinical presentation of an acute type B aortic dissection, a classical dissection flap is never demonstrated in this patient and thus highlights the need for early input from vascular surgery for all potential acute aortic syndromes. We present the case of a 71-year-old lady who attended the emergency department with hypertension and inter-scapular chest pain. Upon investigation with computed tomography aortography (CTA), she was found to have a solitary PAU only with minimal IMH. She did not demonstrate any classical radiological signs of acute type B aortic dissection. She was admitted under a medical team and her chest pain abated with no treatment. The treating medical team adjusted her anti-hypertensive medication and discharged her home with an urgent vascular surgical outpatient appointment for further follow-up and surveillance. We acknowledge that a preferred approach would have been, at least admission and close blood pressure monitoring, with a repeat CTA the next day. Two days later, she represented with further chest pain and on repeat CTA was found to have multiple PAUs and progression of the small IMH. She was then admitted under vascular surgery and subsequently transferred to the parent tertiary referral vascular surgical unit. Despite aggressive anti-hypertensive management, she had persistent intractable chest pain and was treated with a single thoracic stent graft. Completion angiography demonstrated total resolution of the PAUs. This case along with index images demonstrates the whole spectrum of the acute aortic syndrome from a solitary PAU to multiple PAUs with IMH extension. Despite an eventual clinical picture of an acute type B aortic dissection, there was a notable absence of a classical dissection flap on any imaging. We recommend that all aortic pathologies should be at least discussed with and preferably managed by vascular surgeons. The absence of a classical dissection flap on imaging is not a contra-indication to emergent treatment with thoracic stent grafting and in select patients is actually the only therapy that will treat this pathology.

Cardiovascular imaging in aortic disease. Multimodality approach in clinical practice

In the last decade, remarkable advances have been made in noninvasive imaging of aortic diseases. The aim of this article was to provide a comprehensive review of these imaging modalities. Echocardiography plays an important role in the diagnosis and follow-up of aortic diseases. Transthoracic echocardiography (TTE) permits adequate assessment of several aortic segments, particularly aortic root and proximal ascending aorta. Transoesophageal echocardiography (TEE) overcomes the limitations of TTE in thoracic aorta assessment. TTE and TEE should be used in a complementary manner. Although TEE is the technique of choice in the diagnosis of aortic dissection, TTE may be used as the initial modality in the emergency setting. Intimal flap in proximal ascending aorta, pericardial effusion/tamponade and left ventricular function can be easily visualised by TTE. TEE information (entry tear location, mechanisms and severity of aortic regurgitation and true lumen compression) is essential for selecting and monitoring surgical and endovascular treatment and detecting possible complications. Computed tomography has the advantage of providing optimum morphological information of the entire aorta and the accuracy of size measurements. Magnetic resonance imaging offers good morphological and dynamic information on the aorta without radiation, although in clinical practice its availability is lower. The considerable advances in imaging techniques have greatly increased our understanding of aortic diseases. Not only clinical presentation and required information, but also local availability of imaging equipment and staff expertise in this field, should be considered to indicate echocardiography, computed tomography or magnetic resonance, in the assessment of different aortic diseases and their circumstances. Nell’ultima decade si sono avuti notevoli sviluppi dell’imaging non invasivo della patologia aortica. Lo scopo di questo articolo è stato quello di fornire una completa review delle diverse tecniche di imaging. L’ecocardiografia ha un ruolo importante nella diagnosi e follow-up delle patologie dell’aorta. L’ecocardiografia transtoracica (TTE) consente un’adeguata valutazione di alcuni segmenti aortici, in particolare la radice aortica e la porzione prossimale dell’aorta ascendente. L’ecocardiografia transesofagea (TEE) supera le limitazioni della TTE nella valutazione dell’aorta toracica. La TTE e la TEE dovrebbero essere utilizzate in maniera complementare. Benchè la TEE sia la tecnica da scegliere nella diagnosi della dissecazione aortica, la TTE può essere utilizzata come esame iniziale nella fase di emergenza. Il flap intimale nell’aorta ascedente prossimale, il versamento/tamponamento pericardico e la funzione ventricolare sinistra possono essere facilmente visualizzate con l’esame TTE. Le informazioni derivate dalla TEE (localizzazione del foro intimale di ingresso, meccanismi e severità dell’insufficienza aortica e la compressione del vero lume) sono essenziali nella selezione e monitorizzazione del trattamento chirurgico o endovascolare, e nella identificazione delle possibili complicanze. La tomografia computerizzata ha il vantaggio di fornire delle ottime informazioni sulla morfologia dell’intera aorta e una buona accuratezza delle misurazioni. La risonanza magnetica consente una buona valutazione morfologica e dinamica dell’aorta senza l’utilizzo di radiazioni, benché nella pratica clinica la sua disponibilità sia bassa. I notevoli progressi nelle tecniche di imaging hanno notevolmente aumentato la nostra comprensione delle malattie dell’aorta. Nella valutazione delle differenti patologie dell’aorta la scelta di una tecnica di imaging quale l’ecocardiografia, la tomografia computerizzata o la risonanza magnetica, non dipende solamente dalla presentazione clinica e dalle informazioni richieste, ma dovrebbero essere considerate anche altre condizioni quali la disponibilità delle attrezzature e l’esperienza dello staff in questo settore diagnostico.

Midterm Results From Internal Iliac Artery Branched Endovascular Stent Grafts

To evaluate the midterm feasibility, efficacy and safety of internal iliac artery branch grafts for endovascular repair of aortoiliac, common iliac, and internal iliac artery aneurysms. Between December 2006 and September 2008, 8 patients underwent elective endovascular repair of aortoiliac, common iliac, and internal iliac artery aneurysms. Computed tomography aortography (CTA) was used to detect postoperative endoleak, stent migration, branch patency, and aneurysm sac expansion. All stent grafts were correctly implanted. However, intraoperative branch occlusion occurred in 2 of 8 cases. Both occlusions have been managed conservatively, with only 1 patient suffering detrimental symptoms. One endoleak was found. Median follow up by CT was 402 days (range 77 to 718 days). No patients died. Midterm results are encouraging for endovascular branch grafts to include the internal iliac artery. However, patient selection is of great importance and our series illustrates the value of caution and multidisciplinary teamwork.

Embolization of insufficiently ligated renal artery after open nephrectomy with absolute ethanol injection

A 54-year-old woman was admitted to hospital for hypotension and anemia which was due to intermittent hemorrhage from a lumbar drain. She had undergone open nephrectomy ten days earlier in another hospital for the right dysfunctional kidney with staghorn calculi. Ultrasound in our hospital showed a right retroperitoneal hematoma. Surgical exploration was performed twice whereby the hematoma was partially eliminated; however, the point of bleeding was not identified. Repeated attacks of bleeding from the drain accompanied by acute pain made the hypotension with tachycardia even worse, which led to a life-threatening hemorrhagic shock. Extravasation from the insufficiently ligated right renal artery was then shown on computed tomography aortography. After selective catheterization of this arterial stump with a mixture of alcohol and contrast media, complete occlusion of the remaining part of the resected renal artery was achieved. Application of absolute alcohol, though risky, proved to be a quick and efficient alternative method of occlusion of the bleeding renal arterial stump.