Thoracic Aortography Research Articles

Imaging of acute thoracic aortic injury due to blunt trauma: a review.

Much recent work on the use of computed tomography (CT) and transesophageal echocardiography in screening for and facilitating the diagnosis of acute thoracic aortic injury in the patient with blunt chest trauma has shown favorable results. This has led some physicians to question whether conventional thoracic aortography is still the reference standard. The purpose of this review article is to summarize the epidemiology and pathophysiology of acute thoracic aortic injury, the current status of the individual imaging modalities in use, and the surgeon's perspective. Despite a burgeoning literature and a confounding array of clinical and imaging advances, timely diagnosis of acute thoracic aortic injury remains a challenge. To overcome this problem, some trauma centers have used CT, transesophageal echocardiography, or both, in their diagnostic algorithm for acute thoracic aortic injury. These diagnostic algorithms are individually tailored by each institution and are still under investigation; therefore, no definite conclusions can be reached.

Thoracic MR aortography: imaging techniques and strategies.

Three-dimensional (3D) gadolinium-enhanced magnetic resonance (MR) angiography is a promising technique for thoracic aortography that complements electrocardiographically gated T1-weighted spin-echo imaging and cine MR imaging. Axial and left anterior oblique T1-weighted spin-echo images are well suited to measurement of aortic dimensions and evaluation of aortic aneurysms. Sagittal and coronal spin-echo images are helpful in evaluation of vascular rings and aortic dissection. Cine gradient-echo and cine phase-contrast imaging allow dynamic evaluation of aortic and valvular flow. Cine phase-contrast imaging also enables noninvasive quantification of blood flow. Capable of being performed during a single breath hold, 3D gadolinium-enhanced MR angiography provides high-resolution 3D data that can be readily used for projection angiography and multiplanar reformation. This technique enables further demonstration of subtle pathologic conditions. Three-dimensional gadolinium-enhanced MR angiography allows more comprehensive and efficient evaluation of the thoracic aorta.

Thoracic Aortography: Aneurysms, Trauma, Dissection, and Aoritis

Thoracic Aortography: Aneurysms, Trauma, Dissection, and Aoritis

Comparison of bronchopulmonary collaterals and collateral blood flow in patients with chronic thromboembolic and primary pulmonary hypertension.

OBJECTIVE: To compare the visualisation of bronchopulmonary collaterals and bronchopulmonary collateral blood flow in patients with chronic thromboembolic pulmonary hypertension 2nd primary pulmonary hypertension. SETTING: Referral centre for cardiology at...

Thoracic Aortography (Aneurysms, Trauma, Dissection, and Aortitis)

Thoracic Aortography (Aneurysms, Trauma, Dissection, and Aortitis)

64-Year-Old Woman With Chest Pain and Presyncope

64-Year-Old Woman With Chest Pain and Presyncope

Blunt traumatic aortic rupture: detection with helical CT of the chest.

To determine the effectiveness of helical computed tomography (CT) as a screening device to detect traumatic aortic rupture. Helical CT was used to examine 1,518 patients with nontrivial blunt trauma. Of these patients, 127 (8.37%) with abnormal CT scans of the mediastinum or aorta underwent thoracic aortography--89 patients solely for evaluation of mediastinal hematoma depicted at CT. Imaging abnormalities were correlated with surgical or clinical outcome. Twenty-one aortic injuries were identified that ranged from subtle intimal flaps to complete aortic disruption. Helical CT was more sensitive than aortography (100% versus 94.4%, respectively) but less specific (81.7% versus 96.3%, respectively) in detection of aortic injuries in patients who underwent both examinations. The association between CT findings and outcome was phi = 0.62 (chi2 = 49.1, 1 df, P < .01) and between aortography and outcome was phi = 0.85 (chi2 = 92.2, 1 df, P < .001). The P value of the difference between the phi coefficients was .10. Helical CT of the chest is effective for screening critically injured patients with possible blunt thoracic aortic injuries.

Pictorial review: Imaging of traumatic aortic injury

Traumatic aortic injury is a leading cause of death in patients with blunt trauma of the thorax. More than 120 patients with traumatic aortic injury have been admitted to our institution. This institutional experience is the source of the material that is presented in this pictorial review. The appearance of traumatic aortic injury on chest radiography, thoracic aortography and CT scan is demonstrated.

Unenhanced dynamic mediastinal computed tomography in the selection of patients requiring thoracic aortography for the detection of acute traumatic aortic injury

In our institution, the selection of patients who require thoracic aortography to evaluate for acute traumatic aortic injury (ATAI) is based upon an appropriate mechanism of injury and radiologic demonstration of a mediastinal hematoma. When plain chest or chest and/or mediastinal radiographs demonstrate a mediastinal hematoma, the patient undergoes thoracic aortography as promptly as is clinically feasible. If the plain film studies are negative for mediastinal hematoma, thoracic aortography is not performed because the patient is presumed not to have an ATAI.

Aortobronchial Fistula 13 Years Following Repair of Aortic Transection

We describe a 56-year-old man with the new onset of hemoptysis, increasing in frequency and magnitude, initially diagnosed and treated as pulmonary embolism. Bronchoscopy, computed tomography, and thoracic aortography were performed twice before the diagnosis was made. Thirteen years previously, the patient underwent thoracic aortic interposition graft placement for aortic laceration as a result of a motor vehicle accident. The second aortogram demonstrated a small pseudoaneurysm at the expected proximal graft suture line. Aortobronchial fistula, a rare cause of hemoptysis, was diagnosed. The patient underwent successful resection of the graft and placement of a new dacron interposition graft. All cultures, including blood, sputum, and operative specimen cultures, were negative. The patient is alive and well 1 year following surgery.

Blunt thoracic aortic injury in children

Thoracic aortic injury (TAI) in children secondary to blunt chest trauma is rare and less well documented than TAI in adults. To further establishe the incidence and radiographic manifestations of this severe injury, we reviewed our experimence with TAI in children over an 8-year period. We performed a computer search from the Trauma Registry at our level I trauma center for all cases of TAI among patients 16 years of age or younger who were admitted after sustaining blunt chest trauma between August 1984 and September 1992. We reviewed our records of all thoracic aortograms performed on children for blunt trauma during this same time period. Indication for angiography was determined by review of chest radiographs and medical records of all patients who underwent thoracic aortography. We reviewed medical records and all available chest radiographs, computed tomography (CT) examinations, and thoracic aortograms of children diagnosed with TAI. Of 308 children admitted with blunt chest trauma, 26 (8.4%) underwent angiography to exclude aortic or great vessel injury. Of these 26 patients, three (11.5%) were diagnosed with TAI, and one patient demonstrated a traumatic pseudoaneurysm of the proximal left subclavian artery. The incidence of TAI among children who sustained blunt chest trauma was 1.0% in our series. All three patients with TAI in our series were male, ages 10–12 (mean: 11 years). Chest radiographs on two of the patients with TAI revealed mediastinal widening, ill-defined aortic outline, shift of the trachea and nasogastric tube, and depression of the left main stem bronchus. The chest radiograph in one patient with TAI was technically inadequate. CT demonstrated abnormalities in two patients. Angiographic findings were similar to those seen in adults. TAI in children is rare, occurring in 1% of children sustaining blunt chest trauma in our series. Our findings support previous reports that the plain film, CT, and angiographic findings with this injury resemble those found in adults.

TRAUMATIC THORACIC AORTIC RUPTURE: INVESTIGATION DETERMINES OUTCOME

Blunt thoracic aortic rupture (TAR) initially presents with subtle signs but is usually fatal if not diagnosed and treated early. Does the diagnostic process affect outcome? The definitive test most widely promoted is thoracic (arch) aortography but is usually only available in major teaching hospitals. Thoracic computerized tomography (CT) scanning is more readily available but its role in diagnosis of TAR is unproven. A retrospective review of trauma databases and medical record indexes over a 7 year period identified 38 patients presenting with TAR at Westmead and Royal North Shore Hospitals in the period 1984-91. Thirteen patients (34%) were dead on arrival or died within 15 min of arrival at either hospital. Five patients (13%) who arrived in cardiac arrest (with suspected TAR) died after immediate thoracotomy (two in the Emergency Department and three in the operating room). Two patients (5%) died from severe head injuries and were not investigated for TAR. Eighteen patients (47%) remained alive long enough for investigation and were considered potentially salvageable. Nine of these survived. Only 13 patients had arch aortography. No patient survived without an aortogram. Five patients had a chest CT scan; aortography followed in four patients. Computerized tomography scans delayed aortography or were misinterpreted. Review of all trauma thoracic (arch) aortograms for the same period at Westmead Hospital revealed a diagnosis of TAR in 7.4%. Blind thoracotomy did not result in survival. Computerized tomography scanning of the chest was of no value in the management of this injury. Early suspicion of possible thoracic aortic rupture demands urgent arch aortography and this remains the diagnostic 'gold standard'.

Atypical results of thoracic aortography performed to exclude aortic injury

This study was undertaken to determine the incidence and spectrum of “equivocal” findings on thoracic aortography performed: (a) to exclude traumatic aortic injury (TAI), and (b) to identify radiologic signs that might be useful in increasing diagnostic confidence. All cases of thoracic aortography performed during a 5-year period to evaluate possible major thoracic arterial injury were identified. Those with atypical or uncertain results were reviewed by the authors, and medical records were analyzed to determine initial diagnosis, management course, and clinical outcome.

Blunt Injuries to the Innominate Artery

Two patients with aneurysm secondary to blunt traumatic subadventitial rupture of the distal innominate artery (IA) are reported. IA rupture was identified because of a cervical bruit in one patient and detected during thoracic aortography in the other patient. The patients had associated cardiovascular lesions consisting of traumatic aneurysm of the subclavian artery and rupture of the aortic valve, respectively. Both lesions were surgically repaired by resection of the lacerated intima and direct closure of the adventitia. In the patient who underwent repair of the aortic valve with simultaneous cardiopulmonary bypass the IA was approached after cannulation of the right common carotid artery. In the other patient the IA was repaired without use of a shunt under close EEG monitoring. Injury to the IA is rare because the artery is short and relatively well protected by the bony cage. Other cardiovascular lesions may be associated with IA rupture and a routine search should be made.

Controversies in the Surgical Treatment of Thoracic Aortic

The author recommends echocardiography and thoracic aortography com bined with coronary angiography in patients with thoracic aortic aneurysms prior to the operation; resection and replacement of asymptomatic fusiform aneurysms measuring twice or more the size of the normal aorta and of aortic dissections at cardiac operations; and use of active shunts during resection of descending thoracic aneurysms.

Renal artery stenosis in patients with aortic dissection: increased prevalence.

The authors retrospectively analyzed the prevalence of renal artery stenosis in 63 consecutive patients with aortic dissection who underwent thoracic and abdominal aortography. Ten patients (16%) had renal artery stenosis, five with atherosclerosis and five with fibromuscular lesions. Risk factors for aortic dissection were Marfan disease in nine patients, bicuspid aortic valve in one, and hypertension in 54 (including seven patients with Marfan syndrome). If the patients with Marfan syndrome and the patient with the bicuspid aortic valve are excluded, renal artery stenosis was present in 10 of 53 patients (19%) when the cause of dissection was presumably hypertension. This finding suggests that renovascular hypertension is a greater risk factor for aortic dissection than is essential hypertension. The success of angiotensin converting enzyme inhibitors and percutaneous transluminal renal angioplasty (PTRA) in controlling renovascular hypertension has been proved. In this series, emergent PTRA successfully controlled the hypertension in one patient with a type B dissection, resulting in an excellent clinical outcome. Angiography should be routinely performed on patients with aortic dissections to evaluate for renal artery stenosis.

The Widened Mediastinum

Little attention has been given to the sequential assessment and management of a cohort of patients with potential aortic disruption manifested by a widened mediastinum. These patients often require diagnostic peritoneal lavage (DPL), cranial computed tomography (CCT) scan, thoracic aortography, and multiple operations. We surveyed 408 patients with a widened mediastinum who underwent aortography from 1981 to 1989 to determine priorities of management. Multisystem injuries were common with 278 (68%) and 72 (18%) of patients requiring DPL and celiotomy, respectively. Central nervous system (CNS) injury occurred in 276 (68%) patients, and orthopedic injuries were present in 162 (40%). There were 35 thoracic aortic injuries and 17 branch injuries with 15 deaths (11 aortic, 4 branch). Mortality primarily was attributed to hemorrhage, neurologic injuries, and multisystem organ failure. We evaluated the sequence of diagnostic and therapeutic interventions to determine possible sequence errors and 98% of patients had no errors identified. Based on this experience, we have formulated a management protocol for evaluation of patients with multiple injuries and a widened mediastinum.

Pericardium as a thoracic aortic patch: Glutaraldehyde-fixed and fresh autologous pericardium

The repair of complex coarctation of the aorta often requires an aortic patch. Prosthetic patches lack growth potential and are associated with an increased incidence of aneurysm formation opposite the patch. We compared buffered glutaraldehyde-fixed patches, used in six animals (group 1), and untreated autologous pericardial aortic patches, used in five animals (group 2). Weanling pigs underwent pericardial patch replacement of a 1 × 2-cm diamond-shaped segment of the lateral wall of the descending thoracic aorta at the level of the aortic isthmus. Six months following patch aortoplasty, the animals were killed and the in situ patch dimensions were measured and compared to the measurements obtained at implantation. The increases in length, recorded as mean percentage change ± SEM, were 34.7 ± 3.7% for group 1 and 102.8 ± 20.3% for group 2 animals; the increases in width were 91.4 ± 31.7% for group 1 and 192.4 ± 31.4% for group 2. The percentage changes for both length and width were significantly different between groups ( P < 0.05). Pull strength testing of standard-size patch samples demonstrated no significant difference in tensile breaking load between groups: group 1 = 959 ± 277 g, group 2 = 795 ± 86 g. Thoracic aortography revealed no evidence of stenosis or aneurysmal dilation in either group. Autologous pericardium is resilient, strong, and readily available and has expansile potential that makes it an ideal aortic patch material. We conclude that glutaraldehyde fixation does not provide additional strength and limits graft expansile potential when compared to untreated pericardium.

Thoracic aortography following blunt chest trauma

The records of 314 patients who suffered blunt chest trauma and underwent thoracic aortography between 1968 and 1986 were retrospectively reviewed. The patients ranged in age from 7 to 84 years (mean, 37.7 years). There were 255 male and 59 female patients. The majority of injuries were the result of motor vehicle accidents. The most common indication for aortography was a widened mediastinum on chest roentgenogram (83.4%). The aortogram was positive for cardiovascular injury in 19.7% of cases. There were 47 patients with aortic rupture, 15 with subclavian artery disruption, and 1 with traumatic aortic insufficiency. Complications occurred in 1.7% of patients. Two patients sustained groin hematomas and one patient suffered an intimal tear of the ascending aorta from the angiographic catheter. None of the complications required treatment. Aberrant origin of the arch vessels occurred in 0.96% of patients, and ductus diverticulum occurred in 0.64%. There were two false-positive and no false-negative aortograms. It was concluded that thoracic aortography after trauma is accurate and safe.

Urinary tract injury in patients with blunt chest trauma: The value of postaortographic abdominal radiographs

Patients who require thoracic aortography for blunt decelerating chest trauma often sustain injury to other organ systems due to the magnitude and mechanism of injury. Hospital records and radiographs of 117 consecutive, injured patients studied with thoracic aortography were evaluated to assess the accuracy, value, and limitations of postaortographic abdominal plain radiography for detection of major genitourinary injury. In summary, major urinary tract injury occurred with a frequency of 6%, enough to justify a rapid, low cost, noninvasive screening procedure. Postaortographic plain films of the abdomen were found to be an accurate (95%) screen for detection of major urinary tract injury. The sensitivity for detection of patients with renal injury was 100%. The ability to correctly predict patients who may be safely observed (no significant renal injury) was 100%. One limitation of this technique was the poor diagnostic quality found in 15% of the abdominal radiographs, most commonly caused by excessive superimposed bowel gas. Postaortographic pelvic radiographs were believed to be valuable for detection, but not exclusion, of bladder rupture.