Thoracic Aortography Research Articles

Complications following use of four angiocardiographic contrast media in infants and children.

One of four commonly employed and apparently safe contrast media—80% Angio-Conray® (and later Conray 400®), 37% Renovist®, 50% Hypaque® and 60% Renografin®—was pre-assigned to each infant or child undergoing selective angiocardiography or thoracic aortography without regard to diagnosis, age or other factors. Analysis of 492 consecutive procedures showed no apparent differences in the type or frequency of complications associated with any of the above four contrast media.

Results of aortic valve replacement with the Kay-Shiley disc valve.

Between August, 1966, and April, 1968, aortic valve replacement with the Kay-Shiley disc valve was performed in 60 consecutive patients at the Department of Thoracic Surgery, Karolinska Sjukhuset, Stockholm. The cumulative mortality rate after an observation period ranging from 1 to 3 years was 22%. There were 4 hospital (7%) and 9 late deaths (15%). The causes of death were infection (6), myocardial infarction (4), myo-cardial failure (1), postoperative renal insufficiency (1) and thrombosis around the prosthesis (1).Thrombo-embolic complications were observed in 4 patients (7%), in all related to discontinuation of the anticoagulant therapy. Partial detachment of the prosthesis necessitating re-operation was present in three patients (5%).Forty-two (90%) of the surviving patients were re-examined about a year after surgery, 39 of them being subjected to a follow-up catheterization and 32 also to thoracic aortography with cinetechnique.All patients considered their condition improved after operation. At ...

An exercise in radiologic-pathologic correlation.

There are only a few localized pulmonary abnormalities which by their radiographic appearance and location suggest specific pathologic entities. More often the radiologist is faced with a complex of puzzling chest densities, a nonspecific clinical picture, and confusing laboratory data which make a diagnosis of the pathologic problem almost impossible except by thoracotomy and tissue analysis. The case presented this month, however, does not fit this pattern but affords the radiologist the rare opportunity to render a precise and practically histologic diagnosis. Radiology The initial radiographs of the chest (Fig. 1) show a well defined parenchymal abnormality involving the left lower lobe. The density is relatively homogeneous, and there is no evidence of pleural fluid or associated adenopathy. The x-ray appearance is thus consistent with pneumonia. Follow-up chest examination one week later demonstrated partial resolution. Approximately six months later, a repeat chest examination (Fig. 2), performed because of anterior chest pain and cough, demonstrated cystic changes in the same location. No fluid levels are noted, however, and again there is no evidence of pleural effusion, adenopathy, additional pulmonary lesions, or contiguous vertebral abnormality. The persistence of the findings associated with recurrent symptoms and cystic changes suggests a more chronic pulmonary process such as bronchiectasis. Selective bronchography reveals nonfilling of the terminal portions of the major bronchi to the abnormal area (Fig. 3) as well as slight lateral displacement of the adjacent normal bronchial segments. The lack of filling in the cystic areas suggests the probability of an abnormal pulmonary segment, specifically an intralobar bronchopulmonary sequestration which must have had a small communication with the bronchial tree (to account for air-filled cysts) after breakdown secondary to infection. Since these embryologic defects are usually supplied by one or more aberrant arteries, percutaneous transfemoral thoracic aortography was performed as the next diagnostic procedure. It discloses a single aberrant vessel arising between the intercostal arteries at T-9 and T-10 on the left (Fig. 4). Selective catheterization shows the vessel to be of larger caliber than the intercostal arteries. Its course is dorsolateral with mild stretching and arborization around the periphery of the cysts (Fig. 5). Despite adequate arterial filling, venous drainage is not demonstrated satisfactorily. Subtraction films suggested venous drain age to the left atrium through pulmonary veins, which is the usual route in intralobar pulmonary sequestration. Clinical Findings and Analysis The patient is a 19-year-old Negro female who had no pulmonary complaints until the age of eighteen when she experienced an episode of fever, chills, and cough. A chest radiograph at this time showed consolidation of the left lower lobe and she was treated with tetracycline.

Right aortic arch with an aberrant retroesophageal innominate artery: angiographic diagnosis.

A retroesophageal innominate artery is a rare congenital anomaly theoretically occurring if there is a break in either aortic arch proximal to the origin of the common carotid artery. The resulting vessel is the last off the arch and gives origin to a subclavian and common carotid artery (Fig. 1). In reality a persistent dorsal aortic root (5), this vessel may then be considered an innominate artery. The purpose of this paper is to report an angiographically documented, right aortic arch with retroesophageal left innominate artery and to indicate an error that has been made in the diagnosis of this anomaly. S. G., a 19-year-old white male, was referred for evaluation because of a heart murmur and dyspnea on strenuous exertion. His past history was interesting in that he had been hospitalized for four and a half months during the first year of his life with a diagnosis of “mucoviscidosis and aspiration pneumonia.” There had been difficulty with feedings associated with intermittent periods of cough, cyanosis, and dyspnea. Recurrent bilateral pulmonary infiltrations were noted on chest films during that hospitalization, yet a barium swallow examination apparently had not been performed. On physical examination the blood pressure in the upper and lower extremities was within normal limits. A loud, Grade 3 out of 6, diamond-shaped systolic murmur was heard at the upper left sternal border radiating to the suprasternal notch and neck. Routine laboratory studies, pulmonary function studies, and an electrocardiogram were normal. Roentgenographic examination of the chest with barium in the esophagus demonstrated normal-appearing heart and lungs (Fig. 2). A right aortic arch displaced the esophagus to the left, and a smaller defect was noted at the same level on the left lateral aspect of the esophagus. A lateral view showed anterior displacement of the esophagus at this same level, suggestive of a retroesophageal vessel. There was no obliquity to the defect. Left heart catheterization revealed a resting peak, transaortic systolic gradient of 25 mm Hg, with increase to 50 mm Hg with intravenous injection of isoproterenol; the characteristics were those of valvular aortic stenosis. Thoracic aortography confirmed the presence of a right arch from which a retroesophageal left innominate artery arose as the last vessel (Fig. 3). Surgery was not recommended. The patient was discharged to be followed at his local facility, and bacterial endocarditis prophylaxis was implemented. In the classification of aortic arch anomalies offered in the monograph by Stewart, Kincaid, and Edwards (6) the theoretical possibility of a retroesophageal innominate artery is not mentioned with either a left or a right aortic arch. Only two relatively well documented cases with a retroesophageal innominate artery could be found in the literature, both in living patients with a right aortic arch (2, 7).

Selective bronchial arteriography in the demonstration of abnormal systemic circulation in the lung

The systemic blood supply to the lung through bronchial and intercostal arteries been investigated in 89 patients with lung disease. This has been demonstrated by thoracic aortography and selective bronchial arteriography. In many cases abnormal systemic-pulmonary shunts have been shown. These develop by the opening up of precapillary anastamoses between bronchial and pulmonary arteries. In 12 of 23 patients with bronchiectasis, two patterns emerged. In 9 instances contrast material passed freely into the peripheral pulmonary arterial tree, a phenomenon termed ‘forward flow’. In 3 patients the flow was against the normal stream in its passage towards the hilum of the lung, a situation described as ‘reverse flow’. The stress placed upon the pulmonary capillaries and the heart is considered and illustrated by individual cases. The varying systemic circulation in patients with primary lung cancer is also outlined.

A national survey of radiological complications: Interim report

Two hundred and sixty five radiologists co-operated in a national survey of radiological complications. The case reports have been analysed and are presented together with a review of the relevant literature. One third of the cases of sudden death in the X-ray department occur when a doctor is unlikely to be present—usually during chest X-rays—and radiographic staff should therefore be conversant with the immediate treatment of cardiac arrest. Attention is drawn to the hazard of perforation associated with the use of self-retaining catheters for barium enema examinations. The clinical features of contrast media reactions are described and the possible mechanisms of some of these reactions are discussed. Biligrafin should preferably not be administered immediately following oral cholecystography. In cardiovascular investigations, vascular disease may be widespread and coronary thrombosis may follow arteriography. Several deaths followed cardioangiography, and other complications of importance were ventricular fibrillation and pericardial tamponade. Two cases of paraplegia followed translumbar aortography. The main complications of Seldinger catheterisation are arterial occlusion and dissection; guide wire fracture may also occur, In hypertensive patients, excessive bleeding may give rise to complications. Axillary catheterisation may cause peripheral nerve injury. In thoracic aortography, the main complications are due to neurological damage. Complications of cerebral angiography may be related to arterial trauma, and hypotension is also hazardous. Other complications covered in the survey are those occurring during myelography, encephalography, pneumography, bronchography, lymphangiography, salpingography and sialography. There is a brief discussion on electrical hazards.

The interpretation of intracardiac phonocardiography of a continuous murmur developed after radical operation for tetralogy of Fallot.

A patient with tetralogy of Fallot developed a continuous flow-like murmur after radical operation. At right-heart catheterization with intracardiac phonocardio-graphy, the continuous murmur was recorded in the entire inflow tract of the right ventricle and was erroneously interpreted as being due to an arteriovenous fistula to the right ventricle. Thoracic aortography demonstrated aortic insufficiency and a residual ventricular septal defect with left-to-right shunt as the cause of the continuous murmur. The diagnostic value of intracardiac phonocardiography in such cases is based on the assumption that the diastolic component of aortic insufficiency is not recordable in the right ventricle; the reported case indicates that intracardiac phonocardiography may be of limited diagnostic value after radical operation for tetralogy of Fallot.

Surgical correction of absence of proximal segment of left pulmonary artery.

In a 14-month-old patient who had been repeatedly hospitalized for recurrent pulmonary infections, cardiac angiography found "absence" of the left pulmonary artery, but thoracic aortography demonstrated that a rudimentary patent ductus filled a distal patent pulmonary artery. There was a coexistent vascular ring with a retroesophageal right subclavian artery. At surgical exploration it was possible to mobilize the distal left pulmonary artery and perform a direct anastomosis between the left pulmonary artery and the main pulmonary artery. This is perhaps the first patient in whom such an operation has been performed. It is emphasized that the absence of a pulmonary artery on pulmonary angiography does not indicate that the entire pulmonary artery is absent. The presence of a patent and surgically reconstructable distal pulmonary artery can be determined only by aortography or possibly by surgical exploration.

Retrograde Thoracic Aortography

Retrograde thoracic aortography is a safe, simple method of opacifying and recording roentgenographically the thoracic aorta and its branches for the purpose of studying diseases intrinsic to these great vessels as well as those structures adjacent to their course. <h3>Technique</h3> Preliminary studies include a complete blood count; urinalysis; determination of blood urea nitrogen, bleeding and clotting times, and prothrombin time; electrocardiogram; and evaluation of the peripheral pulses. After adequate premedication, percutaneous catheterization of the femoral artery is carried out with local anesthesia using the Seldinger technique.¹Under fluoroscopic control, a No. 7 or 8 Teflon catheter is advanced over a spring guide into the ascending aorta until its tip lies approximately 2 cm above the valve. The negotiation of the arch is facilitated by a gentle preformed curve in the catheter tip. Upon withdrawal of the spring guide, 10 cc of blood is forcefully aspirated to remove any clot formation

Thoracic aortography in cerebrovascular insufficiency. Report of 250 cases.

Thoracic aortography in cerebrovascular insufficiency. Report of 250 cases.

Experimental evaluation of concentrated solutions of iothalamic acid derivatives as angiographic contrast media.

EXPERIMENTAL EVALUATION OF CONCENTRATED SOLUTIONS OF IOTHALAMIC ACID DERIVATIVES AS ANGIOGRAPHIC CONTRAST MEDIACAULEY W. HAYES, M.D., JOHN H. FOSTER, M.D., ROBERT SEWELL, B.S. and DUNCAN A. KILLEN, M.D.Audio Available | Share

ROENTGENOLOGIC FINDINGS IN CONDITIONS OF THE ASCENDING AORTA SIMULATING AORTIC VALVULAR INSUFFICIENCY

Conditions of the ascending aorta responsible for abnormal run-off of blood when viewed roentgenographically may be divided into 2 major categories: (I) those allowing a run-off of blood through the aortic valve and (II) those characterized by an abnormal communication between the ascending aorta, on one hand, and a cardiac chamber or a mediastinal vessel, on the other. In the former situation, the roentgenograms usually indicate that the region in or around the ascending aorta is the site of disease and the decision to perform selective aortography is obvious. In the second major group, the fact that the site of the disease process begins primarily in the ascending aorta is not obvious from conventional roentgenographic data. Correlation, however, of the roentgenographic evidence for a left-to-right shunt with the auscultatory findings of a systolic and diastolic murmur indicates that selective thoracic aortography is of fundamental importance in establishing the correct diagnosis.

Cardiovascular responses to injection of contrast medium into proximal aorta.

The cardiovascular changes which follow the intravascular injection of a contrast medium are indicative of its toxicity (4). Those that occur after intracardiac injection of contrast material, both experimentally (2, 6, 15) and clinically (3, 6), have been well documented. Information is lacking, however, concerning these responses when angiographic medium is injected directly into the proximal aorta. Two major differences exist between the two technics, which may be responsible for significant variations in the reactions produced by each. First, in proximal aortography, there is direct perfusion of the myocardium, via the coronary arteries, by relatively undiluted contrast medium. Second, in this technic, since there is normally no passage of the contrast medium through the cardiac chambers or the pulmonary circulation, there can be no direct action on these structures. The value of thoracic aortography as a diagnostic means is now well established (1). The increasing use of this procedure makes it manda...

Coronary Arteriography

Coronary arteriography is a radiographic exploration of the coronary vessels in living subjects. This procedure was initiated about 32 years ago when Peter Rousthöi demonstrated angiographically the coronary arteries in intact experimental animals.¹Radner, in 1945, was able to perform the technique in the living man.²Although the initial attempts at vascular opacification were viewed with considerable ridicule by skeptical onlookers, enough experience has been accumulated to consider the procedure safe and reasonably accurate. This accomplishment was made possible through the development of new contrast media and significant improvement of roentgenographic and catheterization techniques. Presently, two basically different approaches are used for contrast visualization of the coronary arteries: catheter thoracic aortography and selective catheter coronary arteriography.³In thoracic aortography, improved filling of the coronary arteries is accomplished when attempts are made to decrease the cardiac output, prolong the ventricular diastole, or obstruct the thoracic aorta. Catheterization of

Other forms of left-to-right shunt

Five types of L-R shunt are discussed: (1) LV-RA communication, (2) ruptured aortic sinus aneurysm, (3) coronary artery fistula, (4) anomalous origin of the left coronary artery from the pulmonary trunk, and (5) aorticopulmonary septal detect. Although each of these lesions is characterized pathologically by different sites of communication with the right side of the heart, their point or origin is relatively constant, this being the ascending aorta in the last four and the left ventricle in the first. Because the thoracic roentgenogram and oxygen saturation data obtained at cardiac catheterization reveal evidence of a L-R shunt only in the chamber or vessel in which the shunt terminates, specific anatomic diagnosis usually depends upon the performance of both selective left ventriculography and thoracic aortography. The proper choice of diagnostic studies often may be determined before-hand by correlating the plain films with the clinical findings. Although conventional roentgenographic data usually indicate only a L-R shunt or cardiac myopathy, evidence of a continuous murmur suggests strongly that the site of origin of the L-R shunt lies in the ascending aorta.

The value of contrast studies in the investigation of aortic valve disease

Sixty patients with aortic valve disease were studied by thoracic aortography and left ventricular angiocardiography, and the information obtained from these investigations was then compared with the clinical assessment of the patient, supplemented by measurement of the aortic valve gradient. The authors conclude that these contrast studies are not always essential, but the information provided by them can be of great value in the subsequent management of selected patients. They are rarely needed when making the diagnosis of aortic valve stenosis, they are unreliable for grading the severity of stenosis, but they are particularly helpful for evaluating aortic incompetence when there is clinical uncertainty. The indications for these investigations and the significance of the radiographic signs of aortic valve disease are discussed.

Aortico-left ventricular tunnel: A cause of massive aortic regurgitation and of intracardiac aneurysm

The clinical, roentgenographic, hemodynamic and pathologic findings in a fourteen year old boy with aortico-left ventricular tunnel are presented. The accessory channel between the aorta and left ventricle resulted in massive aortic regurgitation, and the portion of the tunnel which traversed the ventricular septum was aneurysmal, displaced the posterior wall of the right ventricle and caused severe obstruction to right ventricular outflow. The presence of associated cardiovascular anomalies, in this and previously reported cases, suggests that the malformation is congenital rather than acquired. The clinical and hemodynamic manifestations of aortico-left ventricular tunnel are indistinguishable from those observed with the more common forms of aortic regurgitation, and the correct diagnosis can be established only by thoracic aortography. The malformation is usually recognized in childhood; since aortic regurgitant flow can be abolished by simple closure of the aortic ostium, and without aortic valve replacement, the indications for operative treatment differ from those which apply in aortic regurgitation due to a valvular anomaly.

SELECTIVE BRONCHIAL ARTERIOGRAPHY.

The systemic circulation of the lungs may be examined in great detail by percutaneous selective bronchial arteriography. As in angiography of other organs, vascular opacification is improved if the contrast medium is injected selectively into the vascular bed under study. Previous authors (9, 14, 16, 19, 21) have produced opacification of the bronchial arteries by nonselective thoracic aortography. Although on aortography the bronchial arteries may be opacified, detailed analysis of the smaller branches is not possible. Selective bronchial arteriography permits excellent visualization of these vessels, in which the normal anatomy as well as the pathologic changes can be studied (10, 20). Physiologic changes affecting the bronchial circulation may also be studied after selective catheterization of a bronchial artery. In addition, selective chemotherapeutic perfusion of pulmonary neoplasms may be possible with this method of catheterization. Anatomy of the Bronchial Arteries The anatomy of the bronchial arterial circulation has been described previously (2, 5, 15). Normally, the bronchial arteries are small branches arising from the aorta. They supply the bronchi, visceral pleura, walls of pulmonary vessels, and interstitial supporting structures. The middle third of the esophagus, the hilar lymph nodes, vagus nerve, and mediastinal fascia are also nourished by bronchial circulation. Anastomosis with other systemic arteries may occur. Cauldwell et al. (2), on the basis of dissection of 150 cadavers, described 9 variations in the origin of the bronchial arteries. The 4 most common variations are outlined in Figure 1. The site of origin of the right bronchial artery differed from that of the left . Cauldwell and his associates found that the right bronchial artery usually arose from the lateral or posterolateral aspect of the aorta in common with an intercostal artery. The left bronchial arteries usually arose directly from the anterior surface of the aorta, but occasionally from the right side of the aorta in common with a right bronchial artery. In 74 per cent of the dissections the right and left bronchial arteries arose independently, while in the remainder a common trunk divided into right and left bronchial arteries. Rarely, the bronchial artery originated from the subclavian (Fig. 2). The bronchial arteries usually form an acute angle with the aorta at their origin, coursing upward and anteriorly initially. As they extend peripherally, they first lie posterior to the main bronchus and later pass around its lateral aspect to reach an anterior position. The vessels end in an arterial plexus which anastomoses with the pulmonary capill ary plexus. Method The method of selective bronchial arteriography employed by us was initially described by Olin (18) . A green Ödman catheter is tapered to accommodate a wire guide whose outer diameter is 0.025 inches. The end of the catheter is formed into a double curve (Fig. 3).

SELECTIVE BRONCHIAL ARTERIOGRAPHY.

Carcinoma of the lung is one of the most malignant of all visceral tumors, as well as one of the few in which the vascular bed has not been studied intensively in vivo. This is true not only because of its relatively sparse vascularity, but also because of the technical difficulties of perfusing the bronchial circulation with contrast medium in adequate concentration. The study of these tumors is important from the point of view of differential diagnosis. It is at times impossible to distinguish between inflammatory and neoplastic disease in the lung, short of operative biopsy. Our present angiographic methods of evaluating the extent and operability of lung tumors, pulmonary arteriography and superior vena cavography, are indirect and depend on displacement or direct invasion of vessels. The capacity to define a tumor circulation reliably, and to differentiate it from the vascular patterns in inflammatory disease in the lung, would represent a significant advance in diagnostic medicine. The ability to perfuse the tumor circulation selectively might also open the way toward a more rational chemotherapeutic effort to impede the progress of the neoplasm. The role of the bronchial arteries as the primary nutrient channels of pulmonary tissue has long been of interest. It is known that these vessels may increase strikingly in size in the presence of localized pulmonary disease. The extent to which these alterations have been investigated in man has been limited until recently. Within the past few years, a number of workers have attacked this problem. Williams et al. (10), for example, have employed nonselective thoracic aortography to demonstrate the bronchial arteries in patients with pulmonary disease. Neyazaki (5, 6) has utilized balloon catheters in the thoracic aorta to isolate a segment of the aorta, which is then perfused with contrast medium. In this way, he has been able to demonstrate reverse filling of the pulmonary arteries through bronchial collateral channels in the presence of pulmonary disease. Our own interest has focused on the development and application of a selective technic to the study of the bronchial circulation. The purpose of this preliminary report is to describe the technic, to analyze its feasibility, and to record some of the data thus far obtained from in vivo studies of the bronchial circulation in bronchogenic carcinoma. Anatomic Considerations The most thorough study of the anatomy of the bronchial arteries was performed by Cauldwell and his co-workers (1). They dissected 150 cadavers, identifying both the origin and course of these vessels. For the purpose of selective catheterization, several findings from this study are pertinent. A single bronchial artery occurred on the right in 60 per cent of cases, and on the left in 30 per cent. Two bronchial arteries were on the right in an additional 30 per cent, and on the left in an additional 60 per cent.

SELECTIVE BRONCHIAL ARTERIOGRAPHY IN DOGS.

The nutrition of the lungs, including the bronchi, pleura, and walls of the pulmonary vessels, is supplied mainly by the bronchial arteries of the systemic circulation, and it has been demonstrated that pulmonary neoplasms, too, receive their blood from the bronchial arteries (2). The chief function of the pulmonary arteries is oxygenation of the blood, although it is stated that in dogs the blood supply to the pleura is from the pulmonary artery (1). Venous angiocardiography, pulmonary angiography, and azygos venography show distortion or obstruction of the large vessels by unresectable central extension of tumor (3), but these technics have not been of value in less advanced puhnonary tumors. Bronchial arteriography must be performed if the vascularity of pulmonary neoplasms is to be studied in the living subject. History Postmortem roentgenograms of opacified bronchial arteries in dogs have been obtained by intra-aortic injection of bismuth oxychloride (4), iodized oil (5), and barium sulfate (1). In the living dog, bronchial arteriography has been performed by thoracic aortography (6) and by surgical cannulation of the intercostal artery from which the bronchial artery arises (8). Percutaneous aortic catheterization with selective injection of the bronchial arteries would have obvious advantages over these methods. Anatomy The origin and distribution of the bronchial arteries have been studied in 150 human subjects (9). There are many variations, but most commonly one right bronchial artery arises from the first right aortic intercostal artery and two left bronchial arteries arise directly from the thoracic aorta. It should be recalled that the first, the second, and sometimes the third intercostal arteries are supplied by the subclavian artery by way of the costocervical trunk. The intercostal arteries below these arise from the thoracic aorta and are called aortic intercostal arteries. In a dissection of 30 dogs, Notkovich (10) found that the bronchial arteries to each lung were derived from the first to fourth right aortic intercostal arteries. They never arose directly from the aorta or left intercostal arteries. There was usually one, occasionally two, bronchial arteries to each lung. The left bronchial artery arose 0.5 to 5 mm. from the origin of the intercostal artery and the right bronchial artery 10 to 25 mm. from the origin of the intercostal artery. The arteries to each lung did not always arise from the same intercostal artery. Thus, bronchial arteriography could be performed in dogs by selective intercostal artery catheterization. Method A green Ödman catheter is prepared by tapering the end to an inner diameter equal to the size of a No. 120 Seldinger guide wire. The end of the catheter is molded into a short curve. In some cases a No. 120 polyethylene catheter was employed.