of Diseases of Thoracic Aorta - American Society of...
Transcript of of Diseases of Thoracic Aorta - American Society of...
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Multimodality Imaging of
Diseases of Thoracic Aorta
Steven Goldstein MD, FACCDirector Noninvasive CardiologyMedStar Heart InstituteWashington Hospital CenterSunday, October 9, 2016
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DISCLOSURE
I have N O relevant financial relationships
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J Am Soc Echocardiogr 2015;28:119-82
GUIDELINES AND STANDARDS
asecho.org Guidelineswww.
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Multimodality Imaging of the AortaSpecial Features (“unique”)
1. Uniform protocol for measuring aorta
2. Variability of measurements (what
3. Firstline, secondary tests for each entity
represents real change: 2, 3, 4, 5 mm ?)
Leading edge to leading edgeInner-to-innerOuter-to-outer
continued . . .
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Measuring The Aorta
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Measure perpendicular to the long-axis of the aorta
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Imaging Modalities
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Imaging Techniques• Chest X-ray• Echo (TTE, TEE, 3D-echo, epiaortic)• Intravascular echo (IVUS)• Intracardiac echo (ICE)• CT/MDCT• Magnetic resonance imaging• Aortography
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Imaging Techniques• Chest X-ray
• Echo (TTE, TEE, 3D-echo, epiaortic)• Intravascular echo (IVUS)• Intracardiac echo (ICE)
• CT/MDCT• Magnetic resonance imaging• Aortography
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Diseases of
Thoracic Aorta
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Diseases of the Thoracic Aorta• Acute aortic syndromes
• Thoracic aortic aneurysms
continued . . .
- Aortic dissection- Intramural hematoma- Penetrating aortic ulcer- Ruptured aortic aneurysm
- Bicuspid aortic valve-related aortopathy- Marfan syndrome- Other genetic diseases
(Ehlers-Danlos; Loeys-Dietz, Turner syndrome,etc)
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Diseases of the Thoracic Aorta
• Traumatic injury of thoracic aorta
• Aortic coarctation
• Atherosclerosis
• Aortitis- Noninfectious- Infectious
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Acute AorticSyndromes
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Acute Aortic Syndromes
• Aortic dissection
• Intramural hematoma
• Penetrating aortic ulcer
• Ruptured aortic aneurysm
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Acute Aortic Syndromes
• Delay in recognition and treatment isassociated with unacceptable increase in mortality
• Signs and symptoms may be subtle/atypical
• Diagnosis requires high index of suspicion
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AorticDissection
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Tear
Aortic Dissection
AdventitiaMediaIntima
Tear
BloodTrue Lumen
False Lumen
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Aortic Dissection - ImagingPrimary Objectives
• Identify entry site• Determine type A vs B• Involvement of coronary arteries ?• Identify complications:
• Presence, severity, mechanism of AR• Pericardial or pleural effusion• Rupture ?• Branch ischemia
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aortic dissection
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Imaging Modalities for Aortic Dissection
• Initial test in >70% of patients (IRAD)
• Widely available, quickest diagnostic times
• Very high diagnostic accuracy
• Relatively operator independent
• Allows evaluation of entire aorta
CT-Scan
(including arch vessels, mesenteric vessels, and renal arteries)
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CT-Scan for Aortic Dissection
• Ionizing radiation exposure
• Requires iodinated contrast material
• Pulsation artifact in ascending aorta
Disadvantages
(can be improved with ECG gating)
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Imaging Modalities for Aortic Dissection
• Very high diagnostic accuracy• Widely available, portable, convenient, fast• Excellent for:
• Can detect involvement of coronary arteries• Safely performed on critically ill patients• Optimal procedure for guidance in OR
TEE
- Pericardial effusion- Presence, degree, mechanism of AR- L V function
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Author Year n WithDiss'n
ErbelHashimotoAdachiBallalSimonNienaber
198919891991199219921993
16422456132
110
822245342844
Sens Spec
99%100%98%97%
100%98%
98%N/AN/A
100%100%77%
Totals 99% 94%655 376Kang 1998 200 100 100% 91%
Detection of Aortic DissectionAccuracy of TEE
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TEE for Aortic Dissection
• Depends on skill of operator
• “Blind spot” upper ascending aorta
• Not reliable for cerebral vessels,
• Semi-invasive
• Reverberation artifacts (rarely a problem)
Disadvantages
mesenteric vessels, renal arteries
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Imaging Modalities for Aortic Dissection
• Very high diagnostic accuracy
• 3D multiplanar and high resolution
• Does not require ionizing radiation or
• Appropriate for serial imaging over many years
MRI
iodinated contrast material
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MRI for Aortic Dissection
• Less widely available• Difficult monitoring critically ill patients• Longer examination time• Not feasible in emergent of unstable
• Caution with use of gadolinium in
Disadvantages
clinical situations
renal failure
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Spiral CT
MRI
TEE
Sensitivity Specificity Time
100% 100%
100%
100%
94%
94%
28 min
27 min
45 min
Diagnosis of Aortic DissectionComparative Study of Spiral CT, MRI, TEE
49 suspected aortic dissection25 had dissection (18 type A; 7 type B)
Sommer Radiology 199:347(1996)
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Aortic Dissection2D-Echo Findings
• .
• Double-channel aorta (TL and FL)
• Dilated aorta (usual)
• Re-entry sites (ostia of intercostals)
• “Cobwebs” (false lumen)
• Aortic insufficiency
• Pericardial and/or pleural effusion
Hallmark: dissection flap
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LA
TL
FL
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TEE CT-scan
Descending Thoracic Aorta
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CT-scan TEE
Aortic Arch
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Aortic RegurgitationMechanisms of Aortic Regurgitation
• Dilatation of aortic root leading to
• Cusp prolapse• Disruption of aortic annular support
• Invagination of dissection flap through
• Pre-existing aortic valve disease (eg,Bic AoV)
incomplete aortic leaflet copatation
resulting in flail leaflet
the aortic valve in diastole
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Mechanisms of Aortic RegurgitationA B
C
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Case 1
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Case 2
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Intramural Hematoma
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“Atypical" Aortic Dissection
TL
FL
Typical"Atypical"
= Dissection flap and false lumen= No dissection flap; Medial hematoma
(Intramural Hematoma)
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"Atypical" Aortic Dissection(Intramural Hematoma)
• Prevalence 10-20% in CT/MRI/TEE studies
• Type III more common
• Normal size lumen
• False negative aortograms
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Totals 17%289/1,687
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Note: Often missed by aortogram which is a luminogram
Intramural HematomaImaging Features
• Focal aortic wall thickening• Preserved luminal shape with a smooth
• Absence of dissection flap and false lumen• Echolucent regions may be present in the
luminal border
aortic wall
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Intramural Hematoma
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Intramural HematomaCT-scan
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MRI
Intramural Hematoma
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Case 3
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Case 4RM - 46 year old manKnown bicuspid aortic valveS/P coarct repair (remote)Sudden onset of severe chest painSyncope
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Summary
• Advances in imaging techniques have
• Indications for specific modality depends on:
• TTE used most often for aortic root assessment
greatly increased our understanding of thoracic aortic diseases
- Accuracy for specific diseases- Availability- Cost/benefit ratio
continued . . .
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Summary
• CT-scan high resolution of entire aorta
• MRI greatest morphologic and dynamic
• TEE optimal procedure for guidance in OR
information without radiation, but lesswidely available
including arch, mesenteric, and renal vessels
safely performed on critically ill patients, even those on ventilators
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