ct of acute thoracic aortic syndromes - scbtmr · 2013-12-09 · thoracic aortic “aneurysms ......
TRANSCRIPT
![Page 1: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/1.jpg)
CT of Acute Thoracic Aortic Syndromes
Stuart S. Sagel, M.D.
![Page 2: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/2.jpg)
Thoracic Aortic“Aneurysms”
• Atherosclerotic• Dissection• Penetrating ulcer• Mycotic• Inflammatory (vasculitis)• Traumatic
![Page 3: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/3.jpg)
Aortic ImagingOptions
• Catheter angiography• Ultrasound (TEE or TT)• MRI• MDCT
![Page 4: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/4.jpg)
MDCT is the Workhorse
• Non-invasive• Patients easily monitored • Fast • Readily available• Less operator dependent• Easily understood• Good surgical roadmap (Recons)
![Page 5: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/5.jpg)
AtheroscleroticAortic Aneurysm
• Elder hypertensive; smoker• Most discovered incidentally• Symptoms, with advanced disease
mass effectstridor, cough, hoarseness, dysphagia
rupturechest pain, hemoptysis, hypotension
![Page 6: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/6.jpg)
Thoracic Aortic Rupture
• Pre-existing aneurysmatherosclerotic (mycotic, vasculitis)
• Dissection• Penetrating atherosclerotic ulcer
![Page 7: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/7.jpg)
Rupture/Leaking Aortic AneurysmCT Findings
• Abnormal contour of aortic lumen• Contrast outside borders of aorta• High attenuation fluid outside aorta
mediastinal hematomahemopericardium, hemothorax
![Page 8: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/8.jpg)
Aortic Dissection• Hypertension (90%)
50-75 years old, 75% men• Cystic medial necrosis• Coarctation• Bicuspid aortic valve• Prior cardiac (aortic valve) surgery• Pregnancy (3rd trimester)• Cocaine abuse, weight-lifting
![Page 9: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/9.jpg)
Aortic DissectionRequisite Imaging Information
• Is a dissection present?• Is it type A or B?
![Page 10: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/10.jpg)
Aortic DissectionMost common acute aortic syndrome• Type A (60%)
Surgery usually• Type B
Medical management unlesshemorrhagecontinued painvascular compromisepseudoaneurysm formation
![Page 11: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/11.jpg)
Type A DissectionSurgical Emergency
• Pericardial tamponade• Coronary or cerebral ischemia• Aortic insufficiency
![Page 12: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/12.jpg)
Aortic DissectionClassic Pathogenesis
• Intimal tear• Blood splits aortic media• Intimomedial flap
true/false channels• Distal re-entry tear(s)
![Page 13: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/13.jpg)
Aortic DissectionPathogenesis
• Intimal Tear (80%) creation of patent false lumenassociation cystic medial necrosis
• Rupture of vasa vasorumintramural hematomamay rupture into true lumen
“atypical” dissection
![Page 14: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/14.jpg)
Intramural Hematoma (IMH)
Hematoma within the aortic wall
• Aortic Dissectionrupture vasa vasorumthrombosed false lumen
• Penetrating Atherosclerotic Ulcer• Arteritis
![Page 15: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/15.jpg)
Suspected Aortic DissectionCT Technique
• Pre and post contrast (thorax/abdomen/pelvis)• 0.625-1.25 collimation• 90-125 ml (Optiray 350)
4-5 ml/secbolus triggering
• Post-processingreformatted 2D (sagittal, coronal, oblique)multiplanar, 3D
• ? ECG gated thoracic portion
![Page 16: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/16.jpg)
CT: Acute Aortic DissectionPre-contrast Images
• Intimal calcium displacement• High attenuation thrombosed
false lumen• Mediastinal, pleural, pericardial
blood
![Page 17: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/17.jpg)
CT: Acute Aortic DissectionPost-contrast Images
• Intimal flap• Thrombosed false lumen• Narrowed true lumen• (Delayed enhancement false lumen)• Organ ischemia
![Page 18: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/18.jpg)
True vs. False LumenGeneralizations
• True lumen smallerorigin of coronaries, celiac,
SMA, right renal arteries• False lumen larger
generally less opaquecobweb signmay rupture
![Page 19: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/19.jpg)
CT: Thoracic AortaMultiplanar, 3D Reconstructions
• Rarely helpful for diagnosis• Aids communication with surgeons
displays anatomic relationshipspre-operative planning
great vessel involvementcross-clamping
![Page 20: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/20.jpg)
CT: Intramural Hematoma
• Smooth, hyperdense crescenticaortic wall thickening (> 7mm)
much easier to see on non-contrast images• Lack of contrast enhancement• Inward displacement intimal calcification
![Page 21: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/21.jpg)
Natural History of Intramural Hematoma
Variable
• Develop more classic dissection (12%)• Resolve (34%)• Enlarge, pseudoaneurysm, rupture (54%)
![Page 22: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/22.jpg)
Complications ofAortic Dissection
• Ruptureleak into mediastinum
pericardium, pleural spacepulmonary artery adventitia
• Malperfusionmajor branch involvement
(static or dynamic)concave true lumenintimointimal intussusception (windsock sign)
![Page 23: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/23.jpg)
Penetrating Atherosclerotic Ulcer
Ulceration of advanced atherosclerotic plaque
• Penetrates internal elastic lamina• Hematoma of media• Can cause pseudoaneurysm and rupture
• 94% affect mid → descending aorta
![Page 24: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/24.jpg)
Penetrating Atherosclerotic UlcerCT Findings
• Extensive atherosclerotic disease• Focal contrast filled outpouching
surrounded by intramural hematoma
![Page 25: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/25.jpg)
Atheromatous plaque with ulcerno contrast beyond plaque
Penetrating atherosclerotic ulcerassociated intramural hematoma
beyond intima
![Page 26: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/26.jpg)
Penetrating UlcerTreatment
•Like dissectionprognosis worse
•Complicationspseudoaneurysmdissectionrupture
![Page 27: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/27.jpg)
Fate of Intramural Hematoma
• Regress• Pseudoaneurysm formation
rupture• Form classic dissection
![Page 28: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/28.jpg)
Aortic Transection• 16% of MVA deaths• 85% die immediately (rupture)• 50% remaining die in 24 hours
tear, adventitia initially intact• <4% survive 6 months
• > 90% of aortograms done forpossible diagnosis are negative
![Page 29: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/29.jpg)
CXR: Aortic Transection• Sensitive, limited specificity
Mediastinal wideningespecially if done supine
• More specific, less sensitiveLeft apical cap, no rib FxAortic knob obliterationShift nasogastric or ET tubeLeft main bronchus depressionLeft paraspinal widening
![Page 30: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/30.jpg)
MDCT: Aortic Transection• Close to 100% accuracy if
performed and interpreted expertly• Signs
pseudoaneurysm beyond left SCAsudden change caliber descending aortairregular aortic contour; thrombusintimal flapblood contiguous with aorta (almost all)
active bleeding
![Page 31: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/31.jpg)
Minimal Aortic Injury
May not see mediastinal hematoma
![Page 32: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/32.jpg)
Traumatic Aortic InjuryAtypical Locations
• Ascending aorta• Arch• Proximal great vessels
![Page 33: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/33.jpg)
Traumatic Aortic InjuryPitfalls
• Congenital anomaliesDuctus diverticulumRight aortic archPersistent left superior vena cava
No mediastinal hematoma
• Non-aortic injury (spine, pericardium)
![Page 34: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/34.jpg)
Anterior Mediastinal Blood
Not a sign of aortic injuryusually due to venous bleedinglook for sternal fracturelook for arch vessel injury
![Page 35: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/35.jpg)
CT: Aortic Transection
• Aorta is normalSTOP (precludes angiography)
• Not sure or contiguous bloodAngiogram (rarely needed) or TEE
• Positive
• Detects other injuriespneumothorax, fractures, lunghemopericardium
![Page 36: CT of Acute Thoracic Aortic Syndromes - Scbtmr · 2013-12-09 · Thoracic Aortic “Aneurysms ... Microsoft PowerPoint - Sagel - Syllabus SCBT CT Acute Aortic Syndromes Author: kmarshall](https://reader034.vdocuments.site/reader034/viewer/2022042322/5f0c00aa7e708231d43346ba/html5/thumbnails/36.jpg)
MDCT: Traumatic Aortic Injury
Precise characterization of injury has major influence on treatment
• Aortic stentfavorable anatomy, not good operative risk
• Surgical repairpoor anatomy for stenting
• ? Nothingminimal aortic injury