Aortic dissection and malperfusion syndrome: a when, what and how-to guide.

Malperfusion syndrome is a complication of aortic dissection caused by branch-vessel involvement and resulting in end-organ ischaemic dysfunction. Clinical diagnosis is mandatory, and imaging plays a critical role in confirmation and treatment planning. Radiologists must focus on detecting complications (findings of aortic dilation, rupture, organ ischaemia, etc.) and defining vascular compromise and associated malperfusion mechanisms. All these factors guide the multidisciplinary discussion concerning patient management and the suitability of endovascular treatment. Application of dedicated imaging protocols is mandatory in order to answer clinical and anatomical questions. Endovascular therapy has taken a predominant role in the therapeutic management of malperfusion syndrome with aortic fenestration, peripheral stenting and stent-grafting, all of which are procedures within the domain of expertise of current interventional radiologists. The purpose of this editorial is to present a when, what and how-to guide for all radiologists who encounter complicated aortic dissection.

[Clinical indications for the use of cardiac MRI. By the SIRM Study Group on Cardiac Imaging]. / Indicazioni cliniche per l'utilizzo della cardio RM. A cura del Gruppo di lavoro della Sezione di Cardio-Radiologia della SIRM.

Cardiac magnetic resonance (CMR) is considered an useful method in the evaluation of many cardiac disorders. Based on our experience and available literature, we wrote a document as a guiding tool in the clinical use of CMR. Synthetically we describe different cardiac disorders and express for each one a classification, I to IV, depending on the significance of diagnostic information expected.

Clinical indications for cardiac computed tomography. From the Working Group of the Cardiac Radiology Section of the Italian Society of Medical Radiology (SIRM).

Cardiac computed tomography (CCT) has grown as a useful means in different clinical contexts. Technological development has progressively extended the indications for CCT while reducing the required radiation dose. Even today there is little documentation from the main international scientific societies describing the proper use and clinical indications of CCT; in particular, there are no complete guidelines. This document reflects the position of the Working Group of the Cardiac Radiology Section of the Italian Society of Radiology concerning the indications for CCT.

Endovascular approach for acute aortic syndrome.

Acute aortic syndrome (AAS) refers to the spectrum of aortic emergencies that include aortic dissection, intramural hematoma and penetrating atherosclerotic ulcer. These aortic pathologies may lead to aortic rupture and a timely treatment is crucial to obtain clinical success and benefit on survival. Endovascular strategies have gained wide acceptance in the management of AAS and currently represent the new minimally invasive alternative to traditional surgery. In particular in acute complicated aortic dissection endovascular therapy demonstrated a better survival and limited complications with respect to open surgery. Aim of the present study was to provide an overview of AAS and to assess the current role of endovascular aortic repair in its treatment.

Optimal management of traumatic aortic injury.

BACKGROUND: The best time to intervene in traumatic aortic injuries has long been a matter of debate. While emergency surgery is characterized by high morbidity and mortality, initial medical management of uncomplicated aortic injury and subsequent delayed surgery resulted in better outcome. METHODS AND RESULTS: From analysis of medical literature of the last 10 years, major paradigm shift in management of traumatic injuries includes the use of different imaging methods for diagnosis, with a almost complete elimination of aortography and transesophageal echocardiography in favour of CT scan, and a significant change in method of definitive repair, shifting from exclusively open techniques in 1997 to predominantly endovascular repairs in 2007. At present several reports in literature provide data on comparative results of endovascular therapy with respect open surgery, supporting the use of stent-graft in traumatic injuries, both in acute and chronic cases. The authors' personal experience comprises 58 patients treated with endovascular stent-graft repair, with no mortality or treatment failure even during 11 years follow-up. CONCLUSIONS: For many years traumatic aortic injury has been considered a highly lethal lesion and a potential cause of death in blunt chest trauma. Because of the lower invasivity endovascular repair can be applied in traumatic aortic injury with very low risk and limited impact on trauma destabilization. Long term follow-up seems indicate a substantial durability of the procedure.

Subclavian embolization associated to carotid-subclavian bypass and stent-graft repair of acute type-B dissection.

Intentional closure of the left subclavian artery (LSA) during an endovascular procedure can be complicated by retrograde filling of the excluded aorta, increasing the risk of aneurysm expansion and sudden rupture. Retrograde coil embolization of the LSA, as alternative to open subclavian ligature, is a safe and effective method of rapid false lumen sealing in patients requiring coverage of the LSA and carotid-subclavian bypass, even in the setting of acute aortic syndromes.

FBN1 mutation screening of patients with Marfan syndrome and related disorders: detection of 46 novel FBN1 mutations.

Fibrillin-1 gene (FBN1) mutations cause Marfan syndrome (MFS), an inherited connective tissue disorder with autosomal dominant transmission. Major clinical manifestations affect cardiovascular and skeletal apparatuses and ocular and central nervous systems. We analyzed FBN1 gene in 99 patients referred to our Center for Marfan Syndrome and Related Disorders (University of Florence, Florence, Italy): 85 were affected by MFS and 14 by other fibrillinopathies type I. We identified mutations in 80 patients. Among the 77 different mutational events, 46 had not been previously reported. They are represented by 49 missense (61%), 1 silent (1%), 13 nonsense (16%), 6 donor splice site mutations (8%), 8 small deletions (10%), and 3 small duplications (4%). The majority of missense mutations were within the calcium-binding epidermal growth factor-like domains. We found preferential associations between The Cys-missense mutations and ectopia lentis and premature termination codon mutations and skeletal manifestations. In contrast to what reported in literature, the cardiovascular system is severely affected also in patients carrying mutations in exons 1-10 and 59-65. In conclusion, we were able to detect FBN1 mutations in 88% of patients with MFS and in 36% of patients with other fibrillinopathies type I, confirming that FBN1 mutations are good predictors of classic MFS.

Annular ligament reconstruction in chronic Monteggia fracture-dislocations in the adult population: indications and surgical technique.

Chronic Monteggia fracture is defined as dislocation of the radial head that is still present 4 weeks after injury. The cause may reside in residual ulnar deformity after internal fixation, in failure of annular ligament healing, or both. This situation may lead to elbow pain, decreased motion, neurologic problems and valgus deformity. The aim of the present study is to investigate indications and surgical technique for annular ligament reconstruction (ALR) in chronic Monteggia fractures. Relevant articles on annular ligament anatomy and biomechanics, clinical-radiographic evaluation of chronic Monteggia lesions and surgical techniques for ALR were reviewed. A case of an ALR in chronic Monteggia injury using a modified Bell Tawse surgical technique with triceps tendon autograft is presented. Little data exist on chronic Monteggia injury in the adult population. The annular ligament has a critical role in radial head stability. Nonetheless, bony alignment of the ulna is confirmed to be the most relevant feature to address in chronic Monteggia fractures. ALR has been advocated to address radial head instability both combined with ulna osteotomy and as a single procedure, with several surgical techniques described and controversial results reported. A modified Bell Tawse surgical technique resulted to be effective in the presented case. ALR seems to be indicated in chronic Monteggia fractures with normal bony alignment, without conclusive evidence on a preferable surgical technique.

Evolving concepts in the treatment of traumatic aortic injury. A review article.

Traumatic aortic injury (TAI) has long been considered a surgical emergency, despite the high mortality and morbidity rates in traumatized patients submitted to open surgery. Initial medical management until stabilization of associated traumatic lesions has long been a matter of debate because of the inherent risk of rupture in some of these cases. Endovascular techniques in the management of polytraumatized patients provides an additional low-invasive treatment option. Because of its lower invasiveness, without thoracotomy or the use of heparin, endovascular repair can be performed in acute patients, without the risk of destabilizing pulmonary, head or abdominal traumatic lesions. Following the publication of early small series and case reports, endovascular repair has become a widely accepted method for treating both acute and chronic traumatic lesions. Our series comprised 51 TAI patients submitted to endovascular aneurysm repair from July 1997 to December 2006, of which 24 had chronic post-traumatic aneurysms and 27 were treated in the acute or subacute phase after the traumatic event. No mortality occurred; aneurysm sealing was consistently good. Major complications included a cerebellar stroke in 1 patient due to occlusion of the left subclavian artery. No failure of aortic procedure, mortality or complications were observed during the follow-up period. Should long-term follow-up in larger series show substantial durability of the graft material, endovascular treatment will become the management of choice for TAIs.

Assessment of restrictive cardiomyopathy of amyloid or idiopathic etiology by magnetic resonance imaging.

This study was designed to assess the role of magnetic resonance imaging in the differential diagnosis of amyloid and idiopathic etiology of cardiomyopathy. This technique demonstrated the capability to differentiate the 2 forms, providing high-resolution evaluation of the myocardial wall and detecting the infiltrative pathology by tissue characterization.

Usefulness of transesophageal echocardiographic monitoring to improve the outcome of stent-graft treatment of thoracic aortic aneurysms.

The stent-graft procedure is becoming an alternative to surgery for treatment of many diseases of the descending thoracic aorta. This study evaluated the role of transesophageal echocardiography (TEE), used in combination with fluoroscopy and angiography, in monitoring the outcome of stent-graft placement. Twenty-two consecutive patients were submitted to stent-graft positioning in the descending aorta for various pathologies (7 patients had type B aortic dissections, 6 had thoracic aneurysms, 2 had thoraco-abdominal aneurysms, and 7 had post-traumatic aortic aneurysms). Before stent-graft deployment, TEE changed the proximal site of stent positioning initially identified by angiography in 33% of patients (5 of 15) with aortic aneurysms because of calcifications or atheromas that could interfere with stent adhesion to the aortic wall and that were not seen on angiography. In 28% of patients (2 of 7) with aortic dissection, TEE showed the guidewire in the false lumen, allowing an immediate repositioning. After stent-graft deployment, color Doppler TEE showed a perigraft leak in 7 patients, whereas angiography detected a perigraft leak in only 2 patients (p = 0.02). In 4 of these patients, further balloon expansions resulted in resolution of the leak. In the remaining 3 patients, additional stent-graft positioning was necessary. Considering the total patient cohort, TEE yielded relevant information, resulting in procedure changes in 59% (13 of 22). In conclusion, TEE provided additional information with respect to angiography in all phases of stent-graft treatment, improving immediate outcome and reducing complications.

Evolution of aortic dissection after surgical repair.

Patients after aortic dissection repair still have long-term unfavorable prognosis and need careful monitoring. The purpose of this study was to analyze the evolution of aortic dissection after surgical repair in correlation to anatomic changes emerging from systematic magnetic resonance imaging (MRI) follow-up. Between January 1992 and June 1998, 70 patients underwent surgery for type A aortic dissection. Fifty-eight patients were discharged from the hospital (17% operative mortality) and were followed by serial MRI for 12 to 90 months after surgery. In all, 436 postoperative MRI examinations were analyzed. In 13 patients (22.5%) no residual intimal flap was identified, whereas 45 patients (77.5%) presented with distal dissection, with a partial thrombosis of the false lumen in 24. The yearly aortic growth rate was maximum in the descending aortic segment (0.37 +/- 0.43 cm) and was significantly higher in the absence of thrombus in the false lumen (0.56 +/- 0.57 cm) (p <0.05). There were 4 sudden deaths, with documented aortic rupture in 2. Sixteen patients underwent reoperation for expanding aortic diameter. In all but 1 patient, a residual dissection was present (in 13 without any thrombosis of the false lumen). Close MRI follow-up in patients after dissection surgical repair can identify the progression of aortic pathology, providing effective prevention of aortic rupture and timely reoperation. Thrombosis of the false lumen appears to be a protective factor against aortic dilation.

Primary endoleakage in endovascular treatment of the thoracic aorta: importance of intraoperative transesophageal echocardiography.

OBJECTIVES: Endovascular treatment of the thoracic aorta has developed as an efficacious alternative to open surgical repair. However, despite the high primary success rate, perigraft leakage constitutes the major concern in long-term follow-up. Endoleaks are widely reported both in abdominal and thoracic endovascular series and are usually identified by intraoperative angiography. Transesophageal echocardiography is a sensitive imaging technique in the evaluation of aortic diseases, widely used to monitor cardiac surgery. The aim of this study was to evaluate the efficacy of transesophageal echocardiography in leakage detection during endovascular stent procedures of the thoracic aorta. METHODS: Intraoperative transesophageal echocardiography was used in conjunction with angiography in 25 patients subjected to endovascular stent treatment of the descending thoracic aorta. Spiral computed tomographic scanning was performed before discharge and 3, 6, and 12 months after treatment. RESULTS: Information from transesophageal echocardiography was relevant in the selection of the landing zone in 62% of cases. In 8 patients, transesophageal echocardiography with color Doppler sonography showed a perigraft leak, 6 of which were not visible on angiography, suggesting the need for further balloon expansion or graft extension. Postoperative computed tomographic scanning in the 25 patients showed 1 endoleak, which sealed spontaneously. At 3 months, computed tomographic examination confirmed the absence of perigraft leakage in all patients. CONCLUSIONS: During implantation of a stent-graft in the descending thoracic aorta, transesophageal echocardiography provides information in addition to that provided by angiography, improving immediate and late procedural results.

Surgical indications and timing of repair of traumatic ruptures of the thoracic aorta.

BACKGROUND: The outcome of patients with acute traumatic rupture of the thoracic aorta after motor vehicle accidents is strongly conditioned by injuries to other districts. The timing of repair is controversial when the patients arrive alive to the hospital. METHODS: A series of 42 patients with acute traumatic rupture of the thoracic aorta observed between January 1980 and June 1996 was divided into two groups: group I underwent immediate repair (21 patients) and in group II operation was performed after intensive medical treatment and management of the associated lesions and monitoring of the aortic tear. RESULTS: The mortality in group I patients was 19% and the morbidity was more significant than in group II where no deaths were reported and complications were minor. CONCLUSIONS: Patients with acute traumatic rupture of the thoracic aorta may have a better fighting chance if aortic operation is postponed to the most favorable moment after undergoing life-sustaining measures and management of the major associated lesions. Needless to say, evolution should be closely monitored by computed tomographic scans and magnetic resonance imaging.

Percutaneous transluminal coronary angioplasty of the very proximal left anterior descending artery lesions: immediate results and follow-up.

In order to assess the results of percutaneous transluminal coronary angioplasty of the proximal (before the first septal branch) left anterior descending artery lesions, we analyzed the results in 206 consecutive patients, aged 56 +/- 12 years. The distance of the lesion from the origin of the left anterior descending artery was measured in the right oblique angiogram. The location of the lesions proved to be very proximal (less than 0.5 cm from the origin) in 22 patients, intermediate (0.5-1 cm from the origin) in 26 patients and distal (greater than 1 cm from the origin) in 158 patients. The initial angiographic success rate was similar among the 3 groups of patients: 95.8% in those with very proximal and intermediate lesions and 98.1% in those with distal lesions. Occlusive dissection of the left anterior descending artery without involvement of the mainstem occurred in 3.8% of the patients with intermediate lesions and in 1.9% of those with distal lesions. No complications occurred in any patient with very proximal lesions. The clinical follow-up was 25.2 +/- 12 months; angina recurred in 15.5% (31 out of 206 patients). Coronary angiography was performed in 103 patients. Restenosis occurred in 42.3% of the patients with very proximal and intermediate lesions (11 out of 26) and 31.2% of those with distal lesions (24 out of 77). In conclusion, in most patients with very proximal and intermediate lesions of left anterior descending artery, coronary angioplasty can be performed with low risk. The location of the lesion in the proximal portion of left anterior descending artery does not affect the overall success rate.(ABSTRACT TRUNCATED AT 250 WORDS)

Evolution of post-traumatic aortic aneurysm in the subacute phase: magnetic resonance imaging follow-up as a support of the surgical timing.

OBJECTIVES: A recent surgical series documented that in traumatic aortic rupture (TAR) a surgical repair postponed to the treatment of associated lesions reduced operative and overall mortality. Nevertheless some isolated cases may develop to free rupture. Until now, no imaging follow-up studies of post-traumatic aortic lesions have been reported in the early stage. The aim of this study is to analyze the behaviour of traumatic aortic ruptures in the subacute phase, in order to detect the morphological characteristics of unstable post-traumatic aneurysms. METHODS: Twenty-five consecutive patients affected by traumatic aortic rupture (one intimal hemorrhage, 19 partial lesions and five circumferential lesions) were admitted to the department of cardiac surgery. Magnetic resonance imaging (MRI) was the imaging method used to confirm the diagnosis. No one was operated on during the acute phase. All patients were treated with beta-blockers and vasodilators as well as limited fluid administration. Delayed surgery was carried out in 18 patients at 243 days (+/-127), after the resolution of associated lesions. A scheduled MRI follow-up was performed at 7, 15 and 30 days and immediately before the operation. The parameters examined were increase of post-traumatic aneurysm, increase of periaortic hematoma and modification of the thoracic associated lesions. RESULTS: At 30 days a 3.0 +/- 3.7 mm median increase of the aneurysm was observed, while in the subsequent period the lesions became substantially stable, resulting in a 4.4 +/- 3.6 mm increment at the end of the follow-up. The circumferential lesions presented a higher increment with respect to the partial lesions. In three cases an augmentation of 6, 7 and 12 mm was detected and surgical repair was anticipated. In 13 cases a periadventitial hematoma surrounding the aortic aneurysm decreased through the time. One case of intimal hemorrhage healed spontaneously, with no aneurysm formation. Thoracic associated lesions (pleural and pericardial effusions, rib fractures, lung focal contusions and two cases of ARDS) resolved at 30-60 days. CONCLUSIONS: Despite common knowledge, considering TAR highly evolutive in the acute and subacute phase, this study demonstrated that this pathological entity is relatively stable if a proper pharmacological treatment is administrated. MRI follow-up is recommended in order to detect isolated cases of unstable aneurysm.

Iomeprol and iopamidol in cardiac angiography: a randomised, double-blind, parallel-group comparison.

During cardiac angiography, hemodynamic alterations and surface electrocardiographic changes are common, predictable and dose-related adverse reactions to radiocontrast media. High osmolality, inadequate sodium content and local transient hypocalcemia are thought to be the main mechanisms responsible for these untoward cardiovascular effects. The purpose of this double-blind, parallel-group trial was to compare the hemodynamic and electrocardiographic responses to cardiac and selective coronary artery injection of iomeprol 400 (400 mgI/ml) and iopamidol 370 (370 mgI/ml). One-hundred consenting adult inpatients were randomised to receive iomeprol 400 (41 males, nine females; mean age, 56.6 years) or iopamidol 370 (46 males, four females; mean age, 57.6 years). Both agents produced minor and transient hemodynamic and electrophysiological effects. Following left ventriculography, iopamidol 370 produced a significantly greater increase in LVEDP than iomeprol 400 (mean increases after first and second left ventriculogram: 2.5 and 4.6 mmHg with iomeprol 400, 3.3 and 9.9 mmHg with iopamidol 370, P = 0.027). The QT-interval was more affected by iopamidol 370 than by iomeprol 400. However, post-contrast prolongation of the QT-interval was not significant with either agent, nor were there any significant T-wave, ST-segment or RR-interval changes associated with the injection of the test compounds. No serious adverse events occurred throughout the study. Mild pain was complained by only one patient, while most patients reported mild to moderate sensation of heat. Image quality of the vast majority of the procedures was rated as good or excellent in both patient groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Intravenous coronary angiography using synchrotron radiation: technical description and preliminary results.

BACKGROUND: Standard coronary angiography requires an arterial access and catheters; intravenous coronary angiography may image coronary arteries noninvasively and without catheters. The aim of this study was the assessment of the diagnostic accuracy of intravenous coronary angiography validated by selective coronary angiography. METHODS: Seventy outpatients (80% males, mean age 62 +/- 8 years) underwent both standard and intravenous coronary angiography after a previous coronary intervention. Intravenous coronary angiography was performed within 6 weeks before or after selective coronary angiography. Two different projections were used to obtain 6-8 sequences per patient. Images were taken after injection of the contrast agent into the brachial vein or into the superior vena cava. During image acquisition, patients were moved through the scanning beam on a special chair. Thereafter, images were evaluated and compared to selective coronary angiograms for the following criteria: no stenosis, subsignificant stenosis (< 70%), significant stenosis (> or = 70%), and occlusion. RESULTS: One hundred eighty-seven target vessels were analyzed. In 50 target vessels one or more stents had been implanted. Seventeen target vessels were not analyzable due to inadequate image quality. The sensitivity of intravenous coronary angiography for the detection of lesions was 80% and the specificity was 95%. The sensitivity for the detection of significant lesions in the left anterior descending coronary artery was 84% (specificity 93%), in the left circumflex coronary artery 67% (specificity 90%), in the right coronary artery 85% (specificity 97%), and in bypass grafts 85% (specificity 97%). No complications were observed. CONCLUSIONS: Intravenous coronary angiography is efficacious and safe and allows quantification of lesions of the coronary arteries and of bypass vessels. Further advances in image processing are needed to improve sensitivity especially in the left circumflex coronary artery.