Superior Vena Cava Reconstruction Using Femoropopliteal Vein as a Panel Graft.

There has been an increase in superior vena cava (SVC) syndrome secondary to the growing use of indwelling catheters and pacemaker wire insertions. These 2 factors can account up to 74% cases of benign SVC syndrome. Endovascular therapy is considered the first line of treatment. Surgery is an excellent option and is generally reserved for SVC syndrome not amenable to traditional endovascular procedures. We report a case of central venous reconstruction including an SVC reconstruction using the femoropopliteal vein as a panel graft in a patient with SVC syndrome due to pacemaker wires who failed multiple endovascular interventions.

Value of C-Arm Cone Beam Computed Tomography Image Fusion in Maximizing the Versatility of Endovascular Robotics.

BACKGROUND: To report our initial experience and highlight the value of using intraoperative C-arm cone beam computed tomography (CT; DynaCT(®)) image fusion guidance along with steerable robotic endovascular catheter navigation to optimize vessel cannulation. METHODS: Between May 2013 and January 2015, all patients who underwent endovascular procedures using DynaCT image fusion technique along with Hansen Magellan vascular robotic catheter were included in this study. As a part of preoperative planning, relevant vessel landmarks were electronically marked in contrast-enhanced multi-slice computed tomography images and stored. At the beginning of procedure, an intraoperative noncontrast C-arm cone beam CT (syngo DynaCT(®), Siemens Medical Solutions USA Inc.) was acquired in the hybrid suite. Preoperative images were then coregistered to intraoperative DynaCT images using aortic wall calcifications and bone landmarks. Stored landmarks were then overlaid on 2-dimensional (2D) live fluoroscopic images as virtual markers that are updated in real-time with C-arm, table movements and image zoom. Vascular access and robotic catheter (Magellan(®), Hansen Medical) was setup per standard. Vessel cannulation was performed based on electronic virtual markers on live fluoroscopy using robotic catheter. The impact of 3-dimensional (3D) image fusion guidance on robotic vessel cannulation was evaluated retrospectively, by assessing quantitative parameters like number of angiograms acquired before vessel cannulation and qualitative parameters like accuracy of vessel ostium and centerline markers. RESULTS: All 17 vessels were cannulated successfully in 14 patients' attempted using robotic catheter and image fusion guidance. Median vessel diameter at origin was 5.4 mm (range, 2.3-13 mm), whereas 12 of 17 (70.6%) vessels had either calcified and/or stenosed origin from parent vessel. Nine of 17 vessels (52.9 %) were cannulated without any contrast injection. Median number of angiograms required before cannulation was 0 (range, 0-2). On qualitative assessment, 14 of 15 vessels (93.3%) had grade = 1 accuracy (guidewire inside virtual ostial marker). Fourteen of 14 vessels had grade = 1 accuracy (virtual centerlines that matched with the actual vessel trajectory during cannulation). CONCLUSIONS: In this small series, the experience of using DynaCT image fusion guidance together with a steerable endovascular robotic catheter indicates that such image fusion strategies can enhance intraoperative 2D fluoroscopy by bringing preoperative 3D information about vascular stenosis and/or calcification, angulation, and take off from main vessel thereby facilitating ultimate vessel cannulation.

Kinematics effectively delineate accomplished users of endovascular robotics with a physical training model.

OBJECTIVE: Endovascular robotics systems, now approved for clinical use in the United States and Europe, are seeing rapid growth in interest. Determining who has sufficient expertise for safe and effective clinical use remains elusive. Our aim was to analyze performance on a robotic platform to determine what defines an expert user. METHODS: During three sessions, 21 subjects with a range of endovascular expertise and endovascular robotic experience (novices <2 hours to moderate-extensive experience with >20 hours) performed four tasks on a training model. All participants completed a 2-hour training session on the robot by a certified instructor. Completion times, global rating scores, and motion metrics were collected to assess performance. Electromagnetic tracking was used to capture and to analyze catheter tip motion. Motion analysis was based on derivations of speed and position including spectral arc length and total number of submovements (inversely proportional to proficiency of motion) and duration of submovements (directly proportional to proficiency). RESULTS: Ninety-eight percent of competent subjects successfully completed the tasks within the given time, whereas 91% of noncompetent subjects were successful. There was no significant difference in completion times between competent and noncompetent users except for the posterior branch (151 s:105 s; P = .01). The competent users had more efficient motion as evidenced by statistically significant differences in the metrics of motion analysis. Users with >20 hours of experience performed significantly better than those newer to the system, independent of prior endovascular experience. CONCLUSIONS: This study demonstrates that motion-based metrics can differentiate novice from trained users of flexible robotics systems for basic endovascular tasks. Efficiency of catheter movement, consistency of performance, and learning curves may help identify users who are sufficiently trained for safe clinical use of the system. This work will help identify the learning curve and specific movements that translate to expert robotic navigation.

The model for Fundamentals of Endovascular Surgery (FEVS) successfully defines the competent endovascular surgeon.

OBJECTIVE: Fundamental skills testing is now required for certification in general surgery. No model for assessing fundamental endovascular skills exists. Our objective was to develop a model that tests the fundamental endovascular skills and differentiates competent from noncompetent performance. METHODS: The Fundamentals of Endovascular Surgery model was developed in silicon and virtual-reality versions. Twenty individuals (with a range of experience) performed four tasks on each model in three separate sessions. Tasks on the silicon model were performed under fluoroscopic guidance, and electromagnetic tracking captured motion metrics for catheter tip position. Image processing captured tool tip position and motion on the virtual model. Performance was evaluated using a global rating scale, blinded video assessment of error metrics, and catheter tip movement and position. Motion analysis was based on derivations of speed and position that define proficiency of movement (spectral arc length, duration of submovement, and number of submovements). RESULTS: Performance was significantly different between competent and noncompetent interventionalists for the three performance measures of motion metrics, error metrics, and global rating scale. The mean error metric score was 6.83 for noncompetent individuals and 2.51 for the competent group (P < .0001). Median global rating scores were 2.25 for the noncompetent group and 4.75 for the competent users (P < .0001). CONCLUSIONS: The Fundamentals of Endovascular Surgery model successfully differentiates competent and noncompetent performance of fundamental endovascular skills based on a series of objective performance measures. This model could serve as a platform for skills testing for all trainees.

A randomized, controlled animal trial demonstrating the feasibility and safety of the Magellan™ endovascular robotic system.

BACKGROUND: The success of remotely steerable catheters designed for cardiac ablation procedures in the peripheral vasculature (in the laboratory and in highly select live cases) has led to the development of a vascular robotic system designed specifically for use in the arterial and venous systems. Limited bench-top and animal testing has been successful, but no randomized, controlled study of the system's safety has been performed. METHODS: In a 3-phase study, we performed a randomized, controlled trial comparing standard manual catheterization and balloon angioplasty of visceral, renal, and contralateral lower extremity vessels in a porcine model. We also demonstrated feasibility of standard device deployment through the system. RESULTS: There was 100% technical success in test (robotic) and control (manual) arm cannulation and balloon angioplasty of all target vessels, without complications. Pathologic analysis at 7 days revealed significantly fewer traumatic lesions in the test animal arm as compared with the control arm (P < 0.001) and, by 30 days, all lesions had healed in both groups. There was 100% success in delivery of standard devices (balloons and stents) without complications. CONCLUSIONS: Remotely steerable robotic catheters are at least as safe as manual catheter techniques, and may prove less traumatic to peripheral vessels. Standard devices can be deployed through the system, and the stability of the platform may aid in ease of device delivery in difficult vascular segments.

Validated assessment tool paves the way for standardized evaluation of trainees on anastomotic models.

BACKGROUND: Simulation modules allow for the safe practice of certain techniques and are becoming increasingly important in the shift toward education for integrated vascular residents. There is an unquestionable need to standardize the evaluation of trainees on these simulation models to assure their impact and effectiveness. We sought to validate such an assessment tool for a basic open vascular technique. METHODS: Vascular fellows, integrated vascular residents, and general surgery residents attending Society for Clinical Vascular Surgery, Introduction to Academic Vascular Surgery, and Methodist Boot Camp in 2012 were asked to participate in an assessment model using multiple anastomotic models and given 20 minutes to complete an end-to-side anastomosis. Trained vascular faculty evaluated subjects using an assessment tool that included a 25-point checklist and a graded overall global rating scale (GRS) on a 5-point Likert scale with 8 parameters. Self-assessment using the GRS was performed by 20 trainees. Reliability and construct validity were evaluated. RESULTS: Ninety-two trainees were assessed. There was excellent agreement between assessors on 21 of the 25 items, with 2 items found not to be relevant for the bench-top model. Graders agreed that the checklist was prohibitively cumbersome to use. Scores on the global assessments correlated with experience and were higher for the senior trainees, with median global summary scores increasing by postgraduate year. Reliability was confirmed through interrater correlation and internal consistency. Internal consistency was 0.92 for the GRS. There was poor correlation between grades given by the expert observers and the self-assessment from the trainee, but good correlation between scores assigned by faculty. Assessment of appropriate hemostasis was poor, which likely reflects the difficulty of evaluating this parameter in the current inanimate model. CONCLUSIONS: Performance on an open simulation model evaluated by a standardized global rating scale correlated to trainee experience level. This initial work confirms the ease and applicability of the grading tool among multiple expert observers and different platforms, and supports additional; research into applications translating this performance into the operating room.

A nationwide survey of vascular surgery trainees reveals trends in operative experience, confidence, and attitudes about simulation.

OBJECTIVE: There is mounting evidence supporting the benefit of surgical skills training in a simulated environment. However, the use of simulation in vascular surgery has been limited, and its value has been poorly understood. Access to simulation is presumed to be a major barrier to its widespread implementation. While a great deal of discussion is taking place at the national level, input from current trainees has not been obtained. METHODS: The Association of Program Directors in Vascular Surgery Committee on Education and Simulation sent a survey to all vascular surgical trainees assessing access to vascular simulation, the perceived value of simulation, and expectations for the future. Data were analyzed for junior (postgraduate year ≤ 4; n = 73) and senior (postgraduate year ≥ 5; n = 110) level and program type (traditional = 5 + 2/4 + 2; integrated = 0 + 5). RESULTS: A total of 183 of 326 (56%) trainees completed the survey, 72 (0-5), 5 (4+2), 111 (5+2), respectively. Of the respondents, 86% believe there is educational value in simulation. Cadaver dissections, followed by peripheral endovascular simulators and endovascular aortic aneurysm repair simulators, were ranked the most valuable tools by seniors, while anastomotic models are valued most by juniors, followed by cadavers and endosimulators. Fifty-six percent of programs currently offer simulation training, most commonly in the form of peripheral endovascular simulators (70%), anastomotic models (58%), or endovascular aortic aneurysm repair simulation (53%). Senior residents are more likely than juniors to have attended outside simulation courses (37% vs 19%). Overall, 57% of trainees expect that technical skills assessment will be incorporated into the certification process, and 52% endorse skills assessment for certification. CONCLUSIONS: Trainees report limited operative experience and confidence, and confidence levels are improved for a number of index procedures among those trainees with access to simulation. Trainees endorse the use of simulation to augment their surgical training, and a significant proportion of them already have access to it. These data support a perceived need and utility for implementation of a standardized simulation curriculum in vascular surgical training.

A first-in-man study of the role of flexible robotics in overcoming navigation challenges in the iliofemoral arteries.

OBJECTIVE: Current interventional techniques rely heavily on operator familiarity with catheters and wires and on physician skills in effectively navigating through and managing target lesions. A novel robotic technology allows endovascular specialists to remotely control catheter tip deflection and advancement and to coordinate manipulation of currently available wires. The aim of this study was to successfully demonstrate feasibility and safety of navigation to and treatment of iliac and femoral artery lesions using Hansen Medical's vascular control catheter (VCC). METHODS: A total of 20 limbs were included in this analysis for a first-in-man trial of the VCC and vascular catheter control system. The local Institutional Review Board approved the trial, and all patients included had symptomatic femoropopliteal occlusive disease. Preoperative imaging was available on all patients. Target lesions in the contralateral superficial femoral artery ranged from mild stenosis to chronic total occlusions (TransAtlantic Inter-Society A through D). Exclusion criteria included previously treated iliac and femoral lesions in the symptomatic leg and a body mass index >35. The operators comprised three experienced interventionalists (two vascular surgeons and an interventional radiologist) and a novice (cardiac surgeon). The primary end point of the study was to demonstrate successful cannulation of the target vessel (ie, navigation to the lesion with wire and catheter) with the Hansen VCC, with no device-related serious adverse events. Secondary end points were to assess the ability to treat lesions using the flexible catheter defined by successful insertion of a guidewire, angiography of the target vessel, delivery of balloon, and/or stent. Procedure times and radiation delivered were analyzed for the group and by operator, and t-test was performed to determine statistical significance. Complications were assessed by clinical examination and ultrasound. RESULTS: Lesions were successfully and safely cannulated in all limbs treated. The VCC performed as designed in all cases. All interventionalists, regardless of experience, navigated the VCC with ease. However, statistically significant differences in navigation time and radiation per case were observed between the experienced and inexperienced interventionalists. There were no access site complications (hematoma, thrombosis, pseudoaneurysm) as evaluated by ultrasound. CONCLUSIONS: This initial experience in flexible robotics demonstrates that this technology is both efficacious and safe in the arterial tree. Although robotics provides superior maneuverability compared with current techniques, endovascular experience is crucial to taking full advantage of the extra capabilities. Valuable future considerations will include off-the-wall (center lumen) navigation with three-dimensional imaging.

A longitudinal view of improved management strategies and outcomes after iatrogenic iliac artery rupture during endovascular aneurysm repair.

BACKGROUND: Intraoperative rupture of the iliac artery is a serious complication of endovascular aneurysm repair (EVAR), the outcomes of which have changed with increasing experience and improved endovascular tools over the past 2 decades. Over the past 15 years, the incidence and management of iliac rupture has changed as devices have improved and experience has grown. This study reviews our longitudinal experience with this complication. METHODS: All cases of iliac artery rupture during EVAR from 1997 through 2011 were reviewed for presentation, treatment strategies, and outcomes. RESULTS: Iliac artery rupture complicated 20 (3%) of 707 EVARs performed. Sixteen (80%) common and four (20%) external iliac arteries were ruptured. Hypotension (systolic blood pressure: <90 mm Hg) was present in 11 (55%) cases. Five open bypasses were performed (25%), whereas 15 were repaired using an endovascular approach (75%). All open repairs (100%) were associated with postoperative morbidity (one wound infection, four multiorgan system failure), whereas three of the 15 patients (23%) repaired endovascularly experienced postoperative morbidity (cerebrovascular accident, myocardial infarction, line infection). There were no intraoperative deaths. There were four (20%) early deaths in the intensive care unit (<3 days postoperatively), all of which were associated with resection of bilateral hypogastric arteries and were due to complications of pelvic ischemia and/or multiorgan system failure. CONCLUSIONS: Iliac artery rupture remains relatively uncommon but can carry a high morbidity and mortality. As device technology, imaging quality for preoperative planning, and experience level have improved, iliac rupture has become less common, and outcomes in the setting of iliac rupture have significantly improved. Endoluminal management has evolved as the primary treatment strategy. Resection of both hypogastric arteries is associated with mortality from pelvic ischemia, a likely indicator of systemic disease.

TheCardiovascular Fellows Bootcamp.

General surgery residents graduate with an inconsistent knowledge of cardiovascular disease and an inadequate skill set for the practice of vascular surgery. Vascular educators have proposed to overcome these challenges by incorporating standardized milestones and simulation curricula into vascular education, but at present, nonclinical vascular education remains nonstandardized. The first step in this direction is to lay a foundation of knowledge and skill for trainees nationwide, and regionalized courses have begun to be offered to address this need. Through the Methodist DeBakey Institute for Cardiovascular Education, we have developed our own course, The Cardiovascular Fellows Bootcamp. The principles behind The Cardiovascular Fellows Bootcamp are teach early, teach the basics, teach broadly, and teach multiple cardiovascular disciplines, and over a 3-day weekend of didactic lectures and skill training, we aim to lay a foundation for cardiovascular training that prepares the trainees for their fellowship. In this article, we describe the way in which our course is run and the thought process behind our approach. We also address some of the practical concerns that make hosting a course of this magnitude feasible and our plans for improving and expanding in the future.

Preliminary findings in quantification of changes in septal motion during follow-up of type B aortic dissections.

OBJECTIVE: To quantify longitudinal changes in intra-arterial septum (IS) motion with two-dimensional (2D) phase-contrast magnetic resonance imaging (2D pcMRI) in type B aortic dissections (AD) to improve the understanding of AD and its midterm development. METHODS: From a database of 42 patients who underwent a dynamic magnetic resonance imaging (MRI) examination at the Acute Aortic Treatment Center of The Methodist DeBakey Heart & Vascular Center, 2D pcMRI image data was available from 10 patients with type B AD for both short-term (mean, 6.6 days; range, 1-10 days; n = 7) and midterm follow-up (mean, 155 days; range, 60-324; n = 5). IS motion was quantified as motion of IS boundary points averaged over the cardiac cycle. Relative change in IS motion was expressed as percent change compared with initial presentation. Maximum IS extension (true lumen [TL] expansion) and contraction (TL compression), IS fraction in phase with aortic flow and correlation of IS motion with aortic flow (IS compliance) were quantified. RESULTS: IS motion at initial presentation was 0.68 ± 0.2 mm and was reduced at short-term (0.48 ± 0.3 mm; P = .07) and midterm (0.5 ± 0.2 mm; P = .1) follow-up. Trend in relative change of IS motion was variable during short-term follow-up: reduced in three subjects (-75% ± 6%) and elevated in four subjects (48% ± 23%). During midterm follow-up, relative change in IS motion was reduced in four subjects (28% ± 19%) and slightly elevated in one (6.2%). IS contraction decreased with follow-up while IS extension slightly increased. Fraction of IS moving in phase with aortic flow increased but IS compliance decreased, suggesting increasing IS stiffness. CONCLUSIONS: Reduction of IS motion in AD is seen with short-term and midterm follow-up. Intersubject variability of this trend is high at short-term follow-up but low at midterm follow-up. Detailed analysis of IS motion parameters indicate reduction of IS contraction and IS compliance with time. This has potential implications for endovascular management of type B aortic dissections, as expansion of aortic stent grafts can be limited by a stiff IS.

Comparison of outcomes of one-stage basilic vein transpositions and two-stage basilic vein transpositions.

BACKGROUND: Basilic vein transpositions (BVTs) provide autologous hemodialysis access in the upper extremity. We report and compare our experience using the two techniques that are commonly performed to create BVTs: the one-stage and the two-stage technique. METHODS: A retrospective review was performed on patients who underwent BVT from June 2006 to June 2010 from a database of all patients undergoing dialysis access procedures. One hundred six patients, mean age of 54 years (41% male), who received upper-arm basilic vein-only transposition were identified and were stratified based on one-stage and two-stage BVTs. Anatomic outcomes and functionality were determined and compared between stages. RESULTS: Seventy-seven patients underwent two-stage BVT, and 29 underwent one-stage BVT. Fifty-one percent and 79% of the two-stage group and the one-stage group, respectively, had had a previous failed ipsilateral permanent access. Catheter dialysis at time of surgery was 14% in one-stage BVT and 43% in two-stage BVT. Immediate technical success was obtained in all cases. The rate of primary failure was 21% in the one-stage group and 18% in the two-stage group. Reintervention rates for the one-stage group and the two-stage group were 62% and 66%, respectively. Primary patency for the one-stage group and the two-stage group at 1 year was 82% and 67%, at 2 years was 81% and 27%, and at 3 years was 51% and 18%, respectively. Secondary patency for the one-stage group and the two-stage group at 1 year was 91% and 81%, at 2 years was 80% and 61%, and at 3 years was 58% and 45%, respectively. Thirty-day mortality was 0% in both groups, and all-cause morbidity was 12% in both groups (counting all stages). CONCLUSION: One-stage BVTs have a similar number of initial failures and secondary interventions as two-stage BVTs. One-stage BVTs achieved better primary and cumulative patencies. There appears to be no advantage to a two-stage BVT in equally matched patients.

National Simulation-Based Training of Fellows: The Vascular Surgery Example.

Vascular surgery has evolved dramatically as a specialty, with new training paradigms and an ever-developing, technically demanding field. The ability to evaluate trainees on their fundamental skills is an important step in ensuring some uniformity in trainees' basic technical abilities. This article describes the development and implementation of the fundamentals of vascular and endovascular surgery, including lessons applied from the Fundamentals of Laparoscopic Surgery and Fundamentals of Endoscopic Surgery programs.

Bypass surgery in limb salvage: inflow procedures.

Proper management of lower-extremity inflow vessel disease is critical to the success of distal interventions. Aortobifemoral bypass is the most effective means of treating aortoiliac disease, but this invasive procedure is not always ideal for a patient population that often has diffuse vascular disease and multiple comorbidities. Technologic advances and increasing experience have fundamentally altered the management algorithm for lower-extremity vascular lesions, and endovascular options have become the first-line therapy for Trans-Atlantic Inter-Society Guidelines (TASC) class A and B lesions. In fact, an endovascular first approach is being endorsed even for highly complex TASC C and even TASC D lesions. Other alternatives include minimally invasive (laparoscopic or robotic) options or extra-anatomic bypass procedures. Inadequate outflow can compromise any inflow procedure, but inflow treatment failures are the crux of all limb salvage in patients with lower-extremity vascular disease.

The utility of dynamic magnetic resonance venography in the setting of pelvic venous pathology.

The standard initial noninvasive imaging modality for diagnosing May-Thurner syndrome is duplex ultrasound, but this modality provides only indirect measures and is frequently limited, necessitating further imaging to make the diagnosis. Other noninvasive imaging modalities (computed tomographic venography, time of flight, magnetic resonance venography) allow for direct visualization but lack hemodynamic and anatomic information about what is occurring throughout the cardiac cycle. Intravascular ultrasound is the invasive tool of choice in the setting of iliac vein compression syndrome, but quality, noninvasive imaging modalities have yet to be described. Contrast-enhanced, dynamic magnetic resonance venography allows for detailed imaging of the pelvis as well as dynamic vascular imaging, improving preoperative planning.

Advanced imaging in limb salvage.

The evaluation of patients at risk for limb loss secondary to peripheral arterial disease begins with a complete history and physical exam, and noninvasive studies in the vascular lab, including duplex ultrasonography. However, successful revascularization depends on high-quality, accurate imaging of the lower extremity vasculature. The traditional gold standard for vascular imaging, digital subtraction angiography, has been improved upon as technologic advances have enabled high-quality alternatives for preoperative (i.e., computed tomography [CT] angiography and magnetic resonance angiography [MRA]) and intraoperative imaging (i.e., intravascular ultrasound [IVUS], cone beam CT, and CO(2) angiography). Here we describe these advanced invasive and noninvasive imaging alternatives and their utility in limb salvage procedures.

Robotic aortic surgery.

Surgical robotics was first utilized to facilitate neurosurgical biopsies in 1985, and it has since found application in orthopedics, urology, gynecology, and cardiothoracic, general, and vascular surgery. Surgical assistance systems provide intelligent, versatile tools that augment the physician's ability to treat patients by eliminating hand tremor and enabling dexterous operation inside the patient's body. Surgical robotics systems have enabled surgeons to treat otherwise untreatable conditions while also reducing morbidity and error rates, shortening operative times, reducing radiation exposure, and improving overall workflow. These capabilities have begun to be realized in two important realms of aortic vascular surgery, namely, flexible robotics for exclusion of complex aortic aneurysms using branched endografts, and robot-assisted laparoscopic aortic surgery for occlusive and aneurysmal disease.

Correlation between hemodynamic parameters and intra-arterial septum motion in DeBakey Type III aortic dissections using 2D pcMRI and 4D MRA.

Outcome prediction in DeBakey Type III aortic dissections (AD) remains challenging. Large variations in AD morphology, physiology and treatment exist. A patient-specific approach towards a detailed understanding of the distinct features of each single case might be needed to account for this variation. In particular, an improved characterization of hemodynamic parameters in addition to geometrical quantities may yield deeper insight into this complex disease. Advances in cardiovascular magnetic resonance imaging (CMR) have resulted in pulse sequences that provide time-resolved information of blood velocities, aortic wall motion and, with the administration of exogenous intravenous contrast bolus, contrast passage timings. Here we provide a combined approach in a group of 10 AD patients using 2D phase contrast magnetic resonance imaging (2D pcMRI) and Time-resolved Angiography With Interleaved Stochastic Trajectories (TWIST) to quantify blood velocities, flow rates, maximum signal enhancement from exogenous contrast and time to maximum signal enhancement in the true lumen (TL) and false lumen (FL). The FL-TL dynamic pressure gradient was derived from 2D pcMRI velocity measurements. These hemodynamic parameters were correlated with dynamic parameters for the intra-arterial septum (IS) wall motion derived from 2D pcMRI. A strong positive correlation was found between the TL-FL dynamic pressure gradient and maximum IS extension (R=0.76) as well as with maximum IS contraction (R=-0.51) Taking the ratio of maximum extension to maximum contraction, the correlation increased to R= 0.81. The ratio of TL to FL volumetric flow rate showed a high correlation with the difference in FL-TL times to maximum enhancement (R=0.87) illustrating that higher flow in the TL will result in delayed contrast arrival in the FL and vice versa. Analogous, the TL to FL ratio of maximum enhancement correlated with the TL to FL ratio of the maximum volumetric flow rate (R=0.85). 2D pcMRI and 4D MRA in combination with exogenous intravenous contrast bolus allows characterization of hemodynamics in DeBakey type III AD. High correlations between IS wall motion, TL and FL pressure differences, flows and times to maximum enhancement were found. An extension of our analysis to follow-up imaging examinations are warranted to establish the potential for hemodynamic parameters determined with CMR as a marker for clinical outcome in longitudinal studies.