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Dilated aortic root in a 55-year-old man who underwent supracoronary graft placement that was complicated by dissection. (a) Axial CT angiogram shows an intimal flap (arrow) that extends through the lateral aspect of the aortic root. (b) Coronal oblique reformatted CT angiogram better depicts the extent of the dissection flap (arrow) below the proximal anastomosis sites (arrowheads). The use of ECG gating is critical to assess coronary involvement.
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Advances in computed tomography (CT) scanners and electrocardiographic gating techniques have resulted in superior image quality of the ascending aorta and increased the use of CT angiography for evaluating the postoperative ascending aorta. Several abnormalities of the ascending aorta and aortic arch often require surgery, and various open techniq...
Citations
... In almost all surgical techniques the patient's damaged aorta is removed and a graft (whether biological or artificial) is implanted. Nowadays the graft is connected to the patient's undamaged vessel, because it always gives better results than the previous method, where the graft was positioned within the damaged aorta -a technique called inclusion graft [12]. ...
... One possible complication of this technique is dissection or aneurysm of the native aorta proximal to the graft. Some comorbidities increase the risk of these events, such as patients with annuloaortic ectasia or Marfan syndrome [12]. ...
... In 1981, another technique was developed -the Cabrol procedure -in order to offer an alternative approach to patients with aortic dissection or annuloaortic ectasia [12]. In the Cabrol technique, the native aortic valve and ascending aorta are removed and a new valve and a synthetic graft are placed; the coronary ostia are attached to prosthetic conduits and the latter are then connected to the aortic graft [19]. ...
Ascending thoracic aorta disease is often a life-threatening condition. Aortic aneurysm and aortic dissection are the most frequent ascending aorta diseases requiring surgical intervention. Surgical repair techniques of the ascending aorta are various; they include reconstruction of the ascending aorta by using a graft with or without a prosthetic valve, reconstruction with a composite artificial graft or using a biological graft, and reconstruction of the ascending aorta with a composite graft preserving the native valve and arch repair. The radiologist plays a key role in the identification of post-operative complications; differentiation from normal postoperative findings is fundamental. Our aim is to discuss the main diseases affecting the ascending aorta requiring surgery and the different techniques used to treat them. We also discuss the normal computed tomography (CT) imaging findings and after-surgery complications.
... Normal post-surgical appearance A detail description of various aortic surgeries and their postoperative appearances is beyond the scope of this article and is well described in literature dedicated to this topic [66]. We discuss some expected post-surgical appearance of the proximal aorta that general radiologists may encounter and should be familiar with, as it may mimic abnormal conditions. ...
... Infections related to synthetic materials (e.g., suture) or concomitant mediastinal infection may be seen on CT imaging as the following: (a) focal saccular outpouching (pseudoaneurysm), usually with a narrow neck, that contains contrast material and arises from the aortic wall (Fig. 10); (b) periaortic soft tissue stranding or edema; and (c) periaortic gas [66,67]. An aortic pseudoaneurysm close to the aortic cannulation site may be difficult to differentiate but is a surgical emergency with associated high operative morbidity and mortality, given the high likelihood of a coexistent infectious state. ...
Abstract The aortic pathologies are well recognized on imaging. However, conventionally cardiac and proximal aortic abnormalities were only seen on dedicated cardiac or aortic studies due to need for ECG gating. Advances in CT technology have allowed motionless imaging of the chest and abdomen, leading to an increased visualization of cardiac and aortic root diseases on non-ECG-gated imaging. The advances are mostly driven by high pitch due to faster gantry rotation and table speed. The high-pitch scans are being increasingly used for variety of clinical indications because the images are free of motion artifact (both breathing and pulsation) as well as decreased radiation dose. Recognition of aortic root pathologies may be challenging due to lack of familiarity of radiologists with disease spectrum and their imaging appearance. It is important to recognize some of these conditions as early diagnosis and intervention is key to improving prognosis. We present a comprehensive review of proximal aortic anatomy, pathologies commonly seen at the aortic root, and their imaging appearances to familiarize radiologists with the diseases of this location.
... A supravalvular aortic aneurysm may be treated with the excision of the diseased native aorta and the placement of a supracoronary tube graft. The synthetic graft is typically composed of polyethylene (Dacron) [8] . The operation is technically less difficult and spares the native aortic valves when compared to replacing the entire aortic root [9] . ...
... The patient is also at high risk because of ADPKD, hypertension, and cocaine use. Nevertheless, our case emphasizes the importance of carefully reviewing a patient's surgical history and nonenhanced imaging studies when a type A dissection is discovered [8] . ...
Stanford type A dissections usually require surgery because they are associated with high morbidity and mortality. However, there are situations where medical management becomes the definitive treatment. We report the successful medical management of a 16-month chronic type A aortic dissection in a 56-year-old male patient with a past surgical history of ascending aortic aneurysm repair. The dissection is unique because it is distal to the graft and does not extend into the main aortic branches. A review of a patient's surgical history and nonenhanced imaging studies is essential when a type A dissection is discovered. Ascending aortic grafts may preclude the most serious complications of type A dissections.
... Felt rings are wrapped around proximal and distal anastomoses and appear as circumferential high-attenuation material on both pre-and postcontrast images. While they may also mimic a pseudoaneurysm on postcontrast images, the felt ring or even the slightly hyperattenuating graft material along the perimeter of the aorta can occasionally resemble an intramural hematoma on precontrast images (11). Essentials n Perfusion grafts are tied off at the end of aortic surgery and mimic pseudoaneurysms at postoperative imaging. ...
Various surgical techniques of the aorta result in expected imaging appearances on CT images that resemble complications such as pseudoaneurysm, perigraft abscess, and dissection. Awareness of these techniques, understanding the clinical situation in which they are performed, and familiarity with the typical appearances and locations of these mimics are essential for accurate interpretation. CT imaging techniques such as electrocardiographic gating and inclusion of a precontrast series can help distinguish an expected postsurgical finding from a complication. Information in the medical record, particularly the operative note, can clarify challenging cases with unusual imaging features. This review article provides examples of expected postsurgical findings at CT mimicking complications. © RSNA, 2019.
... Blood flows (arrows) from the aorta into the right and left coronary limbs. (Reproduced with permission from Prescott-Focht et al.3 ) ...
... 10,11 L'angio-TC con gating cardiaco è attualmente la metodica più impiegata per tale indicazione. [12][13][14] Di seguito riportiamo un caso di doppio pseudoaneurisma della radice aortica localizzato in corrispondenza delle anastomosi coronariche, studiato con angio-TC prima e dopo re-intervento chirurgico. In particolare, in questo caso clinico si descrive l'aspetto all'angio-TC di tali pseudoaneurismi e si trattano le possibili fonte di errore diagnostico nella valutazione con questa metodica degli esiti postoperatori. ...
Doppio pseudoaneurisma della radice aortica in paziente con sostituzione dell'aorta ascendente mediante protesi tubulare valvolata: studio con angio-TC e gating cardiaco prima e dopo reintervento chirurgico Double pseudoaneurysm of the aortic root with ascending aorta replacement by composite valve graft: ECG-gated CT angiography before and after reintervention Riassunto Gli pseudoaneurismi della radice aortica sono una rara complicanza degli interventi di sostituzione della radi-ce aortica e dell'aorta ascendente mediante protesi tubulare valvolata, con reimpianto sulla protesi delle arterie coronarie. Si riporta il caso di doppio pseudoaneurisma della radice aortica localizzato in corrispondenza delle anastomosi coronariche in un paziente sottoposto circa 12 anni prima a intervento di sostituzione dell'aorta ascen-dente. Il paziente è stato studiato mediante angio-TC con gating cardiaco prima e dopo re-intervento chirurgico. È stato utilizzato in entrambi gli studi il gating cardiaco per ridurre al minimo gli artefatti da pulsazione cardiaca. La metodica si è rivelata molto utile per pianificare in maniera idonea il re-intervento chirurgico. In particolare, ha consentito un'esatta definizione della sede dei due pseudoaneurismi rispetto: alla radice aortica (se anteriori o po-steriori), alle anastomosi coronariche e allo sterno (se distanti più oppure meno di 2 cm). Dopo il re-intervento, ha permesso di escludere la presenza di anomalie, fatta eccezione per una moderata stenosi tra il segmento autologo di vena safena e l'arteria coronaria destra. Infine, il riconoscimento di materiale chirurgico iperdenso sulle imma-gini acquisite in condizioni basali e la valutazione comparativa con le scansioni acquisite dopo mezzo di contrasto hanno consentito di evitare un'errata diagnosi di pseudo-aneurisma o stravaso emorragico. Abstract Pseudoaneurysms are a rare complication of aortic root replacement. We report a case of double pseudoaneurysm of the aortic root located in the coronary arteries anastomosis site. The patient had undergone aortic root and ascending aorta replacement by composite valve graft twelve years before and was assessed by ECG-gated CT angiography before and after surgical re-intervention. Retrospective ECG gating was used in both examinations to minimize motion artifacts at the aortic root. CT angiography provided critical information in the planning of surgical re-intervention. It allowed an accurate definition of the location of the pseudoaneurysms with respect to the coronary arteries, the aortic root and the sternum. In detail, if they were anterior and situated less than 2 cm from the sternum. After surgical re-intervention, it ruled out substantial abnormalities, but a moderate stenosis of the anastomosis between the right coronary artery and saphenous vein autologous segment. Lastly, the detection of hyper-attenuating surgical material on non-enhanced images and the comparative assessment with contrast-enhanced images helped to avoid a misdiagnosis of pseudoaneurysm or contrast extravasation. (Per citare questo articolo: Finazzo M, Duranti C, Interlicchia F, Filippone G, Antonucci M, Messana D. Doppio pseudoaneurisma della radice aortica in paziente con sostituzione dell'aorta ascendente mediante protesi tubu-lare valvolata: studio con angio-TC e gating cardiaco prima e dopo reintervento chirurgico. G Ital Radiol Med 2018;5:578-82.
... original inclusion Bentall procedure offers direct, tension-free coronary artery reattachment that minimizes bleeding and pseudoaneurysm formation [19]. The neocoronary arteries are larger at their origins, reminiscent of buttons on imaging, and should not be mistaken for aneurysms or pseudoaneurysms [20][21][22]. Graft material-usually Dacron or PTFE-and felt are hyperattenuating on CT. They can be obscured by intraluminal contrast and are, therefore, most easily visualized on precontrast imaging. ...
... The graft also typically has a straighter orientation than the natural curve of the native aorta, best appreciated in the coronal or sagittal planes. An abrupt but slight caliber change may be present at the transition from graft to aorta or between separate grafts [20][21][22]. ...
Marfan syndrome is a heritable multisystem connective tissue disease and is the most common genetic cause of aortic disease. Guidelines for surgical repair and recommendations for surveillance imaging aim to prevent aneurysm rupture, aortic dissection, and death. Options for proximal aorta repair include the modified Bentall procedure and valve-sparing aortic root repairs. Hemiarch and total arch replacement are options for aortic arch repair, and the elephant trunk procedure is a special two-staged total arch repair facilitating future descending aorta repair. Endovascular repair is not currently considered an acceptable long-term treatment option in Marfan syndrome but may be performed when open repair is not feasible or in the acute setting as a bridge to definitive surgical treatment. After an initial surgery, patients remain at risk for new aortic dissection, propagation of a pre-existing aortic dissection, and new or enlarging aortic aneurysm. Anastomotic pseudoaneurysm is a potential postsurgical complication at multiple sites including proximal and distal aortic anastomoses, coronary anastomoses, and intercostal and visceral artery patches. Patients undergoing endovascular repair are at increased risk of endoleak and aortic dissection. CT and MR angiography are the main imaging modalities for surveillance of the aorta in Marfan syndrome and are capable of demonstrating these complications, as well as expected postsurgical appearances. 4D flow MRI is an emerging technique providing hemodynamic information that may risk-stratify aneurysms better than size alone and help predict future aortic events.
... The surgical approach to aortic repair varies of a wide range of factors including anatomy, anatomic extent of disease, age, prior surgeries and need for long-term anticoagulation (10,(12)(13)(14). A primary consideration in surgical planning involves assessing the extent of disease in determining whether to involve the aorta valve, coronary sinuses, coronary arteries and/or arch vessels (15). ...
... The Bentall procedure involves complete composite replacement of the proximal aorta with re-implantation of the coronary arteries (18). Several modifications have been made to this technique, including the "button Bentall" technique where buttons of coronary ostia are anastomosed (14), Currently, the "button Bentall" is the preferred approach for aortic root repair. ...
Considerable progress has been made in the management of diseases of the thoracic and abdominal aorta over the past decades, ranging from advances in open repair to the advent of minimally invasive endovascular techniques. Along with this comes an equivalent rise in imaging necessity for these patients, both in preoperative planning and postoperative surveillance. With the growing complexity and diversity of vascular procedures and techniques, it is essential to have a solid understanding of the imaging features and postoperative complications of these procedures to avoid imaging pitfalls. This review is an attempt to define the normal postoperative appearance and important complications of various open and endovascular surgical techniques of the thoracic and abdominal aorta.
... Acquiring a non-contrast CT prior to aorta CTA is useful to look for high-density intramural haematoma, which can be difficult to visualise after contrast administration. In the post-operative setting, it helps distinguish high-density surgical material such as felt pledgets routinely from a pseudoaneurysm [71][72][73]. Using ECG-gating in thoracic aorta CTA helps to overcome the effect of cardiac motion on the aortic root, which can hide or mimic significant pathology, such as aortic dissection. ...
Non-invasive cross-sectional imaging techniques play a crucial role in the assessment of the varied manifestations of vascular disease. Vascular imaging encompasses a wide variety of pathology. Designing vascular imaging protocols can be challenging owing to the non-uniform velocity of blood in the aorta, differences in cardiac output between patients, and the effect of different disease states on blood flow. In this review, we provide the rationale behind—and a practical guide to—designing and implementing straightforward vascular computed tomography (CT) and magnetic resonance imaging (MRI) protocols.
Teaching Points
• There is a wide range of vascular pathologies requiring bespoke imaging protocols.
• Variations in cardiac output and non-uniform blood velocity complicate vascular imaging.
• Contrast media dose, injection rate and duration affect arterial enhancement in CTA.
• Iterative CT reconstruction can improve image quality and reduce radiation dose.
• MRA is of particular value when imaging small arteries and venous studies.
Electronic supplementary material
The online version of this article (10.1007/s13244-018-0597-2) contains supplementary material, which is available to authorised users.
... After many enhancements through the years, 1 the term "Bentall procedure" now often refers to replacement of the aortic valve and root with a composite interposition graft and anastomosis of the coronary arteries onto the graft (Fig. 8). 39 The Cabrol procedure can be performed to address patients in whom coronary button reimplantation is not feasible because of severe atherosclerosis of the ascending aorta or proximal coronary arteries (Fig. 5). 1,35,40 This technique involves a composite aortic root and valve graft and a side-to-side anastomosis of a single Dacron graft that supplies both the right and the left coronary arteries 35,39 (Fig. 5). ...
... 39 The Cabrol procedure can be performed to address patients in whom coronary button reimplantation is not feasible because of severe atherosclerosis of the ascending aorta or proximal coronary arteries (Fig. 5). 1,35,40 This technique involves a composite aortic root and valve graft and a side-to-side anastomosis of a single Dacron graft that supplies both the right and the left coronary arteries 35,39 (Fig. 5). Knowledge of this technique avoids misinterpretation of the coronary graft as a pseudoaneurysm. ...
... 43 Both procedures require coronary reimplantation. An excellent review of various aortic root replacement techniques with diagrams is provided by Prescott-Focht et al. 39 Isolated Aortic Arch or Combined Aortic Arch/ Ascending Aorta: The simultaneous replacement of the proximal arch and ascending aorta can be performed. Total arch replacement, in combination with ascending aortic repair, can be used to treat aortic dissections with Hemorrhage within the media, either through intimal tear and thrombosis in the false lumen, thrombosed dissection lumen, IMH related to PAU, or rupture of vasa vasorum in the media Classified and treated similar to dissection and PAU Coarctation Focal narrowing of the aorta Generally repaired if a pressure gradient Z20 mm Hg across the coarctation or evidence of significant collateral flow complications such as aneurysm or leakage. ...
Techniques for repair of the aorta currently include open and endovascular methods, hybrid approaches, minimally-invasive techniques, and aortic branch vessel reimplantation or bypass. Collaboration among radiologists and vascular and cardiothoracic surgeons is essential. An awareness of the various surgical techniques, expected postoperative appearance, and potential complications is essential for radiologists. This review will cover the postoperative appearance of the thoracic aorta with a focus on the ascending aorta. The value of three-dimensional image evaluation will also be emphasized.
