Optimal Guidance for Intimal Flap Fenestration in Aortic Dissection by Transvenous Two-Dimensional and Doppler Ultrasonography
From the Cardiology Division, Department of Internal Medicine, University Essen, Essen, Germany.:, http://www.100md.com
Transvenous multi-modal ultrasound can safely guide percutaneous fenestration of an intimal flap. It provides longitudinal image planes of the dissected aorta and possibly involved distal vessels. The following case shows that the intimal flap may be extremely resistant to penetration with intravascular needle devices. In a 61-year-old man with type B dissection and consecutive intestinal and left renal mal- perfusion, a Brockenbrough needle-catheter was introduced into the true aortic lumen in an unsuccessful attempt to perforate the flap. Next, a multi-modal, phased array transducer-tipped AcuNav-Catheter (Siemens-Acuson Inc) was positioned in the inferior vena cava and aimed at the neighboring aorta (). Longitudinal image planes revealed true lumen collapse and almost no flow in the false lumen. It became evident that advancement of the needle made it only scrape along the flap, which resisted perforation (). Finally, the flap was perforated and then fenestrated in another attempt guided by transvenous ultrasound. The resulting effected large entry markedly improved flow in both lumina (). Subsequently, plasma creatinine (268 µmol/L before fenestration versus 171 µmol/L after 7 days and 89 µmol/L another 7 days later) and lactate levels (3.53 mmol/L versus 1.41 mmol/L after 1 day and 0.90 mmol/L 2 days later) decreased (see also Movies I through VIII).
fig.ommitted9m11-v2, 百拇医药
Schematic drawing of the transvenous sonographic approach to type B dissection of the aorta. Ao indicates aorta; DF, dissection flap; FL, false lumen; IVC, inferior vena cava; and TL, true lumen.9m11-v2, 百拇医药
fig.ommitted9m11-v2, 百拇医药
The Brockenbrough needle (1) scrapes ineffectively along the flap (2), which it cannot penetrate. FL indicates false lumen; IVC, inferior vena cava; and TL, true lumen.9m11-v2, 百拇医药
fig.ommitted9m11-v2, 百拇医药
After balloon fenestration, color Doppler imaging shows significant flow through the dissection flap into the false lumen. DF indicates dissection flap; FL, false lumen; IVC, inferior vena cava; TL, true lumen; and W, wire.9m11-v2, 百拇医药
Footnotes9m11-v2, 百拇医药
Movies I through VIII are available as an online-only Data Supplement at http://www.circulationaha.org.9m11-v2, 百拇医药
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.9m11-v2, 百拇医药
Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.(Thomas Bartel MD Holger Eggebrecht MD Tiko Ebradlidze MD Dietrich Baumgart MD Raimund Erbel MD)
Transvenous multi-modal ultrasound can safely guide percutaneous fenestration of an intimal flap. It provides longitudinal image planes of the dissected aorta and possibly involved distal vessels. The following case shows that the intimal flap may be extremely resistant to penetration with intravascular needle devices. In a 61-year-old man with type B dissection and consecutive intestinal and left renal mal- perfusion, a Brockenbrough needle-catheter was introduced into the true aortic lumen in an unsuccessful attempt to perforate the flap. Next, a multi-modal, phased array transducer-tipped AcuNav-Catheter (Siemens-Acuson Inc) was positioned in the inferior vena cava and aimed at the neighboring aorta (). Longitudinal image planes revealed true lumen collapse and almost no flow in the false lumen. It became evident that advancement of the needle made it only scrape along the flap, which resisted perforation (). Finally, the flap was perforated and then fenestrated in another attempt guided by transvenous ultrasound. The resulting effected large entry markedly improved flow in both lumina (). Subsequently, plasma creatinine (268 µmol/L before fenestration versus 171 µmol/L after 7 days and 89 µmol/L another 7 days later) and lactate levels (3.53 mmol/L versus 1.41 mmol/L after 1 day and 0.90 mmol/L 2 days later) decreased (see also Movies I through VIII).
fig.ommitted9m11-v2, 百拇医药
Schematic drawing of the transvenous sonographic approach to type B dissection of the aorta. Ao indicates aorta; DF, dissection flap; FL, false lumen; IVC, inferior vena cava; and TL, true lumen.9m11-v2, 百拇医药
fig.ommitted9m11-v2, 百拇医药
The Brockenbrough needle (1) scrapes ineffectively along the flap (2), which it cannot penetrate. FL indicates false lumen; IVC, inferior vena cava; and TL, true lumen.9m11-v2, 百拇医药
fig.ommitted9m11-v2, 百拇医药
After balloon fenestration, color Doppler imaging shows significant flow through the dissection flap into the false lumen. DF indicates dissection flap; FL, false lumen; IVC, inferior vena cava; TL, true lumen; and W, wire.9m11-v2, 百拇医药
Footnotes9m11-v2, 百拇医药
Movies I through VIII are available as an online-only Data Supplement at http://www.circulationaha.org.9m11-v2, 百拇医药
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.9m11-v2, 百拇医药
Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.(Thomas Bartel MD Holger Eggebrecht MD Tiko Ebradlidze MD Dietrich Baumgart MD Raimund Erbel MD)