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Chapter 24: Echocardiography for Aortic Surgery

TEE's role in aortic endovascular procedures is explained, with imaging strategies to guide stent placement. Video documentation of endovascular interventions will be shown in this chapter.

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Figures

Antegrade perfusion and circulatory arrest. This is a 62-year-old man with aortic dissection type A and AxA cannulation with antegrade cerebral perfusion. (A-C) These are the baseline pressure, TCD and NIRS values. (D-F) Upon initiation of circulatory arrest, there was a reduction in the LMCA velocities causing brain desaturation. (G-I) Central aortic cannulation reestablished normal bilateral reperfusion and brain saturation.<em> Abbreviations</em>: %, percentage of mean velocity in relation to the baseline value; AxA, axillary artery; EDV, end-diastolic velocity; HITS, high-intensity transient signals;HR, heart rate; LMCA, left middle cerebral artery; MV, mean velocity; NIRS, near-infrared spectroscopy; Pfa, femoral arterial pressure; PI, pulsatility index; Pral, left radial artery pressure; Prar, right radial artery pressure; PSV, peak systolic velocity; RMCA, right middle cerebral artery; StO<sub>2</sub>, tissue oxygen saturation; T, temperature; TCD, transcranial Doppler. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 24.4

Antegrade perfusion and circulatory arrest. This is a 62-year-old man with aortic dissection type A and AxA cannulation with antegrade cerebral perfusion. (A-C) These are the baseline pressure, TCD and NIRS values. (D-F) Upon initiation of circulatory arrest, there was a reduction in the LMCA velocities causing brain desaturation. (G-I) Central aortic cannulation reestablished normal bilateral reperfusion and brain saturation. Abbreviations: %, percentage of mean velocity in relation to the baseline value; AxA, axillary artery; EDV, end-diastolic velocity; HITS, high-intensity transient signals;HR, heart rate; LMCA, left middle cerebral artery; MV, mean velocity; NIRS, near-infrared spectroscopy; Pfa, femoral arterial pressure; PI, pulsatility index; Pral, left radial artery pressure; Prar, right radial artery pressure; PSV, peak systolic velocity; RMCA, right middle cerebral artery; StO2, tissue oxygen saturation; T, temperature; TCD, transcranial Doppler.

Guidewire position in aortic dissection. (A,B) UE aortic arch LAX view at 90° near the LSCA level shows a type B aortic dissection during TEVAR. The angiography catheter (arrowhead) and the stent-graft delivery catheter wire (small arrow) both appear during retrograde advancement in the TL. (C,D) Descending Ao SAX view in a patient with an aortic dissection shows different guidewires, one correctly in the TL and one incorrectly in the FL.<em> Abbreviations</em>: Ao, aorta; FL, false lumen; LAX, long-axis; LSCA, left subclavian artery; SAX, short-axis; TEVAR, thoracic endovascular aortic repair; TL, true lumen; UE, upper esophageal. <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 24.9

Guidewire position in aortic dissection. (A,B) UE aortic arch LAX view at 90° near the LSCA level shows a type B aortic dissection during TEVAR. The angiography catheter (arrowhead) and the stent-graft delivery catheter wire (small arrow) both appear during retrograde advancement in the TL. (C,D) Descending Ao SAX view in a patient with an aortic dissection shows different guidewires, one correctly in the TL and one incorrectly in the FL. Abbreviations: Ao, aorta; FL, false lumen; LAX, long-axis; LSCA, left subclavian artery; SAX, short-axis; TEVAR, thoracic endovascular aortic repair; TL, true lumen; UE, upper esophageal.

Aortic coarctation in a 45-year-old man who underwent a LCCA to LSCA shunt prior to aortic arch stent insertion. (A-D) TCD of the LMCA and RMCA TCD and intraoperative field (E) before and (F) during carotid clamping. Note in (B) the loss of the pulsatility on the left TCD signal (arrow) with only a small reduction in regional brain saturation (rSO<sub>2</sub>) from 73% to 71% on the left side.<em> Abbreviations</em>: Diast, diastole; DM%: percent difference in the mean velocity compared to baseline; HR, heart rate; LCCA, left common carotid artery; LMCA, left middle cerebral artery; LSCA, left subclavian artery; PI, pulsatility index; RI, resistance index; RBCA, right brachiocephalic artery; RMCA, right middle cerebral artery; rSO2, regional brain saturation; TCD, transcranial Doppler (Courtesy of Dr. Marina Ibrahim) <i class='fa fa-video-camera' aria-hidden='true'></i>

eFigure 24.10

Aortic coarctation in a 45-year-old man who underwent a LCCA to LSCA shunt prior to aortic arch stent insertion. (A-D) TCD of the LMCA and RMCA TCD and intraoperative field (E) before and (F) during carotid clamping. Note in (B) the loss of the pulsatility on the left TCD signal (arrow) with only a small reduction in regional brain saturation (rSO2) from 73% to 71% on the left side. Abbreviations: Diast, diastole; DM%: percent difference in the mean velocity compared to baseline; HR, heart rate; LCCA, left common carotid artery; LMCA, left middle cerebral artery; LSCA, left subclavian artery; PI, pulsatility index; RI, resistance index; RBCA, right brachiocephalic artery; RMCA, right middle cerebral artery; rSO2, regional brain saturation; TCD, transcranial Doppler (Courtesy of Dr. Marina Ibrahim)

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Videos

Chapter 24 Fig02G

Chapter 24 Fig03B

Chapter 24 Fig04

Chapter 24 Fig05A

Chapter 24 Fig07A

Chapter 24 Fig07C

Chapter 24 fig07F

Chapter 24 Fig07G

Chapter 24 Fig09A

Chapter 24 Fig09C

Chapter 24 Fig10A

Chapter 24 Fig10B

Chapter 24 Fig10C

Chapter 24 Fig11A

Chapter 24 Fig11C

Chapter 24 Fig12A

Chapter 24 Fig12C

Chapter 24 Fig14A

Chapter 24 Fig14C

Chapter 24 Fig14D

Chapter 24 Fig15A

Chapter 24 Fig15D

Chapter 24 Fig15FGH

Chapter 24 Fig16A

Chapter 24 Fig16B

Chapter 24 Fig16D

Chapter 24 Fig17A

Chapter 24 Fig17C

Chapter 24 Fig17EF

Chapter 24 Fig20A

Chapter 24 Fig20C

Chapter 24 Fig21A

Chapter 24 Fig22A

Chapter 24 Fig22B

Chapter 24 Fig22D

Chapter 24 Fig22F

Chapter 24 Fig22G

Chapter 24 Fig22H

Chapter 24 Fig23A

Chapter 24 Fig23C

Chapter 24 Fig24A

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Tables

eTable 24.2 Criteria for endovascular repair of thoracic aortic disease

  • Thoracic aortic aneurysm
  • Descending thoracic aneurysm >5.5 cm
  • Aneurysm 4.5–5.5 cm increasing in size 0.5 cm in last 6 months or twice normal size
  • Saccular aneurysm or penetrating ulcer
  • Non-aneurysmal proximal and distal aortic neck measures between 22 and 40 mm (dependent on device availability)
  • Devices available suitable for patient anatomy
  • Patent iliac or femoral arteries allow for 16–26 F delivery system (device dependent)
  • Life expectancy of at least six months
  • Able to consent for intervention and follow-up protocols
  • Type-B aortic dissection
  • Acute dissection with intractable pain, uncontrollable hypertension, progression of dissection, or end-organ ischemia
  • Chronic dissection with aneurysmal dilatation of proximal descending aorta
  • Chronic dissection with acute symptoms
  • Early tear at least 1 cm from LSCA orifice (potentially 2 cm if plan to cover LSCA)
  • No dissection entry site that is proximal to LSCA or involves the arch or ascending aorta
  • Devices available suitable for patient anatomy
  • Patent iliac or femoral arteries allows a 16-26 F delivery system (device dependent) 
  • Life expectancy of at least six months
  • Able to consent for appropriate trials and follow-up protocols

Abbreviations: LSCA, left subclavian artery; Source: Adapted from Lee et al.60