Multimodality imaging and image guidance techniques for endovascular ascending aortic repair

Figures

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  Different imaging modalities provide accurate depiction of the entry tear and aortic valve.

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  Figure 1. CT planning and fusion. Three-dimensional volume-rendered reconstruction of an ECG-gated CTA (A) and translucent rendering (B) of a type A aortic dissection, with an entry tear ∼2.5 cm from the sinotubular junction. Anatomic landmarks, such as the left (green asterisk) and right (red asterisk) coronary arteries, sinotubular junction (yellow arrowhead and dotted line), entry tear (yellow circle), and innominate artery ostium (white arrowhead and dotted circle) are marked and overlayed on the fluoroscopic images after CT fluoroscopy image fusion. C, C-arm angulation and image fusion markers on fluoroscopy were used as a guidance to better align and deploy the proximal end of the stent graft. CT, Computed tomography; ECG, electrocardiography; CTA, computed tomography angiography.

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  Figure 2. Intraoperative transesophageal echocardiographic guidance. Short-axis view showing good coaptation of the aortic valve leaflets (yellow arrow) (A) and Doppler ultrasound (B) demonstrating mild aortic insufficiency after crossing the valve with a stiff wire before device deployment. C and D, Long-axis views showing the realtionship of dissection flap to the wire (yellow arrowhead indicates dissection flap; white arrow shows the wire).

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  Figure 3. Pre- and post-TEVAR comparison. A, 3-dimensional volume-rendered reconstraction of a CTA depicting a penetrating aortic ulcer in the mid-ascending aorta (yellow arrow) (A), with its corresponding fluoroscopic view (B). Sagittal and axial view of the pre- (C, E) and postopearative CTA (D, F) after deployment of stent graft in the ascending aorta, showing complete exclusion. TEVAR, Thoracic endovascular aortic repair; CTA, computed tomography angiography.

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  Figure 4. Imaging techniques for type A aortic dissection. Ultrasound-based techniques for visualizing the aortic root include TEE, IVUS, and ICE (illustration). The illustration depicts the anatomical positioning and field of view of the 3 different ultrasound probes. Clockwise from top to bottom, different imaging modalities illustrate the proximal entry tear of a type A aortic dissection (yellow arrow), including CTA, angiography, IVUS, and TEE. The ICE probe focuses on the aortic valve. These modalities are complementary for intraoperative guidance in endovascular repair of type A dissection. TEE, Transesophageal echocardiography; IVUS, intravascular ultrasound; ICE, intracardiac echocardiography; CTA, computed tomography angiography.

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  Figure E1. ECG-gated CTA. Three-dimensional volume-rendered reconstruction of a CTA depicting a focal ascending aortic dissection (A) and axial planes of an MPR passing through the proximal (green line), mid- (orange line), and distal (blue line) ascending aorta. ECG gating improves image quality and correct measuring for device sizing, as well as highlighting aortic morphology throughout the cardiac cycle. On the left, measurements are taken in the systolic (B, C, D) and diastolic (B', C', D') phases, corresponding to 45% and 70% of the R'R interval. ECG, Electrocardiogram; CTA, computed tomography angiography; MPR, multiplanar reconstruction.