Showing papers on "Aortic arch published in 1984"

Normal thoracic aortic diameters by computed tomography

Abstract: Although computed tomography (CT) has played an important role in evaluation of the thoracic aorta, no standards for aortic dimensions exist. To establish the range of normal variation of aortic diameters, a retrospective study of 102 chest CT studies in adults without clinical evidence of hypertension, diabetes, cardiovascular disease, or renal disease was performed. The coronal aortic diameter was measured at three levels: just beneath the aortic arch, just above the aortic valve, and at the level of the diaphragm. These measurements showed substantial variation according to age, sex, and thoracic vertebral body width. The ratio between the ascending and descending limbs of the aorta varied markedly with age; younger individuals had significantly higher ratios than older age groups. Knowledge of these values allows more precise CT evaluation in suspected aortic disease, specifically reducing the potential for "overinterpretation" of the normal, but prominent, ascending aortic root.

Absent or occult pulmonary artery.

Abstract: Of 12 patients with angiographically absent pulmonary artery, 11 were investigated surgically. The previously occult pulmonary artery was found in 10 patients, in five of whom a vestige of an intrapericardial artery was present and in five the artery was patent only at the hilus, a gap existing between the main pulmonary artery and the hilar vessel, and no artery was found in one. All patients with an intrapericardial artery had right ventricular outflow tract obstruction and a ductus descending vertically from underneath the aortic arch. In those without an intrapericardial vessel the occult artery was on the side opposite the aortic arch, and there was evidence of a ductus coming from the innominate artery on the side of the interruption. The occult pulmonary artery, where identified at operation, was usually joined initially to the systemic circulation. Ultimately, continuity between the hilar and main pulmonary artery may be established surgically. Where no intrapericardial vessel exists, however, a conduit may be required to bridge the gap. It seems advisable to search for the occult artery as early in life as is feasible in the hope that providing a blood supply will ensure development of the vessel and normal lung growth.

Interruption of the aortic arch and coarctation of the aorta: Pathogenetic relations

Abstract: The pathologic anatomic features and associated cardiac anomalies of 63 cases of interruption of the aortic arch (IAA) type A (54 reported and 9 observed) and 145 cases of type B (124 reported and 21 observed) were analyzed and compared with those seen in 57 autopsy cases of infant coarctation of the aorta (CA). There was no significant sex predominance within the 3 groups and the prognosis without surgery was uniformly poor. Ventricular septal defect was much more common in IAA type B than in type A or CA. Anomalous origin of the subclavian artery and DiGeorge syndrome were commonly associated with IAA type B but were rare in type A and CA. Transposition of the great arteries and double-inlet left ventricle are less common in IAA type B than in types A and CA. On the basis of these findings and the observation by Le Lievre and Le Douarin that neural crest cells contribute significantly to the formation of the visceral arch system and associated organs, we postulate that IAA type B may be a manifestation of a developmental error involving the neural crest, as is the DiGeorge syndrome. We believe IAA type A and CA to be closely related anomalies that may be prenatally acquired and pathogenetically distinct from IAA type B.

Two-dimensional echocardiographic assessment of the aorta in infants and children with congenital heart disease.

Abstract: To determine the accuracy of two-dimensional echocardiography in the identification of congenital anomalies of the aorta, we compared two-dimensional echocardiographic with angiographic results in 261 consecutive infants and children with congenital heart disease (age 1 day to 20 years, mean 3.3 years). Two-dimensional echocardiography was performed and interpreted without knowledge of angiographic results. Complete visualization of the ascending and descending aorta and aortic arch branches was possible by two-dimensional echocardiographic examination in suprasternal, parasternal, and subcostal views of 255 patients (98%). Identification of the esophagus during swallowing aided the diagnosis of anatomic characteristics of aortic arch. One or more significant aortic arch anomalies were present on angiograms of 116 of 255 patients (46%) and were detected by two-dimensional echocardiography in 110 (sensitivity 95%, 99% specificity). Anomalies detected by two-dimensional echocardiography/angiography were ascending aorta hypoplasia in four/four, truncus arteriosus three/three, right aortic arch 31/31, anomalous subclavian artery 11/16, coarctation 27/29, and patent ductus arteriosus 53/57. We conclude that two-dimensional echocardiography can be used to determine the anatomy of the aorta in most infants and children. In selected patients, two-dimensional echocardiography may eliminate the need for angiographic examination before surgery for congenital heart disease.

Total Aortic Replacement for Chronic Aortic Dissection Occurring in Patients with and without Marfan's Syndrome

Abstract: Total aortic replacement including aortic valve was performed successfully in the two patients in whom this method of treatment was utilized to correct a chronic dissecting aortic aneurysm. Both patients had moderately severe aortic insufficiency producing increasing heart strain and progressive enlargement of the false lumen of aortic dissection involving the entire aorta despite ideal blood pressure control. In addition, one patient had Marfan's syndrome. The surgical treatment for both patients was performed in two stages. At the first operation, cardiopulmonary bypass, profound hypothermia, and circulatory arrest were employed while the aortic valve and the ascending and transverse aortic arch were replaced and the coronary and brachiocephalic vessels were reattached to the composite valve-graft used for replacement. At the second operation, the entire descending thoracic and abdominal aortic segments were replaced with a graft and the intercostal, lumbar, and visceral arteries reattached thereto. Left vocal cord paralysis occurred in both patients and transient mild paraparesis occurred in only one. Both patients are alive and well, one at 13 months and one at 6 weeks. This experience suggests an additional treatment modality for selected patients with complications of chronic aortic dissection.

Bilateral ductus arteriosus (or remnant): An analysis of 27 patients

Abstract: Bilateral ductus arteriosus (DA) was clinically recognized in 27 patients studied angiographically from 1963 through May 1983. Distal bilateral DA origin of non-confluent pulmonary arteries was identified in 15 patients, ectopic or distal ductal origin of 1 pulmonary artery in 9 patients (5 without evidence of intracardiac disease) and isolation of the left subclavian artery in 3 (all 3 of whom had a right aortic arch). Other conditions reported to be associated with bilateral DA include interruption of the aortic arch with isolation of a subclavian artery, aortic atresia with interruption of the aortic arch in which bilateral DA supports the entire systemic circulation, bilateral DA complicating forms of congenitally malformed hearts other than those just stated, and, rarely, bilateral DA in isolation. Understanding the symmetric or paired nature of the primitive aortic arch system in the developing human heart facilitates recognition of the patterns of fourth and sixth arch anomalies seen with bilateral DA.

Two-dimensional and Doppler echocardiographic evaluation of aortic aneurysm and dissection.

Abstract: Ten patients with nondissecting aortic aneurysm and 10 with aortic dissection proved by angiography, surgery or both, were studied by real-time, 2-dimensional echocardiography. Multiple transducer positions were used to visualize various aortic segments so that a composite image of the aorta could be formulated. Using this comprehensive approach, the site, size and extent of all nondissecting aneurysms were correctly delineated (2 ascending aorta, 3 ascending aorta plus aortic root and 5 aortic arch with brachiocephalic involvement). In all patients with aortic dissection, the condition was identified by the presence of prominent, flap-like, undulating motion of the inner dissected wall or marked parallel wall widening (greater than or equal to 15 mm) and correctly categorized into DeBakey type I (4 cases), II (2 cases) or III (4 cases). Pulsed Doppler studies were useful in diagnosing reopening of dissection in a patient with previous surgical obliteration of the false channel.

Computed tomography of the thorax

Abstract: This book contains chapters on: Principles and Techniques of Chest Computed Tomography; Aortic Arch and Great Vessels; Normal Anatomy and Variants; Mediastinum/Airways/Lobar Collapse/Pulmonary Hila/Pulmonary Nodule/Pulmonary Parenchyma/Pleura and Chest Wall/Pericardium/Diaphragm.

Interrupted aortic arch: brief review and summary of an eighteen-year experience.

Abstract: Interrupted aortic arch (IAA) is an uncommon congenital anomaly representing approximately 1% of congenital heart disease More than 97% of the cases also have associated cardiac anomalies complicating their treatment Because the median age at death in untreated cases is 10 days, this condition usually occurs as a complicated neonatal surgical emergency There are three types of IAA: Type A is interrupted distal to the left subclavian artery Type B, which is the most common form, is interrupted between the left common carotid and the left subclavian arteries Type C, which is the most uncommon type, is interrupted between the innominate and left common carotid arteries Since the first patient with this congenital anomaly was treated at our institution in 1965, 39 patients have undergone surgical treatment Two of these (46%) had no associated intracardiac lesions, and both survived bypass grafting without complications There were 12 Type A (30%), 26 Type B (67%) and one Type C (3%) A variety of individualized techniques were used to repair the defects The three basic techniques were (1) direct aortic to aortic anastomosis bridging the gap, (2) "turndown" or "turnup" of one of the arch vessels to the aorta across the gap, or (3) bypass of the interruption with graft material Because aortic arch and associated cardiac anomalies represent a neonatal surgical emergency, our therapeutic plan consists of treatment for biventricular failure and PGE(1) infusion to maintain ductal patency, and surgical correction as soon as feasible

Evolution of coarctation of the aorta in intrauterine life.

Abstract: The echocardiographic appearances in a case of coarctation of the aorta, first suspected at 21 weeks of intrauterine life, changed progressively during this time. Early right ventricular hypertrophy and increasing aortic arch hypoplasia were evident and suggest the possible sequence of evolution of the coarctation in this case.

Aortic arch aneurysm. A sentinel of extensive aortic disease requiring subtotal and total aortic replacement.

Abstract: Aneurysm of the thoracic aorta is a serious form of disease because it may be extensive or associated with a more distant aneurysm. This manifestation occurs in about one-third of the cases. The actuarial 5-year survival of nontreated patients is only 13% with many patients dying from aortic rupture. The 5-year survival of our patients with aneurysm of the descending thoracic aorta treated by graft replacement is 58% with the two most common causes of late death being myocardial infarction and rupture of another aortic aneurysm. Effective treatment consists of initial total aortic examination, continued follow-up examination, and total replacement of disease. Aneurysmal disease that involves the entire aortic arch is especially prone to extensive involvement because it is due to diffuse aortic dissection or medial degenerative disease in most cases. The latter is most common, being present in 63 of our 81 patients requiring total arch replacement. The disease was extensive in all cases with degenerative medial disease and required extensive graft replacement. In fact, the entire thoracic aorta was involved in ten, the entire thoracic aorta and substantial segments of abdominal aorta in ten, and the entire aorta in 12 patients. Most of these patients were women (84%) over 65 years of age (63%) or older, ten (37%) were over 70 years. Associated pulmonary disease was frequent, aortic valvular insufficiency was present in 12 (38%), and symptoms were present in most. Treatment consisted of removing the disease when possible in stages, the arch in one and the remaining disease in another with the sequence and interval depending upon indications and condition of the patient. A total of 53 operations were performed in these 32 patients, the arch replaced in 29, the descending thoracic aorta in eight, and the thoracoabdominal aortic segment in 16 patients. All of the disease was replaced in 21, including the entire aorta in eight and incompletely replaced in 11 patients. Sixteen (76%) of the former are still alive 4 months to 6 1/3 years. Six (55%) of those in whom operation was limited to replacement of the symptomatic aortic segment because of limited risk are still alive. Of the ten deaths occurring during the study period, four (40%) and perhaps five (50%) were due to natural rupture of unresected disease which indicates its progressive nature and suggests the need for aggressive surgical treatment.

Mediastinal-width/chest-width ratio in blunt chest trauma: a reappraisal

Abstract: The chest radiographs of 54 patients with blunt chest trauma and suspected aortic rupture were reviewed retrospectively. A mediastinal-width/chest-width ratio was calculated at the level of the aortic arch. There were 44 patients without evidence of aortic rupture on aortography or surgical exploration and 10 patients with surgically confirmed aortic rupture. There was no identifiable ratio of significance in distinguishing those with aortic rupture and those without rupture. The mediastinal-width/chest-width ratio is of insufficient sensitivity and specificity in confirming or excluding aortic rupture to be clinically useful.

The importance of abdominal wall collateral blood vessels. Planning incisions and obtaining arteriography.

Abstract: • While several patterns of collateral blood flow around aortoiliac obstruction exist, the thoracic to lower-extremity pathway is often unrecognized. The principal blood vessels involved in this network are the internal mammary, superior epigastric, intercostal, inferior epigastric, and external iliac arteries. Two patients with aortoiliac occlusion experienced precipitation of rest pain because of transverse abdominal incisions for nonvascular procedures. Femoral anatomy was demonstrated arteriographically in two other patients by injection of contrast medium into the aortic arch. Patients with lower-extremity peripheral vascular disease may suffer exacerbation of their symptoms if the thoracic to lower-extremity collateral pathway is divided by poorly planned abdominal incisions. Ascending aortic or subclavian angiography is useful in some patients to define femoral arterial anatomy. (Arch Surg1984;119:854-857)

Aortic uncrossing for compressive circumflex aorta. 3 cases

Abstract: Three children with circumflex aorta developed signs of tracheobronchial compression. Dividing the arterial ligament was ineffective. At endoscopy, the right side of the trachea and the tracheal bifurcation were found to be severely obstructed by the aorta itself. The aortic arch was approached through a median sternotomy and freed from mediastinal adhesions. The aorta was divided below the point of origin of the right carotid artery, then uncrossed and reimplanted on the left surface of the ascending aortic segment. Cerebral protection was ensured by deep hypothermia and cardiopulmonary bypass. Post-operative angiography showed good reconstruction of the aortic arch.

Symptomatic aberrant retro-esophageal subclavian artery: considerations about the surgical approach, management and results.

Abstract: Ten case histories of patients with symptomatic aberrant retro-esophageal subclavian artery are presented. The diagnosis was made on a clinical basis in 8 cases because of symptoms of tracheo-esophageal obstruction, and confirmed by barium meal. All patients were investigated by angiography. Six patients with right abnormal retro-esophageal subclavian artery (arteria lusoria) and its mirror image were treated by transection of the aberrant subclavian artery and reimplantation into the common carotid artery through a single midline sternal splitting incision which gave ample access. Three patients with left abnormal subclavian artery (right aortic arch) were operated by transection of the patent ductus arteriosus or ligamentum arteriosum through a left lateral thoracotomy. After a follow-up of from one to 10 years (mean 6.4 years), 9 patients are free of symptoms like dysphagia, dyspnea or subclavian steal and normal pulses are present on both upper extremities in 8 cases.

Injuries to arterial branches of the aortic arch.

Abstract: Exposure of arch branches for repair following trauma can be difficult. Seven patients with blunt injuries and 5 with penetrating injuries underwent repair of the innominate, common carotid and subclavian arteries. Common associated injuries included head injury, hemopneumothorax, lung contusion, long bone fractures and brachial plexus injury. Widened mediastinum was seen in 5 patients. Six patients with innominate, right subclavian and right common carotid injuries were approached through sternotomy with extension into the right side of the neck. Posterolateral thoracotomy was used to reach the proximal left subclavian artery in 2. Combined supra- and infraclavicular incision were utilized for the distal subclavian artery in 4. Eleven patients are alive, one to 7 years after surgery. One died of an unrelated cause. Head injuries complicated the postoperative management in 4 of the 7 patients with blunt trauma. Two patients with brachial plexus injury continued to have neurologic deficits. All arterial repairs have remained patent and there have been no graft infections.

Interaction of canine carotid sinus and aortic arch baroreflexes in the control of total peripheral resistance.

Abstract: Interaction of carotid sinus and aortic arch reflex control of total peripheral resistance was studied in eight dogs anesthetized with sodium pentobarbital and placed on constant flow cardiac bypass. Carotid sinus and aortic arch baroreceptor areas were isolated and separately perfused at controlled pressures. Combinations of carotid sinus and aortic arch pressures were delivered at random in steps of 25 mm Hg over the 50-225 mm Hg pressure range, and systemic arterial pressure was measured. Changes in arterial pressure reflected changes in total peripheral resistance. A multiple linear regression showed that both carotid sinus and aortic arch pressures exhibited a sigmoidal relationship with arterial pressure. Independent of carotid and aortic baroreceptor pressures, arterial pressure was found to be a periodic function of time (period = 2 hours) in all dogs. The average carotid sinus reflex open loop gain was found to be 0.231 +/- 0.092, while average aortic arch open loop gain was 0.141 +/- 0.088. The gain of either the carotid sinus or aortic arch reflex was not influenced by the absolute pressure level of the other receptor area. In a separate series of experiments performed in the same dogs, we tested the hypothesis that a nonlinear temporal summation of the reflex control of total peripheral resistance might exist when the inputs to carotid and aortic baroreceptors are changed simultaneously. With both inputs held at the region of maximum gain, 25 mm Hg step changes were imposed first on carotid sinus pressure, then on aortic arch pressure, and then on both simultaneously. A temporal inhibition of the two reflexes showed that simultaneous excitation of both receptors resulted in a smaller reflex response than the sum of individual responses.