Showing papers on "Aortic arch published in 1996"

Atherosclerotic disease of the aortic arch as a risk factor for recurrent ischemic stroke.

Abstract: Background Atherosclerotic disease of the aortic arch is found in 60 percent of patients 60 years of age or older who have had brain infarction. The aim of this study was to determine whether atherosclerotic plaques in the aortic arch are a risk factor for recurrent brain infarction and for vascular events in general (i.e., brain infarction, myocardial infarction, peripheral embolism, and death from vascular causes). Methods For a period of two to four years, we followed a cohort of 331 patients 60 years of age or older who were consecutively admitted to the hospital with brain infarction (a total of 788 person-years of follow up). All patients underwent transesophageal echocardiography to determine whether atherosclerotic plaques were present in the aortic arch proximal to the ostium of the left subclavian artery. The patients were divided into three groups according to the thickness of the wall of the aortic arch ( or = 4 mm). Results The incidence of recurrent brain infarction was 11.9 per 100 person-years in patients with an aortic-wall thickness of > or = 4 mm, as compared with 3.5 per 100 person-years in patients with a wall thickness of 1 to 3.9 mm and 2.8 per 100 person-years in patients with a wall thickness of or = 4 mm thick (including the thickness of the aortic wall) were found to be independent predictors of recurrent brain infarction (relative risk, 3.8; 95 percent confidence interval, 1.8 to 7.8; P = 0.0012) and of all vascular events (relative risk, 3.5; 95 percent confidence interval, 2.1 to 5.9; P Conclusions Atherosclerotic plaques > or = 4 mm thick in the aortic arch are significant predictors of recurrent brain infarction and other vascular events.

New graft-implanting method for thoracic aortic aneurysm or dissection with a stented graft.

Abstract: Background To alleviate the invasiveness of surgical treatment for thoracic aortic aneurysm or dissection involving the distal arch, we developed a new method of implanting a graft in the distal anastomotic portion that does not require dissection, suture, or lateral thoracotomy. Methods and Results The tight circumferential attachment between the graft and the aortic inner wall, produced by the hoop strength of a self-expanding (Gianturco) stent that is anchored into the woven polyester graft, takes the place of the conventional anastomotic suture at the distal end of the graft. This new surgical method requires only a median sternotomy and relatively short circulatory arrest time to repair a thoracic aneurysm or dissection involving the distal arch. In a 12-month period in 1994 and 1995, we applied this new method in 10 cases (seven true aneurysms and three dissections). Complete thrombosis of the aneurysms or false lumens surrounding the grafts resulted in all 10. There were no surgical deaths, and the major complications were two cerebral infarctions due to inappropriate protection of the brain and dissecting procedure of an aortic arch, respectively. Conclusions These preliminary results indicate that this new graft-implanting method with the stented graft should be considered one of the iess-invasive surgical treatments for thoracic aneurysm and dissection involving the distal arch.

Aortic dissection: a comparative study of diagnosis with spiral CT, multiplanar transesophageal echocardiography, and MR imaging.

Abstract: PURPOSE: To compare the usefulness of spiral computed tomography (CT), multiplanar transesophageal echocardiography (TEE), and magnetic resonance (MR) imaging in the diagnosis of thoracic aortic dissection and arch vessel involvement. MATERIALS AND METHODS: Forty-nine symptomatic patients with clinically suspected aortic dissection were examined with contrast material-enhanced spiral CT, multiplanar TEE, and 0.5-T MR imaging (T1-weighted, cardiac-gated, spin-echo sequences). Imaging results were confirmed at autopsy (five patients), intraoperative exploration (23 patients), angiography (nine patients), and follow-up (12 patients). RESULTS: Sensitivity in the detection of thoracic aortic dissection was 100% for all techniques. Specificity was 100%, 94%, and 94% for spiral CT, multiplanar TEE, and MR imaging, respectively. In the assessment of aortic arch vessel involvement, sensitivity was 93%, 60%, and 67%, respectively, and specificity was 97%, 85%, and 88%, respectively. CONCLUSION: Spinal CT and multip...

Technique for aortic valve replacement with simultaneous aortic arch graft insertion and apparatus therefor

Abstract: Transfemoral aortic valve replacement with the simultaneous insertion of an aortic arch graft, referred to as "TAVAG", is effected with a device comprising the following components: a U-shaped collapsible nitinol ring which is attached to a bioprosthetic valve, a thin walled predetermined graft with branches, a perforated self-expandable carrier capsule having a large slit therein, diamond shaped guide wires, and a ring to control opening and closing of the carrier capsule. The graft and valve are pulled up from the left femoral artery toward the aortic arch by pulling on the guide wires which are threaded through catheters inserted in each of the bilateral carotid and subclavian arteries toward the left femoral artery. Cerebral circulation is also maintained from the right femoral artery through a novel balloon catheter placed inside the carotid artery.

Cardiac neural crest is essential for the persistence rather than the formation of an arch artery

Abstract: Double-label immunohistochemistry was used to compare early aortic arch artery development in cardiac neural crest-ablated and sham-operated quail embryos ranging from stage 13 to stage 18. The monoclonal antibody QH-1 labeled endothelial cells and their precursors, and HNK-1 labeled migrating neural crest cells. In the sham-operated embryos, the third aortic arch artery developed from a lumenizing strand of endothelial precursors that became separated from the pharyngeal endoderm by migrating cardiac neural crest cells as they ensheathed the artery. The arch artery of the neural crest-ablated embryos lumenized but failed to become separated from the pharyngeal endoderm, indicating that neural crest is unnecessary for the early formation of the aortic arch artery. However, once blood flow was initiated through the third arch artery of crest-ablated embryos at stage 16, the artery became misshapen and sinusoidal. By embryonic day 3, abnormal connections to the dorsal aorta occurred and bilateral symmetry was lost, suggesting that the loss of neural crest-derived ectomesenchyme destabilizes the nascent artery. Although here we show no loss of the third arch artery, past studies have reported hypoplasia or missing carotids in older neural crest-ablated embryos (Bockman et al. [1987] Am. J. Anat. 180:332–341; Bockman et al. [1989] Anat. Rec. 225:209–217; Nishibatake et al. [1987] Circulation 75:255–264; Tomita et al. [1991] Circulation 84:1289–1295). We suggest that the cardiac neural crest is essential for the persistence of an arch artery, but not its formation. Furthermore, since changes in the development of the arch artery are seen prior to the formation of the tunica media, it is suggested that a critical period is reached in the development of the arch artery, after lumenization, but prior to the formation of the tunica media, which necessitates the presence of the cardiac neural crest. © 1996 Wiley-Liss, Inc.

Hemangiomas of the head, neck, and chest with associated vascular and brain anomalies: a complex neurocutaneous syndrome.

Abstract: PURPOSE To describe the vascular and nonvascular intracranial and extracranial anomalies associated with hemangiomas and vascular malformations of the face, neck, and/or chest. METHODS Seventeen patients had a physical examination and imaging studies consisting of one or more of the following: pneumoencephalography, conventional carotid and vertebral arteriography, CT, MR imaging, and MR angiography. RESULTS Conventional arteriography revealed persistence of the trigeminal artery in 5 cases, absence of internal or external carotid and/or vertebral arteries in 11 cases, persistence of intervertebral arteries in 1 case, deformities of the aortic arch in 3 cases, and anomalies of the intracranial arteries in 3 cases. MR angiography revealed persistence of the trigeminal artery in 1 case in which conventional arteriography failed to show the malformation, and permitted visualization of narrowing of the intracranial arteries. CT and MR imaging showed a cerebellar anomaly in 8 cases and cerebral cortical dysplasia with cerebral hemispheric hypoplasia in 1 case. Vascular and nonvascular anomalies appeared ipsilateral to the external vascular abnormalities in most cases. CONCLUSION This study demonstrates the association of cutaneous angiomas with anomalies affecting intracranial and extracranial arteries, the cerebellum, and, less frequently, the cerebral hemispheres and aortic arch. This association constitutes a relatively frequent neurocutaneous disorder, which we call the cutaneous hemangioma-vascular complex syndrome.

Cardiac anomalies associated with a chromosome 22q11 deletion in patients with conotruncal anomaly face syndrome

Abstract: Cardiac anomalies associated with a chromosome 22q11 deletion are typically Tetralogy of Fallot complicated with anomalies of the aortic arch, ductus arteriosus, and pulmonary artery.

Endogenous retinoic acid signaling colocalizes with advanced expression of the adult smooth muscle myosin heavy chain isoform during development of the ductus arteriosus.

Abstract: During fetal development, a specialized vessel the ductus arteriosus, shunts blood from the pulmonary artery to the aorta, thus bypassing the lungs. The ductus differs primarily from the great vessels in that it is a muscular rather than an elastic artery, and the etiology of this differential development remains controversial. We present evidence that retinoic acid (RA) may contribute to the unique muscle phenotype of the ductus arteriosus. Using a transgenic mouse carrying an RA response element-lacZ transgene that expresses beta-galactosidase (beta-gal) in response to endogenous RA signals during embryonic and fetal development, we observe a strong beta-gal signal in the ductus arteriosus. By immunofluorescence, this signal colocalizes with the expression of the adult-specific smooth muscle myosin heavy chain isoform, SM2. The beta-gal signal is present throughout fetal development and persists in the neonate until the ductus arteriosus is completely closed. beta-Gal-positive cells are first detected by immunofluorescence at 13.5 days postcoitum (dpc) in the mesenchyme surrounding the ductus. By 15.5 dpc, very intense beta-gal staining localizes to the ductus arteriosus but is absent or minimal in the pulmonary trunk and aortic arch; by 17.5 dpc, the smooth muscle layers of the tunica media in the ductus arteriosus exhibit positive beta-gal staining. Immunostaining with antibodies against smooth muscle myosins shows that, while SM1 is expressed in all embryonic vessels, SM2 is precociously expressed in the ductus arteriosus. Furthermore, SM2 expression can be detected in the ductus as early as 15.5 dpc. In the neonate, the beta-gal signal persists in the smooth muscle layer of the ductus and immunostaining colocalizes with SM2 expression. These data suggest that RA may play a role in inducing and maintaining smooth muscle differentiation in the developing ductus arteriosus and may promote precocious expression of the adult vascular phenotype.

Associated cardiac anomalies in isolated and syndromic patients with tetralogy of fallot

Abstract: To detect in children with tetralogy of Fallot (ToF) the prevalence of associated cardiac anomalies in syndromic and isolated cases, the additional cardiac defects of 150 consecutive patients with ToF (102 isolated and 48 syndromic cases) were evaluated by review of echocardiographic, angiocardiographic, and surgical reports. Syndromic patients were classified into groups with branchial arch defects, Down syndrome, and other genetic conditions. ToF is significantly associated with additional cardiac malformations in patients with branchial arch (11 of 21, p <0.01) and Down (10 of 20, p <0.0001) syndromes. The subarterial ventricular septal defect with deficiency of the infundibular septum (4 of 21, p <0.01) and the right aortic arch (6 of 21, p <0.05) were prevalent in patients with branchial arch syndromes, whereas atrioventricular canal (10 of 20, p <0.0001) was associated with ToF in patients with Down syndrome. Peculiar anatomic cardiac patterns are present in children with ToF and may alert the cardiologist to look at additional cardiac anomalies. Moreover, the presence of some associated cardiac anomalies may suggest careful clinical evaluation for genetic syndromes.

Thoracic aortic aneurysm and aortic dissection: new endoscopic mode for three-dimensional CT display of aorta.

Abstract: Three-dimensional (3D) endoscopic-mode software was used at helical computed tomography (CT) to evaluate distal aortic arch aneurysms (n = 12) and aortic dissections (n = 10); images were compared with two-dimensional (2D) axial source images. In distal aortic arch aneurysms, the 3D endoscopic mode depicted the relationship of the arterial orifices and the aneurysm, which is difficult to evaluate with 2D axial images alone. In aortic dissections, however, the 3D endoscopic mode did not provide additional information to that provided on the 2D axial source images.

Confirmation and initial documentation of thoracic and abdominal aortic helical flow : An ultrasound study

Abstract: Aortic helical flow may play an important role in plaque deposition, dissection formation, and organ perfusion The authors have previously demonstrated, using in vitro flow models and transesophageal echocardiography, that helical flow begins in the mammalian aortic arch and continues into the descending thoracic aorta The purpose of this study was to confirm thoracic aortic helical flow and document its extent into the abdominal aorta using direct measurements Twelve mongrel dogs underwent surgery with exposure of the abdominal aorta up to the diaphragm Six of the 12 underwent further thoracotomy with thoracic aorta exposure Color Doppler ultrasound images were obtained using a 5 megaHz esophageal transducer, hand held, directly applied, and visually aligned for transverse aortic imaging Helical flow was considered present with the appearance of red/blue hemicircles during a systolic wave when the aorta was imaged transversely All six dogs that had thoracotomy showed clockwise thoracic aortic helical flow (along the direction of blood flow) at the retro left ventricular region In all dogs, clockwise helical flow was demonstrated to and immediately beyond the renal arteries In 11 of 12 dogs, clockwise helical flow was demonstrated 7 cm below the renal arteries The study confirms the presence of helical flow in the thoracic aorta and documents its extent into the abdominal aorta below the level of the renal arteries The teleologic flow pattern of mammals may extend to other classes of vertebrates and must be accounted for in studies of endothelial shear and flow separation In addition, tangential velocities imparted by helical flow may affect organ perfusion

Pencil Excitation with Interleaved Fourier Velocity Encoding: NMR Measurement of Aortic Distensibility

Abstract: A technique is presented for rapidly and noninvasively determining aortic distensibility, by NMR measurement of pulse-wave velocity in the aorta. A cylinder of magnetization is excited along the aorta, with Fourier-velocity encoding and readout gradients applied along the cylinder axis. Cardiac gating and data interleaving improve the effective time resolution to as high as 3 ms. Wave velocities are determined from the position of the foot of the flow wave in the velocity profiles. Evidence of helical flow distal to the aortic arch can be seen in normal subjects, while disturbed flow patterns are visible in patients with aneurysms and dissections.

Quantitative Echocardiographic Analysis of the Aortic Arch Predicts Outcome of Balloon Angioplasty of Native Coarctation of the Aorta

Abstract: Background The use of balloon angioplasty for treatment of native aortic coarctation is controversial. Cineangiographic data suggest that aortic arch hypoplasia and isthmic narrowing are associated with angioplasty failure. This study of echocardiographic measurements of preangioplasty aortic arch morphology was performed to identify potential anatomic predictors of outcome noninvasively. Methods and Results The preangioplasty echocardiograms of 105 patients 3 days to 17 years old with native coarctation of the aorta were analyzed off-line. Angioplasty was considered successful if the residual coarctation gradient was <20 mm Hg and no intervention for recoarctation occurred. Univariate analysis identified young age at angioplasty, presence of a patent ductus arteriosus, and the diameters of the aortic isthmus, distal transverse arch, and aortic valve as predictors of early and late outcomes. Multivariate analysis showed that the preangioplasty aortic isthmus z value was the best independent predictor of o...

Circulatory management with retrograde cerebral perfusion for acute type A aortic dissection

Abstract: Background Cerebral circulation during urgent repair of acute type A aortic dissection has traditionally been managed with cardiopulmonary bypass and aortic cross clamping proximal to the innominate artery or by the use of hypothermic circulatory arrest (HCA). The more recently introduced retrograde cerebral perfusion (RCP) may confer additional cerebral protection during elective aortic arch reconstruction. The purpose of this study was to demonstrate the efficacy of RCP in the urgent repair of acute type A aortic dissection. Methods and Results We evaluated 60 consecutive patients who underwent repair of acute type A aortic dissection over a 6-year period. Patients were grouped according to intraoperative circulatory management strategies. Group I consisted of 41 patients operated on early in the series who were managed by cardiopulmonary bypass and standard aortic cross clamping (n=21) with conversion to HCA (n=20) if the intimal tear extended into the aortic arch. Since 1993, 19 patients, who make up group 2, were managed with routine open distal anastomosis and HCA with RCP. Data were analyzed for clinically evident, radiographically confirmed cerebrovascular accidents and 60-day mortality and evaluated by χ 2 analysis. Stroke and mortality rates of patients managed with either cardiopulmonary bypass or HCA were 26.3% and 29.3%, respectively. Patients undergoing RCP experienced statistically significant reductions in rates of confirmed cerebrovascular accidents (0%, P=.015) and mortality (5.3%, P=.04). Conclusions We conclude that the introduction of circulatory management using RCP with HCA during urgent operative repair of acute type A aortic dissection has significantly improved both stroke and mortality rates.