aortic pathology: aortic trauma, debris, dissection, and ...aortic pathology: trauma injury location...

Aortic pathology: Aortic trauma, debris, dissection, and aneurysm

Ahmed Khalil, MD; Tari Tarik, MD; David T. Porembka, DO, FCCM

Mechanical trauma is usuallysudden and unexpected,and it can have devastatingor subtle results that later

may manifest into dire consequences. Ap-propriate and quick diagnosis may avoid apreventable mishap with significant po-tential of morbidity and even death. Onesuch circumstance is in the rapid accel-eration and deceleration involving motorvehicle accidents, motorcycle accidents,falls, industrial accidents, and domesticviolence. In a motor vehicle accident,there are significant physical forces, re-sulting in compression and distortions,even to the extent of compression ofchest wall contents, particularly the aortaagainst the spinal column.

Traumatic aortic injury is one suchdisease that is life threatening, rangingfrom intimal tears, to mediastinal hema-tomas, to transection. The most commonsites of injury are the aortic isthmus andthe ascending aorta, just proximal to theorigin of the brachiocephalic vessels (Ta-ble 1). Transection of the ascending aortais relatively uncommon (10%). Cammacket al. (1) and others (2–4) showed thatvertical forces of deceleration may lead torupture of the ascending aorta and arch.The majority of the time (65% to 80%),the occupants with an aortic injury inmotor vehicle accidents will succumb atthe scene or at admission because ofrapid hemorrhage. If the hemorrhage iscontained in the chest or if there is thepresence of cardiac tamponade (falls), ini-tially, the patient may survive (5). Of thepatients who arrive alive to the hospital,33% will become hemodynamically com-promised. The mortality in this lattersubgroup (unstable) approaches 100%,whereas the remaining two thirds whoare stable result in 25% mortality, even ifhandled carefully. Most of those deathswill be attributed to other associated in-juries (3, 4, 6–8) (Table 2).

The mechanism of injury, ejection,unrestrained occupant, or death at the

scene may trigger uncertainty. The astutephysician should regard the presence ofaortic injury early in the primary andsecondary surveys. Chest radiographymay or may not reveal a widened medi-astinum. In addition, other radiographicsigns may be present, such as rightwardshift of the trachea, blurring of the aorticknob or descending thoracic aorta, opaci-fication of the juncture between the aortaand pulmonary trunk, and collection offluid in the left lower thorax. This lattersign may be associated with other inju-ries, such as bleeding from intercostals orpulmonary vessels (1, 5, 6, 9). These pa-tients may seem stable or have other pro-found or grave injuries with hypotension(severe traumatic brain injury, crushedlimb injuries, vertical shear of the pelvis,hemorrhage into any body cavity [liverlaceration or splenic rupture], retroperi-toneal bleeding, or any combination ofthe above), thus diverting attention froman existing aortic injury (5). If there is apositive Focused Assessment with Sonog-raphy for Trauma (FAST) examination oraffirmative results from computed to-mography, it is not unusual that the pa-tient will undergo emergent laparotomyfor intra-abdominal hemorrhage, notknowing of the potential of an aortic in-

From the Departments of Anesthesiology (AK), In-ternal Medicine (Cardiology) (TT), and Anesthesiology,Surgery, and Internal Medicine (Cardiology) (DTP), Uni-versity of Cincinnati College of Medicine, Cincinnati,OH.

The authors have not disclosed any potential con-flicts of interest.

For information regarding this article, E-mail:[email protected].

Copyright © 2007 by the Society of Critical CareMedicine and Lippincott Williams & Wilkins

DOI: 10.1097/01.CCM.0000270276.01938.C0

The aorta is a conduit from the left ventricle that deliverspulsatile blood distally in either a compliant or stiffened vessel toorgans and tissue beds. Only recently, since the advent of trans-esophageal echocardiographic imaging, did its presence and as-sociated pathologies become more profound and more prominentfor the intensivist. Angiography, the “gold standard” for diagnos-tic imaging, now seems to be in question since the advent ofultrasound (transesophageal echocardiography), improvements inmagnetic resonance imaging, and particularly the advancementto 64-slice computed tomography. It is now a revelation of howrevealing these newer imaging tools have expanded our knowl-edge potential of pathologies that involve the aorta. The latterthree imaging modalities are continuing to improve, with estab-lished efficacy, particularly in the critically ill and injured patient.This article will enlighten the intensivist and others of theirpotential and contrast each imaging device in several prominentpathologies common to the critical care physician. The disadvan-

tages of all will be brought forth. Evidence will be presentedrevealing the dynamic nature of imaging technologies that willcontinue to affect the outcome of our patients. The most commonindications for interrogation of the aorta are in traumatic events inwhich there might be a catastrophic transection, intimal tear orflap, or subadventitial tear. The identification of hematomas (bythese imaging devices) in the mediastinum might be associatedwith significant physical forces, and this article will show therelevance. The significance of atherosclerotic plaques, ulcers, anddebris will also be debated. Finally, imaging of a patient withaortic dissection or aneurysm will be discussed, as its pathologyand pathogenic process are well known, and the changing natureor paradigm shift in the imaging of this life-threatening diseasewill be addressed. (Crit Care Med 2007; 35[Suppl.]:S392–S400)

KEY WORDS: aorta; pathology; transesophageal echocardiogra-phy; magnetic resonance imaging; computed tomography; criticalcare

S392 Crit Care Med 2007 Vol. 35, No. 8 (suppl.)

jury pattern. So, when time permits in theperioperative resuscitative portion, trans-esophageal echocardiography (TEE) shouldbe considered. In addition, the clinician willalso interrogate, in real time, ventricularfunction and volume, ventricular interac-tions, and other contiguous structures.

TEE is one of the most powerful diag-nostic tools immediately available in aportable fashion for the critical care phy-sician in the assessment of the criticallyill injured patient, and this tool can fol-low the patient to various settings. It canbe readily available in any situation, aslong as there are appropriately trainedindividuals with immediate access to theequipment and who are clinically in-clined to these types of patients (7, 10,11). There is still some controversy aboutthe overall acceptance of TEE as a first-line diagnostic tool when an aortic injurymay be under question, probably becauseof historical reasons (angiography as a“gold standard,” lack of excellent ran-domized, prospective investigations, andbias) (12). Other imaging modalities areavailable, such as computed tomography

(CT), angiography with or without con-trast and with digital subtraction, andmagnetic resonance imaging (MRI) (13)(Table 3). All of the imaging tools havetheir advantages and disadvantages. Tim-ing is of the essence for appropriate careof these patients.

The early survival of these patientsdepends on the initial resuscitation andtimeliness of correct diagnostic modali-ties implemented. In the not-so-distantpast, angiography was considered thegold standard for detecting an aortic rup-ture (2, 3, 7, 10, 11, 14, 15). Fortunately,other modalities came to bear, especiallyTEE multiplanar technology, with thepackaging of pulsed-wave Doppler, con-tinuous-wave Doppler, color flow, tissueDoppler imaging, harmonic imaging, andtwo-dimensional imaging changing to re-construction imaging methods for three-dimensional input and eventual strain-rate development. Particularly in thehemodynamically unstable patient, TEEshould be the first line of choice of diag-nostic methods (7, 10, 11).

The difficulty with CT and MRI istransportation of the critically ill, espe-cially in remote areas, and the time in-volved (60 to 70 mins). If time permitsand the patient can withstand transpor-tation, helical or multidetector CT is alsoa viable option, rendering similar sensi-tivities and specificities to that of aortog-raphy (13, 16–18) (Table 4). In an inves-tigation by Dyer et al. (4) over a 51⁄2-yr

period, in which 1,561 patients werestudied for the potential of traumatic aor-tic injury at two trauma centers, CTfound only 30 aortic injuries. They con-clude that liberal use of CT should beimplemented in these situations. CT ex-amination in this series reveals a 100%nonpredictive value (4, 19). In a smallerprospective series (n � 110), patientswith a severity score �34 underwent TEEand CT. The results were that imagingmodalities correctly identified subadven-titial tear (confirmed at surgery) (20) (Ta-ble 5).

It is not unusual to use TEE first inthe diagnostic schematic, complementedby reconstruction of CT images. MRIviews the aorta with excellent quality butshould be used only in a stable patient inthe chronic phase of the aortic diseasestate. The entire thoracic aorta is easilyvisualized by imaging devices, includingthe use of transthoracic echocardiogra-phy (TTE) via the suprasternal notch forthe ascending aorta and its arch. TheFAST examination is limited and does notinclude the aorta. The interrogation ofthe thoracic aorta in the comprehensiveTEE examination is crucial. The limita-tion of TEE is difficulty in interrogationof the distal thoracic aorta and arch ves-sels. Occasionally, reverberation artifactsbecome problematic. When this occurs,other modalities such as CT may comple-ment the TEE images (if the patient hastime to be transported to radiology). The

Table 1. Aortic pathology: trauma

Injury location %

Proximal descending 54–64Aortic arch 10–14Multiple sites 13–18Distal aorta 12

Diaphragmatic


EpidemiologyFalls, motor vehicle accidents, industrial

accidents, blast injuries, domesticviolence

Blunt and/or penetrating injuriesClinical presentation

Mortality at scene of 65% to 80%At arrival, 33% become unstable

Mortality, unstable: 100%Mortality, stable: 25%


Diagnostic imaging modalitiesChest radiographyAngiographyComputed tomography (CT)

Helical CTMultidetector CT64-slice CT

EchocardiographyTransthoracicTransesophageal

Magnetic resonance imaging

Table 4. Transesophageal echocardiography (TEE) and angiography (aortography or contrast-enhanced spiral computed tomography for traumatic aortic imaging �TAI�)

Sensitivity, % Specificity, % NPV, % PPV, %

Minor TAI (n � 7)TEE (n � 208) 100 100 100 100Angiography (n � 206) 84 100 97 100

Major TAI (n � 33)TEE (n � 208) 97 100 99 100Angiography (n � 206) 97 100 99 100

All TAI (n � 41)TEE (n � 208) 98 100 99 100Angiography (n � 206) 83 100 96 100

NPV, negative predictive value; PPV, positive predictive value.Adapted from Goarin (10).

Table 5. Transesophageal echocardiography (TEE) and helical chest computed tomography (CT) forthe identification of traumatic arterial injuries in severe blunt trauma

Sensitivity (%) Specificity (%) NPV (%) PPV (%)

Multiplane TEE (n � 106) 93 (68–100) 100 (96–100) 99 (94–100) 100 (77–100)Helical CT (n � 99) 73 (45–92) 100 (96–100) 95 (89–99) 100 (71–100)

NPV, negative predictive value; PPV, positive predictive value. Reprinted with permission fromVignon et al (20).

S393Crit Care Med 2007 Vol. 35, No. 8 (suppl.)

difficulty with CT is that it is not in realtime and cannot assess left ventricularperformance, valvular integrity, and car-diac hemodynamic factors. The benefit ofangiography is the ability to see extrava-sations, defects of the aortic wall with thepresence of aneurysmal dilation. How-ever, it does not have the capability tointerpret intraluminal defects. TEE easilyidentifies the intimal flap, tear, or throm-bus. With color flow Doppler, integrity ofthe aorta and its contents can be as-sessed, showing flow patterns or turbu-lence (aliasing) as a sign of a potentialinjury (21–29).

Numerous studies have shown the ex-treme benefit of TEE and some of itslimitations (2, 7, 11) (Figs. 1 and 2). Oneinvestigation overwhelmingly reveals theefficacy of TEE. It is quite evident thatwhen there is a seasoned TEE operativewith experience in trauma patients, the

results are formidable (30). In this series,they immediately performed TEE andaortography in sequential fashion. Thepositive predictive value of TEE is 90.9%.A false-negative result did not undergocorrection and it is believed that angiog-raphy in this case is also nonconclusive(31). Similarly, Vignon et al. (32) studied32 consecutive patients who exhibited awidened mediastinum with a associatedviolent deceleration impact. The majorityof injury pattern is subadventitial (n �10) and intimal tears (n � 3). One medialtear was missed by TEE and confirmed atnecropsy. The sensitivity and specificityof TEE for the diagnosis of subadventitialtear are 91% and 100%, respectively. Awidened mediastinum on the chest radio-graph (�8 mm) is a red flag, increasingthe suspicion for an aortic injury. In aninvestigation by Vignon et al. (33), thismarker was analyzed. They had two

groups; one with an enlarged mediasti-num and one with a mediastinum of �8mm. The total group consisted of 40 con-secutive patients. They revealed that lackof a widened mediastinum does not obvi-ate the need for a TEE examination. Theybelieve that TEE is really the only first-line tool in these diagnostic dilemmas.One of the benefits of TEE is the avail-ability of other diagnostic tools in realtime. A prospective study by Catoire et al.(34) found how efficacious TEE is inthese inherently complicated patients(n � 70). Within 48 hrs of admission, acomprehensive examination was com-pleted. Myocardial contusion was identi-fied in 25 patients, invalidating 18 sus-pected contusions and visualizing fivepositive cases that were unsuspected. Ofimportance, pericardial effusions weresuspect in one case, and TEE identified13 unsuspected cases. In 13 patients witha widened mediastinum, aortic injury wasexcluded in all of them. Hypovolemia waseasily detected in seven of these patientsin whom it otherwise might not havebeen appreciated. In one group, 70% ofthe patients had a new diagnosis con-firmed only by TEE. Over an extendedperiod or time, as follow-up (9 yrs),Goarin et al. (10) evaluated TEE in trau-matic aortic injury in a substantial cohort(n � 209). Of patients identified with anaortic injury, angiography (aortography,contrast-enhanced CT, or both) was lessaccurate (sensitivity of 83%, specificity of100%) than TEE (sensitivity of 98%,specificity of 100%). It became apparentthat smaller lesions (intimal flaps) wereeasily detected by TEE. However, whenthere were larger lesions, the sensitivitiesand specificities became more equivalent(Tables 6 and 7).

Despite the apparent overwhelmingdata for TEE in the diagnosis of traumaticaortic injuries, controversy exists. Fabianet al. (3) and Cinnella et al. (12) do pointout some differences. In the 50-centertrial by Fabian et al. (3), only 274 bluntaortic injury cases were detected. Themajority (81%) of these vascular injurieswere attributed to motor vehicle acci-

Figure 1. Transection of proximal distal thoracic aorta adjacent to the isthmus.

Figure 2. Intimal tear of proximal posterior aorta.

Table 6. Aortic pathology: diagnostic imaging oftrauma with computed tomography

DisadvantagesTime consumingTransportation to remote areaNot real timeIntraluminal defects not observed

Small, multiple, irregular


dents. Of note, only 88 and 30 patientsunderwent a CT and TEE, respectively.The diagnostic potential was described as75% and 80%, respectively. In this au-thor’s opinion, this is an inherent biasbecause lack of the number of patientswith a comprehensive TEE examination.Also, it seems that operators of TEE, andtheir experience and expertise, were notcontrolled and were quite varied (3) (Ta-ble 8). However, in the review by Cinnellaet al. (12), the controversy is more estab-lished, as numerous investigations arecritically evaluated. They found 17 rele-vant TEE studies out of 758 during a timeperiod from 1994 to 2002. They devel-oped several quality scores that met cer-tain criteria. They believe that TEE is ahighly useful diagnostic tool for detectingtraumatic aortic injury but noticeablyequivalent to angiography. However, theydid state that smaller lesions and multi-ple lesions were easily detected with cer-tainty by the TEE method (12). In thisauthor’s opinion, I believe this criticalappraisal confirms the benefit of TEE. Itreaffirms that experience is vital, as istiming of the study, and that TEE com-plements other diagnostic modalities andshould be used in a critical fashion. TEEshould still be the first line of defense inthe detection of these critical injuries. Anechocardiographic team with extensivetraining (the team does not have to be

just cardiologists) and with expertise inTEE should be immediately available. Forpractical purposes, this could only bepossible in level I trauma centers. As im-aging tools improve in quality (64-sliceCT), the diagnostic scheme may alter, butif timing is of the essence, particularly incritically ill multiple trauma patients whomay be unstable, it behooves the clinicianto bypass TEE.

Aortic Atheroma

Echocardiography is a valuable tool inthe evaluation of aortic atheroma. Inter-estingly, most of the TEE/TTE studies areperformed on patients who already havehad an event (stroke, traumatic aorticinjury, or systemic emboli) necessitatingevaluation. Occasionally, aortic atheromais detected incidentally on TEE per-formed to evaluate other pathologic con-ditions.

However, this entity is largely underdi-agnosed, as shown by the Stroke Preven-tion: Assessment of Risk in a Community(SPARC) study (35). This investigation en-rolled 588 randomly sampled subjects (av-erage age of 66.9 yrs) from 1993 to 2000who underwent medical record review,home medical interview, TEE, carotid ul-trasound, and repeated blood pressuremeasurement. The incidence of detecting asimple aortic plaque (�4 mm) in the as-cending arch and descending aorta was43.7%. Of those, 29.9% were located in theascending aorta and the aortic arch. Thepresence of complex plaque (mobile or �4mm) was 7.6% in the ascending arch anddescending aorta, with 2.4% located in theascending aorta and aortic arch (35).

Classification of Grades of Atheroma.The importance of detecting aortic ather-oma is based on its association with othersignificant diseases that might be en-

countered in the intensive care unit(Fig. 3).

Stroke is one of the leading causes ofmorbidity and mortality in the UnitedStates. Many studies examined the asso-ciation between aortic atheroma andstroke (36 –38). One of these studiesfound that atheroma in the ascendingaorta and aortic arch was a significantand independent risk factor for cerebralischemia. The odds ratio for a cerebrovas-cular event in the presence of simple ath-eroma was 2.3, and for complex atheroma(�5 mm, mobile or ulcerated surface), itwas 7.1 (36).

A French study (38) of aortic plaquesshowed that, in the stroke group, aorticatheroma of �4 mm was an independentrisk factor for recurrent brain infarctionafter adjusting for other factors. Thesepatients had a significantly higher inci-dence of recurrent brain infarction of11.9 per 100 person-years in patientswith aortic atheroma of �4 mm in theascending aorta and proximal arch, ascompared with 3.5 per 100 person-yearsin patients with aortic atheroma of 1–3.9mm and 2.8 per 100 person-years in pa-tients with aortic atheroma of �1 mm(p � .001).

In the same study (38), the presence ofaortic atheroma of �4 mm was associ-ated with all vascular events (stroke,myocardial infarction, peripheral embo-lism, and death from vascular causes) atan incidence of 26 per 100 person-years.

Furthermore, the presence of aorticatheromatous plaque on TEE has beencorrelated with a higher prevalence ofcoronary artery disease (39), and the lackof aortic plaque with TEE has been shownto predict the absence of coronary arterydisease (40).

Patients with significant carotid ste-nosis also have a higher prevalence ofaortic atheroma (41). The incidence ofabdominal aneurysm is ten times higherin patients with severe thoracic aorta ath-erosclerosis (41).

However, the proper treatment forthis condition is unknown so far. It wasfound in a large retrospective, nonran-domized analysis that only statins showeda significant reduction in recurrentstrokes and embolic events. Interestingly,the use of warfarin or antiplatelet agentswas not beneficial in this study (42).

In another study, the detection of aor-tic thrombi by TEE changed the second-ary prevention to oral anticoagulation for�4–6 wks in patients with acute brainischemia; later in the course of the dis-

Table 7. Aortic pathology: Computed tomography for trauma

Parameter Hematoma Direct Signs Periaortic Direct Signs Direct Signs

Patients, n 1346 1346 1346TN 671 1258 1299FP 656 69 28NPV, % 100 100 99.9Sensitivity, % 100 100 95Specificity, % 50 95 98TAI 19 19 19TP 19 19 18PPV, % 3 22 39FN 0 0 1

TN, true negative; FP, false positive; NPV, negative predictive value; TAI, traumatic aortic injury;TP, true positive; PPV, positive predictive value; FN, false negative.

Adapted from Dyer et al (4).

Table 8. Aortic pathology: transesophageal echo-cardiography for diagnostic imaging of trauma

DisadvantagesReverberation artifactsDifficulty in visualizing distal ascending aortaDifficulty in interrogation arch vesselsOperator dependent

Experience and trainingAvailability


ease, platelet inhibitors and statins wereused for plaque stabilization (43). Theongoing Aortic arch Related CerebralHazard (ARCH) trial, comparing clopi-dogrel plus aspirin vs. warfarin, will con-tribute substantial information for theoptimal treatment (43).

Thoracic Aortic Dissection

Aortic dissection can be associatedwith a high mortality rate, especially ifnot diagnosed and treated rapidly. In thefollowing section, the etiology, classifica-tion, and diagnosis of aortic dissectionwill be discussed.

All of the causes that lead to aortic an-eurysms, as discussed before, can lead toweakening of the aortic wall, with resultantdissection or rupture. Other causes includetrauma and iatrogenic dissection, such asafter cardiac catheterization or aortic can-nulation and manipulation during heartsurgery.

There are two widely known classifica-tions, Stanford and De Bakey. Stanfordtype A includes dissection that involvesthe ascending thoracic aorta, whereastype B dissection does not involve theascending thoracic aorta. De Bakey type Idissection involves the whole aorta, typeII dissection involves the ascending aorta,and type III is a dissection of the descend-ing aorta. Thus, Stanford type A dissec-tion includes De Bakey types I and II, andStanford type B equals De Bakey type III.Because intramural hematoma, intramu-ral hemorrhage, and aortic ulcer may bea sign of evolving dissection, a new dif-

ferentiation has been proposed (44)(Fig. 3).

Class 1: Classic Aortic Dissection. Aor-tic dissection is characterized by the pres-ence of an intimal flap that separates be-tween the true and false lumen. This canfurther divide into communicating andnoncommunicating dissection. Commu-nicating dissection has an intimal tearwith unidirectional or multidirectionalflow between the true and false lumen.On the other hand, noncommunicatingdissection, no flow, and no intimal tearcan be detected. That dissection canspread either in an antegrade fashion,with involvement of the distal part of theaorta, or extend to different branches,like the carotid, subclavian, and renal. Itcan also spread in a retrograde fashion toinvolve the coronaries (44).

Class 2: Intramural Hematoma/Hem-orrhage. Intramural hematoma/hemor-rhage may be the result of rupture vasavasorum and may be the initial lesion incases of cystic medial degeneration. Itoften coexists with or progresses to class1 dissection. It is present in 10% to 15%of patients with suspected aortic dissec-tion (44, 45) (Fig. 1).

Class 3: Subtle-Discrete Aortic Dissec-tion. This form of dissection is character-ized by a stellate or linear intimal tearwith the exposure of the underlying me-dia and adventitia but without progres-sion to separation of medial layers.Svensson et al. (46) described the occur-rence of this rare type of dissection innine patients with suspected aortic dis-section, but diagnostic tests failed to di-

agnose it, including TEE, CT, and MRI.They concluded that aortography shouldbe done if dissection is still a highly likelydiagnosis, but other noninvasive testswere negative. In aortography, the dissec-tion may look like an eccentric bulge(Fig. 2).

Class 4: Plaque Rupture and Ulcer-ation. Ulceration of the aortic plaquescan lead to aortic dissection or aorticrupture. The natural history and progres-sion of aortic ulcer and the treatment isof controversial issue. In a symptomaticpatient, it might be similar in presenta-tion to other causes of acute chest pain,or it might be asymptomatic and diag-nosed accidentally (47) (Fig. 3).

Class 5: Traumatic and IatrogenicAortic Dissection. Blunt trauma maycause dissection at the level of aortic isth-mus. Iatrogenic dissection may be seenafter aortic angioplasty for aortic coarc-tation or after cross-clamp of the aortaduring heart surgery (44).

Clinical Presentation and Diagnosis.Acute sudden onset of severe pain is thetypical manifestation of aortic dissection,but a wide variety of symptoms can bepresent. The patient may have symptomssuggestive of congestive heart failure,stroke, shock, or loss of distal pulse (Ta-ble 9).

Other features might include diastolicmurmur of aortic regurgitation and neu-rologic deficits. If the dissection causesbleeding into the pericardium, distantheart sounds secondary to pericardial ef-fusion may be noted, and symptoms andsigns of tamponade may be seen in ex-treme cases.

Early diagnosis is critical becauseearly intervention can decrease the mor-tality rate, which is estimated to be 1–2%per hour in the first 48 hrs of ascendingaortic dissection (44).

The most common modalities for di-agnosing aortic dissection include TEE/TTE, helical CT, and MRI (Table 10). Aor-tography is another method for makingthe diagnosis, but it is invasive and re-quires the use of contrast. The utility isalso limited in critically ill and unstablepatients. Nevertheless, it remains themethod of choice in diagnosing class 3dissection, as previously mentioned. Eachtest has its advantages and limitationsand must be evaluated carefully in thecontext of the patient’s medical condi-tion, need to transfer outside the inten-sive care unit, feasibility, and cost-effectiveness.

Figure 3. Large free-flowing thrombus with plaques on the anterior arch.


In the Task Force on Aortic Dissectionstudy by the European Society of Cardi-ology and others (44), they found thatmost centers use an average of 1.8 meth-ods to diagnose aortic dissection, reveal-ing the uncertainty of this potentiallylife-threatening disease.

A recent meta-analysis by Shiga et al.(48) reviewing published studies of thediagnosis of aortic dissection by TEE, he-lical CT, and MRI showed that tests yieldclinically equally reliable diagnostic val-ues. TEE had a 99% sensitivity and 95%specificity, helical CT had a 100% sensi-tivity and 98% specificity, and MRI had a98% sensitivity and 98% specificity.

Echocardiography TTE and TEE.Echocardiography is a bedside test that issimple to perform, with proven value and

accuracy. It might be the most appropri-ate test for a patient who is hemodynam-ically unstable. It also provides importantinformation regarding the function of theheart, presence of pericardial effusion, in-volvement of the aortic valve, and aorticregurgitation.

Other complications of aortic dissec-tion, such as mediastinal hematoma,might show as echo-free space betweenthe esophagus and left atrium duringTEE exam. Pleural effusion may also de-velop.

The TTE can only evaluate the ascend-ing aorta and arch, but it might be diffi-cult to visualize in mechanically venti-lated patient. On the other hand, TEE willprovide better images to the ascending,arch and descending aorta but will notvisualize the distal ascending aorta be-cause of the presence of the left mainbronchus in between (Table 11). It is im-portant to differentiate between differentclasses of aortic dissection because treat-ment and prognosis vary accordingly. Forexample, classic type A dissection needsrapid surgical intervention, whereas clas-sic type B will need medical manage-ment. It is important to localize the tear,if possible, because the main goal of in-tervention is to occlude the entry point.

By two-dimensional echocardiography,the intimal flap, the point of entry, andtrue and false lumens can be easily seen.The true lumen is usually smaller, ex-pands during systole, and by the use ofcolor flow, it has faster flow comparedwith the false lumen, which might belarger in size, become compressed duringsystole, and may have slow or no flow, asevident by presence of smoke or throm-bus (Fig. 4). Another limitation of echo-cardiography is the inability to evaluateextension to the abdominal aorta or otherbranches.

Helical CT. Helical CT is the mostwidely used method for diagnosis, withvery high sensitivity and specificity. In ameta-analysis, helical CT was found tohave the highest negative predictivevalue, making it the best test to rule outaortic dissection (48).

MRI. MRI has the highest accuracyand sensitivity for detection of all types ofdissection, with the exception of class 3,which is only diagnosed with aortography(44, 46, 48).

Problems with MRI include patienthemodynamic instability, length of timeneeded to do the study, many incompat-ibility problems, and contraindicationslike pacemakers. It is also expensive andnot readily available at all times and in allcenters.

Aortic Aneurysms

Aortic aneurysmal disease is a condi-tion that carries significant risk of mor-bidity and mortality. Aortic aneurysmsare considered to be one of the majorcauses of mortality in the western coun-tries (ranked 13th). The incidence of aor-tic aneurysms is estimated to be 4.5 per1,000 (49).

Definition and Classification. An aor-tic aneurysm is a localized dilation of theaorta. There are two types of aneurysms:a true aneurysm, in which the dilatedsegment involves all three layers of thevessel, and a false or pseudoaneurysm,which is a contained hematoma outlinedby adventitia or surrounding tissue. Aor-tic aneurysms can be further classifiedaccording to their morphology into fusi-form or saccular.

Aneurysms can affect different loca-tions of the aorta: the aortic root, ascend-ing aorta, aortic arch, or the descendingaorta. Sixty percent of thoracic aneu-rysms involve the aortic root or the as-cending aorta, 40% involve the descend-ing aorta, 10% involve the arch, and 10%

Table 9. Demographics and history of patients (n � 464) with acute aortic dissection

Variable n (%)Type A

n (%) (n � 289)Type B

n (%) (n � 175)p Value

Type A vs. B

Patient historyHypertension 326/452 (72.1) 194 (69.3) 132 (76.7) .08Atherosclerosis 140/452 (31.0) 69 (24.4) 71 (42) �.001Previous cardiac surgery 83 (17.9) 46 (15.9) 37 (21.1) .16Previous aortic aneurysm 73/453 (16.1) 35 (12.4) 4 (2.3) .006Previous aortic dissection 29/453 (6.4) 11 (3.9) 18 (10.6) .005Diabetes 23/451 (5.1) 12 (4.3) 11 (6.6) .29Marfan syndrome 22/449 (4.9) 19 (6.7) 3 (1.8) .02

Adapted from Ince H, Nienaber CA: Diagnosis and main management of patients with aorticdissection. Heart 2007; 93:266–270.

Table 10. Aortic pathology: dissection and aneurysm

Variable Aortography CT MRI TEE

Sensitivity ** ** *** ***Specificity *** *** *** **/***Site of intimal tear ** * *** *Thrombus *** ** *** *Aortic insufficiency *** — * ***Pericardial effusion ** *** *** ***Branch vessel involvement *** * ** *Coronary artery involvement ** — — **

CT, computed tomography; MRI, magnetic resonance imaging; TEE, transesophageal echocardi-ography.

Asterisks, gradation of importance, sensitivity, or detection.

Table 11. Aortic pathology: dissection andaneurysm

Echocardiographic characteristicsSmall true lumenLarger false lumenIntimal flapEntry site, single vs. multiplePresence of thrombus in false lumenIntramural hematoma, rupture of vasa

vasorum within aortic media


are thoracoabdominal aorta, with someinvolving more than one segment (50).

Etiology. There are a variety of condi-tions that lead to weakening of the aorticwall (most importantly the media), caus-ing aneurysmal formation. Interestingly,the etiology may differ depending on thelocation of the aneurysm. The most com-mon cause of the descending aortic an-eurysm is atherosclerosis, whereas theetiology for aortic root aneurysm couldbe associated with connective tissue dis-orders like Marfan syndrome, Ehlers-Danlos syndrome, and bicuspid aorticvalve disease. Other etiologies include in-fectious, inflammatory, trauma, dissec-tion, and idiopathic (49).

Marfan syndrome is an autosomaldominant connective tissue disorder witha mutation in one of the genes for fibril-lin-1, which is the major component ofelastin. Ehlers-Danlos syndrome is an-other connective tissue disorder and isassociated with aortic aneurysm, articu-lar hypermobility, skin hyperextensibil-ity, and tissue fragility (44, 50). Familialthoracic aortic aneurysm syndrome is as-sociated with cystic medial degenerationof the aorta but no other connective tis-sue abnormalities. It is believed to be anautosomal dominant disorder, withmarked variability in expression and pen-etration (44, 50). Bicuspid aortic valve isalso associated with aortic aneurysmalformation. Not only is it related to post-stenotic dilation, but interestingly, it wasfound that up to 52% of patients with anormally functioning bicuspid aorticvalve have aortic dilation (51). Inade-quate production of fibrillin-1 is thoughtto be the underlying pathology (50).

Inflammation could also lead to aneu-rysm formation. Syphilitic aortitis issomewhat rare now, but this used to be acommon cause of aortic root and ascend-ing aortic aneurysms. Other inflamma-tory disorders include Takayasu arteritis,

which occurs more in women with amean age of 29 yrs. It mainly causes ob-structive lesions, but aortic dilation ispresent in 15% of cases. Giant-cell arteri-tis is another rare disease, which com-monly affects the temporal artery but alsomay affect the ascending aorta.

Trauma may lead to dissection ortransection, with subsequent formationof pseudoaneurysm, which commonly af-fects the descending aorta distal to theorigin of the left subclavian artery. Chronicdissection can dilate with time, causing an-eurysmal formation (44, 49, 50).

Natural History of Aortic Aneurysms.Aortic aneurysm is usually a progressivedisease that needs to be monitoredclosely or treated by intervention. As an-eurysms grow in size, there is an in-creased incidence of rupture, dissection,and death. Ascending aortic aneurysmswill grow an average of 1–4 mm everyyear, but in patients with bicuspid aorticvalve and Marfan syndrome, the rate ofgrowth is more rapid (49). After aneurys-mal size exceeds 6 cm, the risk for rup-ture and dissection is �6.9% per year andrisk of death is 11.8% per year (52).

Clinical Manifestations. Most patientsare asymptomatic, and the aneurysm isdiscovered incidentally by chest radiogra-phy, echocardiography, or CT. Aortic an-eurysms may manifest with symptomslate in the course of the disease.

Progressive dilation of the ascendinganeurysm may cause dilation of the aorticannulus, with resultant aortic regurgita-tion. This represents a significant volumeoverload on the left ventricle, resulting inprogressive left ventricular dilation andfailure. Compression of the adjacentstructure may lead to chronic chest pain,but when a patient experiences a newonset of severe chest pain, this may be anearly indication for dissection.

Role of Echocardiography in the Eval-uation of Aortic Aneurysms. Transtho-

racic two-dimensional echocardiographyis very effective in evaluating the aorticroot, but the mid and distal ascendingaorta, aortic arch, and the descendingaorta are not seen. Thus, it is a valuableand useful noninvasive test to evaluateand follow up on patients with an aorticroot aneurysm (e.g., Marfan syndrome).It also provides important information onaortic valvular regurgitation and on thefunction and dimensions of the left ven-tricle.

Newer technology might improve thevisualization of the thoracic aorta, as de-tailed in case report of visualization of amycotic descending aneurysm usingthree-dimensional transthoracic echocar-diography (53). TEE allows better visual-ization of the aortic root, ascendingaorta, aortic arch, and descending aorta.Images are usually accurate, with the ex-ception of part of the aortic arch and thedistal part of the ascending aorta due tothe position of the left bronchus betweenthe probe and aorta. TEE allows near-complete evaluation of the aorta due tothe proximity of the high-frequencyprobe to the aorta. Images are far supe-rior to TTE, especially in intubated pa-tients or patients with severe pulmonarydisease and poor echocardiographic win-dows. TEE also provides significant dataon cardiac structural abnormalities, val-vular disorders, and cardiac function. It isa semi-invasive test that can be per-formed at the bedside in the critical careunit or in the operating room, withouthaving to transfer unstable patients, un-like other imaging modalities. Disadvan-tages of TEE include being invasive, needfor an experienced operator, and the in-ability to perform the test in patients withsignificant esophageal pathology.

There are other imaging modalitiesfor aortic aneurysmal disease. Helical CTand CT angiography allow for the fullevaluation of the entire aorta and theextension of the aneurysm. They arealso superior in evaluating the aorticbranches. Three-dimensional reconstruc-tion allows optimal measurement of theaneurysm size, especially when the aortais tortuous. Another important tool thatCT can provide is the visualization andlocalization of the artery of Adamkiewicz,which supplies the anterior spinal artery.Most causes of paraplegia after repair ofthoracoabdominal aneurysm or dissec-tion are related to interrupted blood sup-ply to the anterior spinal artery. Detec-tion of the artery of Adamkiewicz canhelp in the surgical decision and may

Figure 4. Left, aortic dissection with intimal flap and entry site of distal thoracic aorta; Right, aorticdissection renal flow via color flow Doppler through intimal tear. TL, true lumen; FL, false lumen.


prevent postoperative paraplegia. In onestudy, Takase et al. (54) was able to detectit in 63 of 70 patients (90%). The maindisadvantage of CT is the need for con-trast administration and radiation expo-sure. It is not the optimal test for criti-cally ill patients who are not stable fortransfer to the radiology suite.

MRI is another modality for evaluatingaortic aneurysms. It is very sensitive andrequires no radiation exposure, but it isexpensive and time consuming and mightnot be suitable in critically ill patients. Itis also possible to detect the artery ofAdamkiewicz with MRI angiography withgreat sensitivity. In a study by Hyodoh etal. (55) they were able to detect the arteryof Adamkiewicz in 42 of 50 patients(84%), which led to a change in the sur-gical approach to preserve the artery. Inthe 42 patients, there was no postopera-tive paraplegia. Of the other eight pa-tients in whom the artery of Adamkiewiczwas not visualized, two had postoperativeparaplegia.

Finally, chest radiography may showenlarged cardiac silhouette, aortic knob,and tracheal deviation by the large aneu-rysm, but smaller aneurysms will not beshown on radiography.

Sinus of Valsalva Aneurysm

Sinus of Valsalva aneurysm (SVA) is arare cardiac anomaly, which may be ei-ther congenital or acquired. CongenitalSVAs may be attributed to lack of conti-nuity between aortic media and annulusfibrosis (56). Acquired aneurysms may re-sult from trauma (57), infection, endo-carditis (58, 59), syphilis, Marfan syn-drome, and senile dilation. A supracristalventriculoseptal defect may frequentlycoexist with the right SVA (60). Dilationof all three sinuses of Valsalva may beseen with aging, Marfan syndrome, syph-ilis, and other connective tissue diseases.

Aneurysm of one or two of the sinusesis unusual and may be related to congen-ital or, more commonly, endocarditis.The right coronary sinus is involved mostoften, followed by the noncoronary sinus,and least frequently is the left coronarysinus (60).

The natural history of the SVA is hardto study due to the rarity of the disease,but it can either present with or withoutrupture (60, 61). A nonruptured SVA mayremain asymptomatic but might be com-plicated with right ventricular outflowobstruction, infective endocarditis, ar-rhythmias and myocardial infarction, and

ischemia due to distortion of the coro-nary Ostia or compression of the coro-nary trunk. Progressive dilation may leadto aortic regurgitation. There may be as-sociated symptoms of dyspnea, chestpain, syncope, or congestive heart failure.

An intracardiac rupture of the aneu-rysm into the right atrium, right ventri-cle, or both right atrium and ventricle ispossible, leading to shunting with pro-gressive congestive heart failure; also,the aneurysm might dissect into the in-terventricular septum (62), which mayresult in complete heart blockage, requir-ing a permanent pacemaker. An extracar-diac rupture of the aneurysm into thepericardium might be fatal.

An SVA (ruptured or nonruptured)can be seen with TTE (transthoracicechocardiography) parasternal short-axisview or TEE aortic valve short-axis view.A nonruptured SVA will be seen as a thin-ner wall and is larger than other sinuses.If ruptured, color Doppler will show acontinuous turbulent jet within the an-eurysm into the receiving chamber. If theaneurysm ruptured into the right atrium,the flow will be continuous during bothsystole and diastole. If it ruptured intothe left ventricle, the flow will occur onlyduring diastole. Other features might in-clude volume overload in the rightatrium and ventricle in the case of rightsinus of Valsalva to right atrium shunt(the most common). In cases of left SVAto left ventricle shunt, the volume over-load will be seen in the left ventricle. Anassociated ventriculoseptal defect mayalso be seen with the SVA.

The treatment options are beyond thescope of this article, but the main strat-egies for treatment include:

Observe (noncomplicated asymptom-atic cases) for this case, follow-up withechocardiography to evaluate the sizeof the aneurysm is needed.

Catheter closure, which is done withthe help of fluoroscopy and TEE (63–66).

Surgical treatment, for which echocar-diography is needed to look for theassociated lesion before surgery and tomake sure the aneurysm is adequatelytreated and no further shunt exists af-ter bypass.

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