Intraprocedural imaging: Thoracic aortography techniques, intravascular ultrasound, and special equipment Rodney A. White, MD, Carlos E. Donayre, MD,

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Presentation transcript:

Intraprocedural imaging: Thoracic aortography techniques, intravascular ultrasound, and special equipment Rodney A. White, MD, Carlos E. Donayre, MD, Irwin Walot, MD, George E. Kopchok, BS Journal of Vascular Surgery Volume 43, Issue 2, Pages A53-A61 (February 2006) DOI: 10.1016/j.jvs.2005.11.003 Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 1 Organization of the interventional suite provides all key personnel with an unobstructed view of procedural images. A, B, C are Primary Interventionalist Assistants H is; an Xray Technician. Journal of Vascular Surgery 2006 43, A53-A61DOI: (10.1016/j.jvs.2005.11.003) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 2 Long back table extension of the interventional table for preparation and passage of equipment and devices. Inset demonstrates the hemostatic valve and tapered tip that are recommended for large-diameter Check-Flow sheaths compared with the adjacent Keller-Timmerman sheath on the table (arrow). Journal of Vascular Surgery 2006 43, A53-A61DOI: (10.1016/j.jvs.2005.11.003) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 3 Large-diameter (40 to 46 mm) compliant balloons: (a) Gore Trilobe, (b) Boston-Scientific Equalizer, (c) Cook Coda, and (d) Medtronic Reliant. Journal of Vascular Surgery 2006 43, A53-A61DOI: (10.1016/j.jvs.2005.11.003) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 4 Pigtail catheter (black arrow) inserted via right radial artery for visualization of the origin of the brachiocephalic arteries from the aortic arch during the procedure. The white arrow points to an intravascular ultrasound probe positioned at the origin of the left carotid artery from the bovine innominate. Journal of Vascular Surgery 2006 43, A53-A61DOI: (10.1016/j.jvs.2005.11.003) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 5 Starter wire (single arrow) advanced from the left radial artery across the origin of the left subclavian artery from the aorta. Intravascular ultrasound (IVUS) probe (double arrows) demonstrates IVUS image from the aortic lumen (a) at the origin of the subclavian artery (s). Journal of Vascular Surgery 2006 43, A53-A61DOI: (10.1016/j.jvs.2005.11.003) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 6 Example of gantry angle correction after deployment of a Talent thoracic device, demonstrates (a) angulations between anterior (black line) and posterior (white line) ends of the stents on the proximal end of the device, and (b) additional 20° left anterior oblique angulations rotate the stents in the image that is rotated so anterior and posterior stents are aligned. This figure also demonstrates the utility of wires with radiopaque, atraumatic proximal tips to aid in identifying the wire in the ascending aorta. Journal of Vascular Surgery 2006 43, A53-A61DOI: (10.1016/j.jvs.2005.11.003) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 7 Angiographic assessment of the origin of a nearly occluded celiac artery origin (arrow) with a distal extension thoracic device having an open wire configuration positioned for deployment. The end of the cloth-covered portion of the device is identified by figure 8 markers. Double arrows point to patent superior mesenteric artery. Journal of Vascular Surgery 2006 43, A53-A61DOI: (10.1016/j.jvs.2005.11.003) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 8 Top, Monorail intravascular ultrasound (IVUS) catheter (left) with image artifact (right) produced by attenuation of the ultrasound energy by the wire (thick arrow) compared with attenuation of the signal by calcified arterial plaque (thin arrows). Bottom left, IVUS catheter with phase-array imaging elements positioned over a wire through the center of the catheter produces 360° vessel images. Right, Phase array image of the abdominal aorta at the origin of the left renal artery (L) with the renal vein (V) coursing over the superior aspect of the aorta. Journal of Vascular Surgery 2006 43, A53-A61DOI: (10.1016/j.jvs.2005.11.003) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 9 Intravascular ultrasound images of (a) transverse thoracic aorta with adjacent innominate vein and soft tissue in the mediastinum on the superior aspect; (b) soft plaque (double arrows) in an iliac artery with monorail wire artifact (a) disrupting the image of the normal appearing iliac artery wall (single arrow); (c) descending aortic dissection with septum (arrow) between the true and false lumens (f) with stagnation of flow in the false lumen; and (d) natural fenestration (re-entry) of flow at the origin of the superior mesenteric artery (arrow). Journal of Vascular Surgery 2006 43, A53-A61DOI: (10.1016/j.jvs.2005.11.003) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 10 Intravascular ultrasound (IVUS) images acquired with the catheter lying in the true lumen demonstrating (a) transverse arch at the origin of the carotid artery (c), (b) origin of the subclavian artery (s), (c) chronic dissection with the IVUS probe in the true lumen (t), and (d) re-entry tear at the origin of the right renal artery (arrow). Journal of Vascular Surgery 2006 43, A53-A61DOI: (10.1016/j.jvs.2005.11.003) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions

Fig 11 Intravascular ultrasound (IVUS) images before (left) and after (right) endograft deployment over the entry site of a type B descending thoracic aortic dissection (arrows). After device deployment, IVUS confirms enlargement and return of pulsatile flow to the true lumen with stagnation of flow in the false lumen (f). Both images were acquired from the same area in the descending aorta just above the origin of the celiac artery. Journal of Vascular Surgery 2006 43, A53-A61DOI: (10.1016/j.jvs.2005.11.003) Copyright © 2006 The Society for Vascular Surgery Terms and Conditions