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    Dissection Octobre 2019

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    ARMVOP
    1. CT is the preferred initial imaging modality for acute aortic syndromes like dissection due to its wide availability, short acquisition time, ability to accurately classify and assess complications of dissections, and coverage of the entire aorta. 2. CT can identify intimal tears, extensions, complications involving side branches and organs, and is useful for endovascular repair planning. 3. Follow up is generally done with CT, while MRI may provide additional information for risk stratification or detection of endoleaks after endovascular repair.

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    Dissection Octobre 2019

    Uploaded by

    ARMVOP
    158 views48 pages
    1. CT is the preferred initial imaging modality for acute aortic syndromes like dissection due to its wide availability, short acquisition time, ability to accurately classify and assess complications of dissections, and coverage of the entire aorta. 2. CT can identify intimal tears, extensions, complications involving side branches and organs, and is useful for endovascular repair planning. 3. Follow up is generally done with CT, while MRI may provide additional information for risk stratification or detection of endoleaks after endovascular repair.

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    Dissection Octobre 2019

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    1. CT is the preferred initial imaging modality for acute aortic syndromes like dissection due to its wide availability, short acquisition time, ability to accurately classify and assess complications of dissections, and coverage of the entire aorta. 2. CT can identify intimal tears, extensions, complications involving side branches and organs, and is useful for endovascular repair planning. 3. Follow up is generally done with CT, while MRI may provide additional information for risk stratification or detection of endoleaks after endovascular repair.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    158 views48 pages

    Dissection Octobre 2019

    Uploaded by

    ARMVOP
    1. CT is the preferred initial imaging modality for acute aortic syndromes like dissection due to its wide availability, short acquisition time, ability to accurately classify and assess complications of dissections, and coverage of the entire aorta. 2. CT can identify intimal tears, extensions, complications involving side branches and organs, and is useful for endovascular repair planning. 3. Follow up is generally done with CT, while MRI may provide additional information for risk stratification or detection of endoleaks after endovascular repair.

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    Download as pptx, pdf, or txt
    of 48

    Imagerie des

    Dissections
    Aortiques (CT, IRM)
    12.10.2019 – ARMVOP 2019 ENGHIEN-LES-BAINS

    Arshid AZARINE MD, Msc


    Imaging Department
    Hôpital Paris Saint Joseph
    Dissection
    Aortique:
    Le Scanner
     Accessible
     Acquisition Rapide et
    facile
     Couverture large
     Diagnostic précis
     Extension
     Classification
     Complications
     Portes d’entrée et de ré
    entrée…
     …mais Rx
    Aortic Dissection:
    Accuracy of different imaging modalities

    Mussa et al. JAMA 2016


    Localisation: Synchronisation ECG+++
    = Classification

    ESC Guidelines. EHJ 2014


    Acquisition rapide
    Facile à réaliser
    Large couverture
    Accessible quasiment partout
    Données 3D analysable a posteriori
    Suspicion de dissection aortique:
    Quel protocole d’acquisition?

    Angio-TDM : intérêt d’une 2°spirale « tardive »


    Suspicion de dissection
    aortique: Quel protocole
    d’acquisition?

    SS IV : temps artériel temps tardif


    Croissant
    Spontanément hyperdense
    = Hématome pariétal ou hématome disséquant
    CT: acquisition

    1. Non contrast 2. Arterial 3. Delayed


    • ECG gated • ECG Gated • ECG gated
    • Iodinated Contrast • 2-3’ after injection
    • 0.6-2.5mm slice
    bolus • False lumen
    • Hematome, Ca • 0.6mm slice permeability, organ
    ischaemia
    Dissection Aortique Aigue:
    Histoire Naturelle

     Mussa et al. JAMA 2016


    Acute Aortic Syndromes
     Intramural • Penetrating • Aortic
    haematoma aortic ucler dissection
    Acute Aortic Syndromes
     Intramural • Penetrating • Aortic
    haematoma aortic ucler dissection
    Type A IMH: Urgent surgery
    IMH Diagnosis

    • Crescentic Thicknessing
    • High attenuation
    • No flap
    Acute Aortic Syndromes
     Intramural • Penetrating • Aortic
    haematoma aortic ucler dissection
    Penetrating aortic ucler
     Ulceration of an atherosclerotic plaque
    penetrating into the media
     Middle and lower descending aorta
     Ascending aorta Involvement rare
     Older male, hypertension, smoking, CAD.
     Lead to IMH, pseudoaneurysm, AD
    Penetrating aortic ulcer: Diagnosis + sizing for TEVAR
    Acute Aortic Syndromes
     Intramural • Penetrating • Aortic
    haematoma aortic ucler dissection
    Aortic dissection: diagnosis

     Intimal flap
    Tears localization, extension

    Ascending Arch Descending

    TEVAR?
    Valve Ao
    + Bentall
    + TEVAR
    CT Depicting complications:
    Pericardial effusion
    Pericardial effusion
    Low
    attenuation High attenuation

    Non hematic Hemopericardium


    Pericardial
    effusion, rupture
    High attenuation

    Hemopericardiu
    m
    CT Depicting complications:
    Pleural effusion
    CT Depicting complications:
    Coronary involvement
    CT Depicting complications:
    Aortic Valve?
    CT Depicting complications:
    Supra aortic trunk
    CT et Dissection aortique :
    Complications
    abdominales

     Sténose aortique

     Extension aux artères viscérales

     Thrombus dans un chenal circulant

     Ischémie

     Evolution anévrysmale (14 à 30% - ATCD, controle HTA)

     Rupture (6%)
    Iliac involvement

    • Relevant before endovascular


    approach
    ?
    o Dissection/Stenosis
    o Diameter
    o Tortuosity
    Branch viceral artery
    Dynamics ischaemia:
    FC pressure>VC
    No branch flap
    Dissection de l’aorte
    abdominale

    Occlusion mixte du TC
    Branch viceral artery

     Flap involvement
    Branch viceral artery

     Ostial tear

    Surveiller la taille des Reins

    Traité d’imagerie médicale, Pr NAHUM (Flammarion)


    Dissection de l’aorte abdominale

    Sténose statique de l’AMS


    Dissection de l’aorte abdominale

    Occlusion dynamique de l’ARD


    Organ malperfusion
    Organ malperfusion: mauvais pronostic

    Tolenaar et al IRAD, Circulation 2014


    CT Weakness

    Baliga et al. JACC imaging


    Aims of imaging in acute aortic
    syndromes:
    High sensibility and specificity
     Availability, short acquisition time
     Classification, extent
     Entry and re-entry tears localization
     Complications
     Pericardial effusion, pleural effusion
     Aortic valve Involvement
     Side branch involvement
     Coronary artery involvement
     Malperfusion
    TTE accuracy?

     For aortic dissection diagnosis


     Sensitivity 59 to 83%
     Type A: 78 to 100%
     Type B: 31 to 51%
     Specificity 63 to 93%

     For IMH >5mm


     Sensitivity < 40%

    “TTE cannot be used as the sole imaging technique


    in patients with suspected AAS”
    Baliga et al. JACC imaging
    2014 ESC Guidelines. EHJ 2014
    Time to diagnosis?
    International registry of Acute aortic dissection (IRAD)

    Harris et al, Circulation 2011


    Suivi post-op Dissection type A: plutôt Scanner

    Anastomose
    distale

    Azarine et al. Heart 2005 Faux anévrysmes des anastomoses


    IRM Aortique : Ciné

    Suivie des
    Dissection
    aortique B

    Écho de spin

    Angiographie
    Evolution des chenaux ?
    Evolution anévrysmale?
    Smaller, Early and homogenous
    enhancement, Low angle
    True lumen
    Surrounded Calcification

    Acute angle

    False lumen Thrombus

    Thin membranes

    Traité d’imagerie médicale, Pr NAHUM (Flammarion)


    Aortic dissection : 4D Flow MRI
    Type A dissection
    False aneurysm

    True lumen
    4D Flow MR : Follow up aortic dissection

    No regression of the size of the false


    lumen was noted after TEVAR.
    TYPE I or II endoleak?
    4D Flow MRI demonstrates systolic
    type 1 proximal endoleak (arrow).
    EVAR: Type II b Endoleak

    IMA

    LA
    LA

    L= AORTIC LUMEN, LA= LOMBAR ARTERIES, E= ENDOLEAK, IMA=


    INFERIOR MESENTERIC ARTERY
    4D Flow MR in Aortic Disease
    Wall Sheer Stress
    Marker or dissection?

    WWS Increased
    Diastole Flow derived WWS
    during Systole
    CONCLUSION
     CT is essential in diagnosis of acute aortic disease and could be
    the first line imaging.
     Widespread availability
     Reliability
     Short acquisition time
     Re reading
     CT : entire aorta coverage
     Tears localization
     Coronary involvement
     Pericardial effusion
     Organ malperfusion
     Side branch involvement
     Endovascular repair planning
     MR for follow up or risk stratification

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