Rotational Aortogram With Three-Dimensional Reconstruction in a Case of Repaired Aortic Coarctation
A 54-year-old white woman with a history of hypertension, hyperlipidemia, atrial fibrillation, bicuspid aortic valve, and a previously repaired aortic coarctation in adulthood underwent a computed tomography (CT) scan of the chest to evaluate her surgical repair after an episode of chest pain. Her original repair consisted of a coarctectomy with placement of a side-to-side graft. The CT scan revealed a 4-cm, proximal descending thoracic aortic aneurysm in the repaired portion of the aorta. Magnetic resonance angiography (MRA) and a conventional aortogram did not clarify the underlying problem. She was referred to our center for further investigation and possible surgical or endovascular repair.
We performed a rotational aortogram with 3D reconstruction to solve the anatomic enigma (Figure). The study showed a prosthetic graft placed at the site of the coarctectomy, between the midportion of the aortic arch and the descending thoracic aorta, with the left subclavian artery and left carotid artery reimplanted into the proximal portion of the graft. Two aortic stumps left from the previous surgical repair were visualized. One smaller stump was located at the proximal end-to-side anastomosis of the graft with the aortic arch. A larger distal stump was located adjacent to the distal end-to-side anastomosis of the prosthetic graft with the descending thoracic aorta. The distal aortic stump and the graft were very close together, giving the impression of a dilatation in the repaired portion of the proximal descending aorta on the CT and MRA scans. The diameter of the graft and the distal stump together was exactly 4 cm. This corresponded to the size measured by the previous radiological studies that was reported as an aortic aneurysm. The patient was discharged with no further intervention after her anatomical conundrum was solved.
Rotational aortography with 3D reconstruction is a new angiographic technique currently under clinical development. It consists of a 180-degree fast rotation (22.5 degrees/second) of the C-arm around the plane of imaging while a bolus of contrast is injected through a power injector with a pigtail catheter in the area of intereSt. This motion creates a real-time 3D picture of the structures studied. The images are processed by specialized software to create a 3D tomographic model, which can be rotated around its 3 axes to establish an optimal viewing plane. Measurements of diameters, lengths, cross-sectional areas, and volumes can be done in any position or angle, with a high degree of precision and great definition of the underlying anatomy. The superior resolution of the 3D aortic tomographic reconstruction thus avoided further diagnostic tests and a possible exploratory thoracotomy for a presumed repaired aortic coarctation aneurysm.
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke’s Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
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