Optimal Guidance for Intimal Flap Fenestration in Aortic Dissection by Transvenous Two-Dimensional and Doppler Ultrasonography
Transvenous multi-modal ultrasound can safely guide percutaneous fenestration of an intimal flap. It provides longitudinal image planes of the dissected aorta and possibly involved distal vessels. The following case shows that the intimal flap may be extremely resistant to penetration with intravascular needle devices. In a 61-year-old man with type B dissection and consecutive intestinal and left renal mal- perfusion, a Brockenbrough needle-catheter was introduced into the true aortic lumen in an unsuccessful attempt to perforate the flap. Next, a multi-modal, phased array transducer-tipped AcuNav-Catheter (Siemens-Acuson Inc) was positioned in the inferior vena cava and aimed at the neighboring aorta (Figure 1). Longitudinal image planes revealed true lumen collapse and almost no flow in the false lumen. It became evident that advancement of the needle made it only scrape along the flap, which resisted perforation (Figure 2). Finally, the flap was perforated and then fenestrated in another attempt guided by transvenous ultrasound. The resulting effected large entry markedly improved flow in both lumina (Figure 3). Subsequently, plasma creatinine (268 μmol/L before fenestration versus 171 μmol/L after 7 days and 89 μmol/L another 7 days later) and lactate levels (3.53 mmol/L versus 1.41 mmol/L after 1 day and 0.90 mmol/L 2 days later) decreased (see also Movies I through VIII).
Movies I through VIII are available as an online-only Data Supplement at http://www.circulationaha.org.
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.
Circulation encourages readers to submit cardiovascular images to the Circulation Editorial Office, St Luke’s Episcopal Hospital/Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.