Coronary CTA co-registration for guiding antegrade dissection re-entry in chronic total occlusion percutaneous coronary intervention

The simultaneous display of the proximal cap and distal CTO segment (including the localization of calcifications) on CTA offers the unprecedented opportunity for influencing ADR.² Herein, we present the emerging application of CTA co-registration for guiding ADR strategy in CTO PCI by: 1) clarification of proximal cap ambiguity, 2) navigation of intra-CTO dissection trajectory and 3) selection of the most optimal re-entry site. We believe that wider adoption of CTA might improve the efficiency and success rates of ADR.     

Radiological evaluation of the ascending aorta following repair of type A dissection

A patient with persistent chronic dissection proximal to an aortic interposition graft for repair of a type A dissection prompted us to review the computed tomographic (CT) findings in 14 other such patients 5–47 months after surgery. No other case of proximal aortic dissection was identified although dilatation of the aortic root proximal to the graft was present in 8 patients (57%). Persistent dissection distal to the graft in 11 patients (79%) was in keeping with that reported by other workers. Chronic dissection proximal to the surgical repair of a dissection seems a rare although important complication     

椎基底动脉夹层瘤的影像学特征和介入治疗策略

目的　总结椎基底动脉夹层瘤的影像诊断和介入治疗经验。方法　收治临床表现为蛛网膜下腔出血 ,小脑梗死或基底动脉供血不足的椎基底动脉夹层患者 4 8例 ,全部病人进行DSA ,部分作CTA或MRA。 4例患者行单纯口服抗凝治疗 ,6例行血管内孤立治疗 ,4例行单纯血管内支架植入治疗(其中 2例行双支架植入 ) ,34例行支架植入加弹簧圈栓塞治疗。结果　无患者出现严重并发症或再次出血 ,椎基底动脉供血不足者临床症状明显改善 ,无手术死亡病例。结论　椎基底动脉夹层瘤好发于椎动脉PICA上段 ,内膜剥脱造成的血管内充盈缺损、血管狭窄和膨大相混杂呈串珠状或血管线样狭窄、偏心性动脉瘤为椎基底动脉的主要影像学特征。治疗策略应根据临床症状、夹层瘤的部位、形态及其与周围分支的关系而确定。对影像表现为血管轻度狭窄的缺血性颅内外夹层瘤可行药物抗凝治疗 ;对狭窄较重 ,尤其是累及基底动脉者可行支架植入。对出血的颅内夹层瘤均应手术治疗 :非供血主干侧PICA上段或PICA下段夹层瘤可行血管内隔绝 ;与PICA或前脊髓动脉毗邻者行支架植入加弹簧圈栓塞 ;累及PICA或前脊髓动脉者行近端闭塞 ,支架植入或外科手术治疗。优势供血侧或侧支循环不足的椎基底动脉夹层瘤应作支架植入加弹簧圈栓塞治疗。随着支架性能的不断改进     

Vertebral artery dissection: spectrum of imaging findings with emphasis on angiography and correlation with clinical presentation.

A study was performed to evaluate the relationship between the imaging features and clinical presentation of vertebral artery (VA) dissection. Twenty-two patients with 24 VA dissections at angiography and clinical evaluation also underwent computed tomography and magnetic resonance imaging. The angiographic patterns of VA dissection were categorized as aneurysmal (n = 10) or steno-occlusive (n = 14). All 10 patients (10 lesions) with the aneurysmal pattern had dissection in the V4 (intradural) segment and presented with headache (n = 5), neurologic deficit (n = 2), dizziness (n = 2), or altered mentality (n = 1). However, the 12 patients (14 lesions) with the steno-occlusive pattern had dissection from the V1 segment to the V4 segment and presented with neurologic deficits caused by infarction of an embolic nature. Overall, the most frequent VA dissection site was the V4 segment. The distribution of the dissection sites and the clinical presentation tended to differ according to the angiographic patterns of aneurysm or stenosis-occlusion.     

Accordion effect during carotid artery stenting

Introduction The term “accordion effect” is used to describe a mechanical distortion of tortuous arteries mimicking spasm or dissection. This phenomenon has been reported in patients undergoing percutaneous coronary intervention. To our knowledge, this is the first documentation of the accordion effect during carotid artery intervention. Methods Two patients who developed the accordion effect during carotid artery stenting (CAS) are described. Results Angiograms obtained just after CAS showed a stenosing lesion with wall irregularity at the distal part of the stent. This lesion disappeared and tortuosity of the internal carotid artery developed after withdrawing the guidewire until its floppy segment rested equally on the lesion. In another patient, the lesion did not disappear completely until the guiding catheter had been withdrawn to the proximal portion of the common carotid artery. We conclude that these stenosing lesions reflected the accordion effect. Conclusion It is essential to differentiate the accordion effect from dissection, spasm, and thrombosis because the management is importantly different. We report our findings and present a review of the literature.     

128层螺旋CTA对自发性孤立性肠系膜上动脉夹层的诊断

目的探讨64排128层螺旋CTA对自发性孤立性肠系膜上动脉夹层(spontaneous isolated superior mesen-terric artery disection,SISMAD)的显示方法及诊断价值。方法回顾性分析64排128层螺旋CTA诊断SISMAD的患者资料8例,总结及优化扫描方案,采用多种后处理方法显示。结果共诊断SISMAD 8例,SISMAD起止的长度在10～75 mm之间;夹层发生的部位7例靠近于肠系膜上动脉(SMA)近段,其中3例发生于SMA近心端距SMA开口处约10～30 mm;1例起于发出胰十二指肠下动脉后。发现3处及以上破口的SISMAD 5例,发现2处破口1例,发现1处破口2例。部分假腔内可见血栓形成。结论 SISMAD涉及的多种病理改变64排128层螺旋CTA均可清楚显示,可作为诊断SISMAD的首选影像学检查手段。     

大鼠坐骨神经损伤后雪旺细胞、层粘连蛋白动态变化研究

目的 研究大鼠坐骨神经损伤后的变性以及其再生过程中雪旺细胞（Schwann cell,SC)、层粘连蛋白（laminin,LN)变化规律。方法 用硅胶管桥接大鼠（60只）左侧坐骨神经缺损（缺损长6mm)，分别于伤后3、7、15、30、60、90天用免疫组化方法检测损伤神经近、远端和新生神经中段雪旺细胞，层粘连蛋白的表达。结果 损伤神经近、远SC和LN均于伤后30天达增殖高峰，新生神经中段LN的增殖于伤后60天达高峰，近端SC和LN的数量多于远端，LN在神经损伤区存在明显的浓度梯度。结论 LN的表达依赖于SC的增殖，LN的浓度梯度引导神经生长和雪旺细胞迁移的方向。     

肘前穿支皮瓣的解剖与临床应用

目的 探讨肘前穿支皮瓣解剖、供区的设计和临床应用. 方法通过10侧尸体解剖,应用红、黄、蓝三色乳胶灌注研究皮瓣的血管、神经的起源、走行、分支、外径、分布及其吻合情况,一侧新鲜尸体标本行墨汁注射测量皮瓣面积,根据肘前穿支皮瓣血供来源及其与前臂筋膜皮肤血供的相互关系,设计肘前穿支皮瓣.利用近端蒂肘前穿支皮瓣转位修复肘部各方位的皮肤软组织缺损、远端蒂肘前穿支皮瓣修复前臂中下段掌背侧皮肤软组织缺损共7例. 结果术后皮瓣完全成活,创面Ⅰ期愈合.经3～15个月随访,皮瓣质地优良,色泽接近正常,外形美观.结论 肘前穿支皮瓣解剖位置恒定,血液供应良好,手术方法简单、安全,为修复肘部、前臂中下段皮肤软组织的缺损提供一种新的术式,可供临床选择.     

多层螺旋CT冠状动脉成像临床应用价值探讨

目的 探讨冠状动脉多层螺旋CT成像的临床应用价值。资料与方法 38例冠状动脉进行多层螺旋CT血管造影,利用多种重建方法进行重建,分析冠状动脉的成像质量及其显示率,以及冠状动脉疾病的影像特点。结果 图像质量的优良率：优28．9％(11／38),良60．5％(23／38),差10．5％(4／38),优良率为89．5％(34／38);冠状动脉分段显示率为：右冠状动脉近段100％(38／38),中段76．3％(29／38),远段60．5％(23／38);左冠状动脉前降支近中段100％(38／38),远段81．6％(31／38),左回旋支近段100％(38／38),远段55．3％(21／38)。发现冠状动脉管壁欠光滑18例,钙化8例,管腔充盈缺损2例,冠状动脉仿真内镜发现冠状动脉夹层1例,管腔狭窄3例。结论 多层螺旋CT冠状动脉成像可以作为冠心病的一种筛选手段。     

Endovascular Stenting and Stent-graft Repair of a Hemorrhagic Superior Mesenteric Artery Pseudoaneurysm and Dissection Associated with Pancreaticoduodenectomy

This report presents a 73-year-old woman with intraperitoneal bleeding from a superior mesenteric artery (SMA) pseudoaneurysm and dissection after pancreaticoduodenectomy (PD). A self-expanding bare metal stent was placed in the distal SMA across the area of dissection, and a stent-graft was subsequently placed across the pseudoaneurysm emerging from the proximal site by overlapping the bare stent, resulting in complete exclusion of the pseudoaneurysm and control of the dissection. Bleeding was controlled after the endovascular procedure. The combination of endovascular stenting and stent-graft repair is feasible and useful in comorbid cases of SMA pseudoaneurysm and dissection.     

The spontaneous regression of a dissection of the descending aorta

The outcome of an aortic dissection is either endothelialisation of the false lumen forming a so-called double aorta, or thrombosis of the sack leading to fibrosis. Healing of an aortic dissection, particularly if thrombosis and organisation have obliterated the dissected segment, is rare and there are only a few case reports on this finding. We report on a case where spontaneous resolution of the false lumen of Type B aortic dissection was demonstrated by serial contrast enhanced computed tomography after antihypertensive medical treatment.     

Acute Myocardial Infarction Due to Spontaneous Dissection of the Right Coronary Artery in a Young Male

Spontaneous coronary artery dissection is a rare cause of acute myocardial infarction. We report a case of a 33-year-old male who presented with an acute inferior myocardial infarction. Coronary arteriography performed 3 hours after the episode revealed a dissection involving the middle segment of right coronary artery. Because of a spiral form of dissection and the TIMI 3 flow grade, our patient was treated medically and repeat coronary angiography 6 months later was decided.     

CT recognition of acute aortic dissection

Twenty-six patients with suspected acute aortic dissection were investigated using computed tomography (CT) as the primary mode of investigation. The diagnosis was controlled by aortography or surgery or both. There were no false-positive or false-negative studies using CT. Aortography was performed on 19 of the 21 patients with aortic dissection and was positive in each instance. However, in two illustrated cases, CT indicated proximal or type A aortic dissection, whereas the corresponding aortograms indicated distal or type B aortic dissection. In two of the 21 acute aortic dissections, only CT was performed, and in both instances surgical confirmation was obtained. The results suggest that CT is at least as accurate as aortography in the diagnosis of acute aortic dissection.     

特殊类型主动脉夹层的电子束CT表现及诊断

目的探讨表现特殊的主动脉夹层的电子束CT(EBCT)影像特征及诊断.材料和方法20例表现特殊的主动脉夹层,其中不典型夹层13例,三腔以上夹层动脉瘤3例,合并升主动脉壁内血肿的Stanford B型夹层2例,动脉瘤样夹层1例,外伤性主动脉夹层1例.结果主动脉不典型夹层为主动脉壁新月形或环形的低密度血肿包绕,常可见穿透性溃疡或钙化内移等征象;三腔以上夹层动脉瘤有2～3个内膜片,3～4个腔,瘤体管径较大;合并升主动脉壁内血肿的B型夹层见升主动脉管壁低密度新月形或环形增厚,降主动脉则见内膜片及真假两腔形成;动脉瘤样主动脉夹层见降主动脉局限性瘤样扩张,破口大,内膜片不易发现.1例外伤性夹层于主动脉弓峡部及降部起始见破裂内膜片.结论特殊类型的主动脉夹层表现各具特征,EBCT可清晰显示,是极适用于胸部急症的快速、无创的检查方法.     

覆膜支架治疗降胸主动脉瘤

目的评估覆膜支架治疗术治疗Stanford B型主动脉夹层和降主动脉瘤的安全性和近期疗效。方法2003年3月至2005年9月期间,共29例Stanford B型主动脉夹层和2例降胸主动脉瘤患者接受覆膜支架治疗术,所有患者均有高血压病史,其中急性发病27例.本组采用两种支架(Mdtronic Talent15例,上海微创Aegis 16例),术后采用CTA进行定期随访。结果所有支架均成功按预期定位释放,术后即刻DSA复查显示23例夹层患者近端破裂口完全封闭,2例降主动脉瘤也完全隔离,6例发现有内漏;术后7 d CTA复查发现16例假腔内完全血栓形成,12例近端假腔形成血栓,远端假腔仍开放。结论覆膜支架术治疗Stanford B型主动脉夹层和降主动脉瘤安全、有效,可替代外科手术。但覆膜支架术的确切长期疗效尚待进一步的大样本、前瞻性对照研究才能确定。     

Traumatic pseudo-aneurysm and dissection of the thoracic aorta in the presence of an aberrant right subclavian artery: value of multi-slice helical CT

A case of traumatic pseudo-aneurysm and dissection of the proximal descending thoracic aorta in association with an aberrant right subclavian artery and a common trunk for both common carotid arteries is presented. The diagnosis of this traumatic pseudo-aneurysm and dissection in association with these congenital anomalies by means of a multi-slice helical CT is discussed. To our knowledge, this is the first such case reported in the literature. Received: 10 December 1999; Revised: 15 March 2000; Accepted: 4 April 2000     

Isolated posterior cerebral artery dissection: report of three cases

Isolated dissection of the posterior cerebral artery (PCA) is a rare but important cause of stroke in younger patients, particularly women. We present 3 cases of dissection of the P2 segment of the PCA. In 2 patients, an association with minor axial head trauma was documented, suggesting shearing injury of the PCA as it crosses over the free edge of the tentorium. The clinical and imaging findings are discussed, and the therapeutic management is reviewed.     

Treatment of Stanford type B aortic dissection with stent-grafts: preliminary results

PURPOSE: To evaluate the feasibility and safety of endovascular stent-graft placement in treating Stanford type B aortic dissection. MATERIALS AND METHODS: Seven patients underwent endovascular stent-graft placement for type B aortic dissection. Five patients had acute and two had chronic dissection. In five patients, the proximal entry tear was within 2 cm of the origin of the left subclavian artery, and in two patients it was beyond this site. In three patients, the noncovered proximal portion of the stent-graft was placed across the origin of the left subclavian artery. The efficacy of the procedure was assessed at follow-up studies 3, 6, 12, and 24 months after intervention. RESULTS: The procedure was technically and clinically successful in six patients (86%). The left subclavian artery remained patent in all patients. In two patients with involvement of aortic branches, endovascular stent-graft placement restored adequate blood flow to the compromised branches. One patient was readmitted 1 month later because the dissection extended into the ascending aorta. In all but this patient, closure of the entry tear and thrombosis of the false lumen along the stent-graft were achieved. All false lumina shrank considerably. The mean follow-up time was 14 months (range, 1-25 months). CONCLUSION: Type B aortic dissections within and beyond 2 cm of the origin of the left subclavian artery can be treated safely and effectively by means of endovascular stent-graft placement.     

Computed tomography evaluation of traumatic rupture of the thoracic aorta: an outcome study.

OBJECTIVE: [corrected] To assess the long-term outcome of blunt trauma patients with suspected thoracic aortic or great vessel injury that was evaluated with contrast-enhanced chest computed tomography (CT). METHODS: We studied the outcome of 278 consecutive patients who received contrast-enhanced CT for blunt chest trauma with computerized searches of the regional trauma database, hospital medical records, universal government medical coverage plan billing records, and regional vital statistics databases. Data retrieved included patient demographics, mechanism of injury, status of the aorta and proximal great vessels at contrast-enhanced CT, hospital discharge diagnoses, and outpatient procedural billings with specific attention to aortic or great vessel injury. Median follow-up was 615 days following the traumatic event. RESULTS: Six subjects demonstrated direct signs of aortic or proximal great vessel injury on contrast-enhanced chest CT, as follows: aortic pseudoaneurysm and intimal flap (n = 4), carotid artery dissection (n = 1), and aortic dissection (n = 1). All were surgically treated, except the patient with aortic dissection, who was treated medically. In the other subjects, contrast-enhanced CT was negative (n = 230) or showed isolated mediastinal hematoma (n = 42). The computerized searches of the medical databases showed that none of these 272 subjects had procedures for, or died from, aortic or great vessel injury during the follow-up period. CONCLUSION: Computerized searches of medical databases found no evidence of missed thoracic aortic or proximal great vessel injury in blunt trauma patients who were evaluated with contrast-enhanced chest CT.     

Coil embolisation for ruptured vertebral artery dissection distal to the origin of the posterior inferior cerebellar artery

Although many surgical or endovascular treatments for ruptured vertebral artery dissection have been reported, the best treatment is controversial. We treated five cases of ruptured vertebral artery dissection distal to the origin of the posterior inferior cerebellar artery (PICA), using retrievable platinum coils packed in the dissection site and the immediately proximal vertebral artery. All patients had a contralateral vertebral artery of the same calibre or larger. All dissections were occluded completely, together with the portion of the vertebral artery distal to the PICA origin. No complications related to the procedure were seen. The purpose of the treatment is to isolate the dissection from the cerebral circulation. Occlusion of the rupture site, preserving perforating arteries arising from the vertebral artery, would be ideal. Short-segment occlusion by retrievable platinum coils is close to the ideal. Received: 21 December 1998/Accepted: 21 July 1999