Role of contrast-enhanced helical CT in the evaluation of acute thoracic aortic injuries after blunt chest trauma

The purpose of this retrospective study was to determine the value of contrast-enhanced helical CT for detecting and managing acute thoracic aortic injury (ATAI). Between June 1995 and February 2000, 1419 consecutive chest CT examinations were performed in the setting of major blunt trauma. The following CT findings were considered indicative of ATAI: intimal flap; pseudoaneurysm; contour irregularity; lumen abnormality; and extravasation of contrast material. On the basis of these direct findings no further diagnostic investigations were performed. Isolated mediastinal hematoma on CT scans was considered an indirect sign of ATAI: In these cases, thoracic aortography was performed even if CT indicated normal aorta. Seventy-seven patients had abnormal CT scans: Among the 23 patients with direct CT signs, acute thoracic aortic injuries was confirmed at thoracotomy in 21. Two false-positive cases were observed. The 54 remaining patients had isolated mediastinal hematoma without aortic injuries at CT and corresponding negative angiograms. The 1342 patients with negative CT scans were included in the 8-month follow-up program and did not show any adverse sequela based on clinical and radiographic criteria. Contrast-enhanced helical CT has a critical role in the exclusion of thoracic aortic injuries in patient with major blunt chest trauma and prevents unnecessary thoracic aortography. Direct CT signs of ATAI do not require further diagnostic investigations to confirm the diagnosis: Isolated aortic bands or contour vessel abnormalities should be first considered as possible artifacts or related to non-traumatic etiologies especially when mediastinal hematoma is absent. In cases of isolated mediastinal hematoma other possible sources of bleeding should be considered before directing patients to thoracic aortography.     

Detection of prosthetic vascular complications: comparison of CT and angiography

The value of CT and angiography to detect complications of prosthetic arterial grafting was compared in 24 patients. There was a total of 27 grafts including 18 aortic or aortofemoral, five femoral-popliteal, two femoral-femoral, and two axillary-femoral reconstructions. Nineteen grafts were uninfected; eight were infected. In the absence of infection, the complications and the percentages detected by the two procedures were as follows: five graft occlusions (CT 80%, angiography 100%), six pseudoaneurysms (CT 100%, angiography 83%), three with perigraft fluid (CT 100%, angiography 0%), and one with pseudointimal hyperplasia (CT 100%, angiography 0%). Seven grafts were normal and without abnormalities on both CT and angiography. In the presence of infection the results were as follows: eight with perigraft fluid (CT 100%, angiography 0%), four with perigraft or intragraft gas (CT 100%, angiography 0%), three pseudoaneurysms (CT 100%, angiography 100%), two open groin wounds (CT 100%, angiography 0%), and two graft occlusions (CT 100%, angiography 100%). In addition, three patients with infected grafts had graft enteric fistulae. All three had fluid around the proximal anastomosis and two had gas around the graft as well. The data show that angiography is sufficient for patients with graft occlusion if there is no suspicion of infection, postoperative hemorrhage, or anastomotic pseudoaneurysm. In these cases CT has an ancillary role in detecting hemorrhage and defining pseudoaneurysms. CT is superior to angiography in patients with graft infection.     

CT Imaging Findings and Their Relevance to the Clinical Outcomes After Stent Graft Repair of Penetrating Aortic Ulcers: Six-year, Single-center Experience

Purpose

To present the computed tomographic (CT) imaging findings and their relevance to clinical outcomes related to stent graft placement in patients with penetrating aortic ulcers (PAUs).

Methods

Medical and imaging records and imaging studies were reviewed for consecutive patients who underwent stent graft repair of a PAU. The distribution and characteristics of the PAU, technical success of stent graft repair, procedure-related complications, associated aortic wall abnormalities, and outcomes of the PAUs at follow-up CT scans were evaluated.

Results

Fifteen patients underwent endovascular treatment for PAU. A total of 87% of the PAUs were in the proximal (n?=?8) or distal (n?=?5) descending thoracic aorta. There was a broad spectrum of PAU depth (mean, 7.9?±?5.6?mm; range 1.5–25.0?mm) and diameter (mean, 13.5?±?9.7?mm; range 2.2–41.0?mm). Atherosclerosis of the thoracic aorta and intramural hematoma were associated in 53 and 93% of the patients, respectively. Technical success was achieved in 100%. Two or more stent grafts were used in five patients. Endoleaks were observed in two patients within 2?weeks of the procedure, both of which resolved spontaneously. At follow-up CT scanning, regression and thrombosis of the PAUs were observed in all patients. The average patient survival was 61.8?months, with an overall mortality of 13% (2 of 15) at follow-up. Neither death was related to the endograft device or the PAU.

Conclusion

Endovascular stent graft placement was safe and effective in causing regression and thrombosis of PAUs in this small series of patients. Two or more stent grafts were used in five patients (33%) with associated long-segmental atherosclerotic changes of the thoracic aorta or intramural hematoma.     

The use of computed tomography in the diagnosis of coronary artery bypass graft patency

In a preliminary evaluation of the use of dynamic computed tomography (CT) for the detection of patent aortocoronary bypass grafts, 30 patients were scanned either during the early postoperative peroid or after graft patency was determined by angiography. To visualize the proximal grafts, CT scans were taken through the aortic root following an intravenous bolus injection of contrast medium. Patent bypass grafts to the left anterior descending and right coronary arteries were demonstrated in 77.5%, while posterior grafts to the circumflex and obtuse marginal coronary arteries were detected in 40%. With its pontential for extracting dynamic events, CT scanning provides a new, noninvasive modality for the diagnosis of patent bypass grafts, which heretofore have only been visualized by selective angiography.     

Descending thoracic aortic aneurysm: thoracic CT findings after endovascular stent-graft placement.

PURPOSE: To evaluate the usefulness of thoracic computed tomography (CT) after placement of an endovascular stent-graft for the treatment of descending thoracic aortic aneurysm. MATERIALS AND METHODS: From 1992 to 1996, 85 patients with thoracic aortic aneurysm underwent stent-graft placement. In 63 patients, thoracic CT scans were obtained both before and within 10 days after placement. The CT findings were retrospectively studied, and their clinical effect analyzed. In 20 of 63 patients, long-term follow-up CT findings were also evaluated. RESULTS: After stent-graft placement in the 63 patients, CT demonstrated an increase in pleural effusion in 46 (73%), periaortic changes in 21 (33%), perigraft leak in 13 (21%), atelectasis in six (10%), mural thrombus within the stent-graft in two (3%), and new aortic dissection in one (2%). The mean maximum diameter of the aneurysm was 58.8 mm before and 60.0 mm after stent-graft insertion. Sixty-two (98%) patients were successfully treated until discharge. Interventional procedures were performed to eliminate the leakage into the aneurysm sac in 10 patients with perigraft flow depicted at CT. Other complications were managed conservatively. CONCLUSION: Thoracic CT is useful in the treatment of patients after stent-graft insertion for the management of descending thoracic aortic aneurysm.     

Postoperative CT follow-up of aortic dissection

Computed tomography with contrast enhancement permits noninvasive follow-up of patients treated for aortic dissection. We used CT to examine 52 patients with aortic dissections for up to 14 years postoperatively. The mean interval between surgery and CT was 32 months. Computed tomography demonstrated the aortic graft in 45 patients. Persistent patency of a false lumen was observed in 40 cases. In one case, CT demonstrated extension of the dissection. No rupture or thoracic pseudoaneurysm was noted in our series.     

Urgent thoracic aortal dissection and aneurysm: treatment with stent-graft implantation in an angiographic suite

The aim of this study was to evaluate the feasibility of endoluminal stent-graft placement in an angiographic suite for the treatment of emergent type-B aortic dissections and ruptured thoracic aortal aneurysms. Twenty-six patients with either urgent type-B dissection (n=8) or aneurysms (n=18) of the descending thoracic aorta were chosen for stent-graft implantation. All patients received a multidetector-row CT angiography of the whole aorta and pelvic arteries prior to stent-graft implantation. All procedures were performed in a fully equipped digital subtraction angiography (DSA) suite under general anesthesia. In 20 patients Talent LPS tube grafts and in 4 patients an Excluder graft were used. Access was achieved via surgical cut-down in the left (n=7) or right (n=19) groin. Sealing was successful in 24 patients. The proximal covered portion of the stent graft was placed across the left subclavian artery in 2 patients. Procedural success was achieved in 23 of 24 patients. One patient required a second stent-graft placement before the aneurysm was sealed. One patient with an acute perforation of the descending aorta died due to cardiac failure prior to stent-graft implantation. In 1 patient stent-graft delivery failed due to severe calcification of both common iliac arteries. Endoluminal treatment of both urgent type-B aortic dissections and thoracic aortal aneurysms with stent graft is an attractive alternative treatment to surgical repair. The placement of stent grafts in an angiographic suite is a safe and feasible method with good clinical effectiveness and, so far, good clinical outcome.     

Endovascular Repair of Traumatic Rupture of the Thoracic Aorta: Single-Center Experience

Purpose Traumatic rupture of the thoracic aorta secondary to blunt chest trauma is a life-threatening emergency and a common cause of death, usually following violent collisions. The objective of this retrospective report was to evaluate the efficacy of endovascular treatment of thoracic aortic disruptions with a single commercially available stent-graft. Methods Nine men (mean age 29.5 years) were admitted to our institution between January 2003 and January 2006 due to blunt aortic trauma following violent motor vehicle collisions. Plain chest radiography, spiral computed tomography, aortography, and transesophageal echocardiography were used for diagnostic purposes in all cases. All patients were diagnosed with contained extramural thoracic aortic hematomas, secondary to aortic disruption. One patient was also diagnosed with a traumatic thoracic aortic dissection, secondary to blunt trauma. All subjects were poor surgical candidates, due to major injuries such as multiple bone fractures, abdominal hematomas, and pulmonary contusions. All repairs were performed using the EndoFit (LeMaitre Vascular) stent-graft. Results Complete exclusion of the traumatic aortic disruption and pseudoaneurysm was achieved and verified at intraoperative arteriography and on CT scans, within 10 days of the repair in all patients. In 1 case the deployment of a second cuff was necessary due to a secondary endoleak. In 2 cases the left subclavian artery was occluded to achieve adequate graft fixation. No procedure-related deaths have occurred and no cardiac or peripheral vascular complications were observed within the 12 months (range 8–16 months) follow-up. Conclusions This is the first time the EndoFit graft has been utilized in the treatment of thoracic aortic disruptions secondary to chest trauma. The repair of such pathologies is technically feasible and early follow-up results are promising.     

Application of spiral computerized tomography in the study of traumatic lesions of the thoracic aorta

PURPOSE: Acute thoracic aortic injuries account for up to 10-20% of fatalities in high-speed deceleration road accidents and have an estimated immediate fatality rate of 80-90%. Untreated survivors to acute trauma (10-20%) have a dismal prognosis: 30% of them die within 6 hours, 40-50% die within 24 hours, and 90% within 4 months. We investigated the diagnostic accuracy of Helical Computed Tomography (Helical CT) in acute traumatic injuries of the thoracic aorta, and the role of this technique in the diagnostic management of trauma patients with a strong suspicion of aortic rupture. MATERIAL AND METHODS: We compared retrospectively the chest Helical CT findings of 256 trauma patients examined June 1995 through August 1999. All patients underwent a plain chest radiograph in supine recumbency when admitted to the Emergency Room. Chest Helical CT examinations were performed according to trauma score, to associated traumatic lesions and to plain chest radiographic findings. All the examinations were performed with no intravenous contrast agent administration and the pitch 2 technique. After a previous baseline study, contrast-enhanced scans were acquired with pitch 1 in 87 patients. All examinations were assessed for the presence of mediastinal hematoma, periaortic hematoma, traumatic pseudodiverticulum, irregular aortic wall or contour and intimal flap as signs of aortic rupture. RESULTS: Helical CT showed thoracic aortic lesions in 9 of 256 patients examined. In all the 9 cases we found a mediastinal hematoma and all of them had positive plain chest radiographic findings of mediastinal enlargement. Moreover, in 6 cases aortic knob blurring was also evident on plain chest film and in 5 cases depressed left mainstem bronchus and trachea deviation rightwards were observed. All aortic lesions were identified on axial scans and located at the isthmus of level. Aortic rupture was always depicted as pseudodiverticulum of the proximal descending tract and intimal flap. We also found periaortic hematoma in 6 cases and intramural hematoma in 1 case. There were no false positive results in our series: 7 patients with Helical CT diagnosis of aortic rupture were submitted to conventional aortography that confirmed both type and extension of the lesions as detected by Helical CT, and all findings were confirmed by gross inspection at surgery. No false negative results have been recorded so far: untreated aortic ruptures are fatal within 4 months in 90% of patients, or they may evolve into chronic pseudoaneurysm in about 5% of survivors. CONCLUSIONS: In our experience Helical CT had much higher diagnostic sensitivity and specificity than plain chest radiography. In agreement with larger published series, in our small one the diagnostic accuracy of Helical CT was 100% in the evaluation of traumatic aortic ruptures. Moreover, Helical CT is faster and less invasive than conventional aortography, which makes this diagnostic modality increasingly used and markedly improves the management of the serious trauma patient. The more widespread use of this diagnostic tool has permitted to standardize the technique and now Helical CT can be used not only as a screening modality for patients that undergo digital aortography, but also as a reliable diagnostic method for surgical planning.     

Normal thoracic aortic diameters by computed tomography

Although computed tomography (CT) has played an important role in evaluation of the thoracic aorta, no standards for aortic dimensions exist. To establish the range of normal variation of aortic diameters, a retrospective study of 102 chest CT studies in adults without clinical evidence of hypertension, diabetes, cardiovascular disease, or renal disease was performed. The coronal aortic diameter was measured at three levels: just beneath the aortic arch, just above the aortic valve, and at the level of the diaphragm. These measurements showed substantial variation according to age, sex, and thoracic vertebral body width. The ratio between the ascending and descending limbs of the aorta varied markedly with age; younger individuals had significantly higher ratios than older age groups. Knowledge of these values allows more precise CT evaluation in suspected aortic disease, specifically reducing the potential for "overinterpretation" of the normal, but prominent, ascending aortic root.     

Descending thoracic aortic diseases: stent-graft repair

PURPOSE: To evaluate endovascular treatment of descending thoracic aorta with commercially available self-expanding stent-grafts. MATERIALS AND METHODS: Seventy patients with aortic dissection, intramural hemorrhage, degenerative and posttraumatic aneurysm, penetrating atherosclerotic ulcer, and pseudoaneurysm underwent endovascular treatment. Eleven patients had impending rupture and were treated on an emergency basis. Stent-grafts were customized or selected on the basis of spiral computed tomographic (CT) or magnetic resonance (MR) imaging measurements. Preprocedure diagnostic angiography was performed in patients with aortic dissection and in other selected patients. All procedures were performed in an operating room and monitored with digital subtraction angiography (DSA) and transesophageal echocardiography (TEE). Follow-up was at 1, 3, 6, and 12 months after treatment and yearly thereafter. RESULTS: Stent positioning was technically successful in 68 cases. At DSA and TEE, complete aneurysm or false-lumen exclusion was achieved in 66 (97%) cases. No intraoperative mortality or complications occurred. In-hospital complications included transient monoparesis (one patient) and extension of dissection into ascending aorta (one patient) that was repaired surgically. Early endoleak was observed in five (7%) patients: In three (type 2), endoleak resolved spontaneously; in one (type 1), it was persistent; and in one (type 1), treatment was converted to surgery. At long term, one (1%) patient died of aortic rupture; another, of respiratory insufficiency. Five (7%) late endoleak (type 1, one caused by migration of the stent) cases were observed. In three (4%), endovascular treatment was successful; in two (3%), surgery was performed. In one patient with persistent postimplantation syndrome, treatment was converted to surgery after successful aneurysm sealing. Procedure failure (ie, aortic disease-related mortality or conversion to surgery) occurred in six (9%) patients. CONCLUSION: Endovascular stent-graft repair is less invasive in patients with chronic and acute descending thoracic aortic aneurysm and dissection.     

Endovaskuläre Therapie des thorakalen Aortenaneurysmas

Clinical issue of thoracic aneurysms

Aneurysms are among the most common diseases affecting the thoracic aorta, with a continuous increase in incidence over the recent decades. The main cause of thoracic aneurysms is atherosclerosis, which, due to the frequent lack of major symptoms and the potentially lethal complications such as ruptured aortic aneurysm, remains a challenge in clinical practice.

Standard radiological methods

CT angiography remains the imaging method of choice for acute aortic aneurysms, with MR angiography being increasingly used for follow-up imaging.

Threshold for treatment

In the ascending aorta a diameter larger than 5–5.5 cm (descending aorta 6.5 cm) is regarded as the threshold for treatment.

Thoracic endovascular aortic repair

The continuous evolution of aortic stent grafting (i.e., thoracic endovascular aortic repair [TEVAR]) since Parodi, Palmaz and Dake has led to a steep rise in stent grafting procedures in recent years.

Practical recommendations

Particularly in elderly patients with multiple comorbidities, TEVAR is a valuable, less invasive option compared to open surgical repair.     

Hybrid endograft for one-step treatment of multisegment disease of the thoracic aorta

PURPOSE: At present, a two-step surgical approach is necessary to treat patients with coexistent pathologic conditions involving the proximal and descending thoracic aorta. A hybrid endograft is described here that enables such treatment during a single operation. MATERIALS AND METHODS: The Chavan-Haverich endograft consists of a Dacron vascular prosthesis with stainless-steel stents affixed at its distal end. After approval by the institutional review board, the endograft was prospectively implanted in 22 patients with multisegment thoracic aortic disease (13 men, nine women; median age, 64 years). Eleven patients had type A dissections (one acute, 10 chronic), four had a chronic type B dissection, and seven had atherosclerotic aneurysms of the ascending aorta or aortic arch as well as of the descending aorta. Of these patients, 11 additionally required aortic valve replacement or coronary artery bypass grafting. Via median sternotomy, the aortic arch was opened in circulatory arrest. After antegrade deployment of the stent-containing portion in the descending aorta, the proximal non-stent-containing endograft was used to reconstruct the aortic arch. Median follow-up was 14 months. RESULTS: Endograft implantation was successful in all but one patient. Complications included neurologic deficits that were transient in one case and lasting in two, two cases of vocal cord paralysis, and one death. In all patients with atherosclerotic aneurysms who received the endograft (six of seven), aneurysm thrombosis was noted at follow-up. In aortic dissections, partial or complete false-lumen thrombosis to the level of the stents occurred in all patients. None of the patients showed a progressive widening of the descending aorta. CONCLUSION: The Chavan-Haverich endograft enables one-step treatment of multisegment pathologic conditions affecting the thoracic aorta that otherwise would require two or more operations.     

The "Carpentier" thoracic aortic by-pass technique for management of descending aortic aneurysms and dissections--a radiological perspective

The "Carpentier" thoracic aortic bypass procedure is a recently described and, until now, little used surgical technique for the treatment of descending thoracic aortic aneurysms and dissections. It involves the placement of a large conduit from the ascending aorta to the distal abdominal aorta through a midline sternotomy incision extended to the umbilicus and the subsequent interruption of the aorta just distal to the left subclavian artery via a left postero-lateral thoracotomy. As radiologists we should be aware of this alternative surgical option so that, in addition to diagnosing and classifying these aneurysms and dissections, we can assist our surgical colleagues in:-- a. The pre-operative assessment of the aorta for bypass grafting including the distal abdominal aorta b. The post-operative monitoring of the anticipated thrombotic occlusion of the descending thoracic aorta to the coeliac axis.     

Aortoenteric fistula and perigraft infection: evaluation with CT

A blinded retrospective study was performed to determine the sensitivity and specificity of computed tomography (CT) in detecting perigraft infection (PGI) and aortoenteric fistula (AEF), rare but devastating complications of aortic reconstructive surgery. Two observers independently reviewed CT scans in 55 cases including AEF (n = 23); PGI (n = 12); and normal, noninfected grafts (n = 20). Each scan was assessed for ectopic gas, focal bowel wall thickening, perigraft fluid, perigraft soft tissue, pseudoaneurysm formation, disruption of the aneurysmal wrap, and increased soft tissue between the graft and surrounding wrap. Comparison of CT findings with operative results revealed that each observer correctly identified as abnormal 33 of 35 cases of PGI either with or without AEF (sensitivity, 94%) and that results were falsely positive in three cases (specificity, 85%). CT findings ranged from large amounts of perigraft soft tissue and ectopic gas to subtle findings of minimal or no abnormalities; thus, strict criteria must be applied to the interpretation of CT scans after aortic surgery. Although CT is not 100% sensitive or specific, the authors conclude that it will continue to be valuable for diagnosing PGI and AEF.     

主动脉假性动脉瘤的影像诊断

目的：探讨主动脉假性动脉瘤的影像表现，评价MRI的诊断价值。方法：报道5例经手术证实的主动脉假性动脉瘤的影像所见，MRI检查4例，彩超检查3例，CT检查2例和主动脉造影1例。结果：胸、腹主动脉假性动脉瘤分别为3例和2例，假性动脉瘤位于主动脉轮廓外。彩超显示瘤体与主动脉有双向血流。CT和主动脉造影表现层状密度瘤体、早期强化和显影。MRI表现假性动脉瘤壁厚薄不均和信号不均质，均有破裂口。GRE显示经主动脉狭窄破裂口向瘤腔内喷射高信号血流。结论：MRI对假性动脉瘤的诊断有重要价值。     

Aortic branch artery pseudoaneurysms accompanying aortic dissection. Part I. Pseudoaneurysm anatomy

PURPOSE: Small areas of blood flow are sometimes seen within an otherwise thrombosed false lumen on computed tomography (CT) scans of intramural hematomas of the aorta. These are blood-filled spaces that, although they have no apparent communication with the true lumen, appear isodense with the aorta on contrast-enhanced CT scans. The purpose of this report is to describe angiographic and autopsy studies that establish the nature of this entity and describe the principal CT features distinguishing it from a penetrating ulcer. MATERIALS AND METHODS: Conventional angiographic and CT aorta findings in two cases with small collections of contrast material within an otherwise thrombosed false lumen of an aortic dissection are discussed. Also examined is another case with pathologic and histologic findings in addition to those of small collections of contrast material within an otherwise thrombosed false lumen of an aortic dissection, which illustrate the pathoanatomy of these lesions. RESULTS: Angiographic and necropsy evidence shows that some of these lesions represent branch artery pseudoaneurysms and, as such, are secondary to an intramural hematoma, not the primary cause of it. CONCLUSIONS: Difficulty in demonstrating communication between these collections of contrast material and the adjacent true lumen of the aorta on helical CT examinations and the characteristic location of these lesions along the nonpleural portion of the aortic circumference distinguish them from penetrating ulcers and should suggest the diagnosis of branch artery pseudoaneurysm. Demonstration of a branch artery originating from the contrast collection confirms the diagnosis. These branch artery pseudoaneurysms should be distinguished from penetrating atherosclerotic ulcers.     

Morphological progression of emphysema on thin-section CT: Analysis of longitudinal change in the number and size of low-attenuation clusters

OBJECTIVES: To evaluate morphological changes in the number and size of low-attenuation clusters on computed tomography (CT) in patients with emphysema. MATERIALS AND METHODS: In 27 patients who had follow-up CT scans for 6 months or greater, initial 27 scans and follow-up 39 scans were analyzed. The number per slice (LAN/s) and mean size (LAS) of low-attenuation clusters less than -950 HU, and total low-attenuation area below -950 HU per slice (LAA-950/s) were calculated. RESULTS: LAS and LAA-950/s were significantly increased over time. No significant correlation was found between LAN/s and follow-up period. LAS increased in 37 of 39 (95%) follow-up scans, whereas LAN/s decreased in 17 of 39 (44%) follow-up scans. CONCLUSIONS: On the morphological progression of emphysema, the mean size of low-attenuation clusters was significantly increased during the follow-up period, whereas no significant correlation was found between the number of low-attenuation clusters and follow-up period.     

JAG Tearing Technique with Radiofrequency Guide Wire for Aortic Fenestration in Thoracic Endovascular Aneurysm Repair

An innovative approach, the JAG tearing technique, was performed during thoracic endovascular aneurysm repair in a patient with previous surgical replacement of the ascending aorta with a residual uncomplicated type B aortic dissection who developed an aneurysm of the descending thoracic aorta with its lumen divided in two parts by an intimal flap. The proximal landing zone was suitable to place a thoracic stent graft. The distal landing zone was created by cutting the intimal flap in the distal third of the descending thoracic aorta with a radiofrequency guide wire and intravascular ultrasound catheter.     

Diagnosis of acute thoracic aortic dissection using combined echocardiography and computed tomography.

Acute dissection of the thoracic aorta is a life-threatening emergency requiring a diagnosis which is rapid, accurate and safe, and which will distinguish between dissections involving the ascending and descending aorta. In the absence of any general agreement on the best method of making this diagnosis we studied the use of combined echocardiography and contrast-enhanced computed tomography (CT) to diagnose acute aortic dissection. Over a 3 year period 23 patients were investigated in this way. Aortic dissection was demonstrated in 18 cases, involving the ascending aorta in 15, and the descending aorta alone in three. The diagnosis of aortic dissection was confirmed in 13 patients at surgery, in one at aortography and in one at autopsy. Three patients died without surgery or autopsy being performed to confirm the diagnosis and the subsequently which accounted for their symptoms. This combined approach has proved a valuable and safe means of investigating aortic dissection.