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Endovascular Stent-Graft Treatment of Thoracic Aortic Disease¹

¹ From the Departments of Radiology (G.G., M.F.V., M.M., I.A., F.Y.) and Vascular Surgery (L.R.), Hospital Universitario La Paz, Paseo de la Castellana 261, 28046 Madrid, Spain. Recipient of a Certificate of Merit award for an education exhibit at the 2004 RSNA Annual Meeting. Received February 28, 2005; revision requested March 30 and received May 16; accepted May 23. The authors discuss an investigational or unlabeled use of a commercial product, device, or pharmaceutical that has not been approved for such purpose by the FDA. All authors have no financial relationships to disclose.

View larger version (171K): [in a new window]   Figure 1a.  Endovascular procedure. (a) Image from digital subtraction angiography (DSA) shows a saccular aneurysm of the descending thoracic aorta. (b) DSA image shows the delivery system positioned at the desired location. The outer sheath is withdrawn for deployment of the stent-graft. (c) DSA image obtained after deployment shows correct positioning of the stent-graft in the descending aorta. (d) Postprocedure DSA image shows complete exclusion of the aneurysmal sac.

 

View larger version (111K): [in a new window]   Figure 1b.  Endovascular procedure. (a) Image from digital subtraction angiography (DSA) shows a saccular aneurysm of the descending thoracic aorta. (b) DSA image shows the delivery system positioned at the desired location. The outer sheath is withdrawn for deployment of the stent-graft. (c) DSA image obtained after deployment shows correct positioning of the stent-graft in the descending aorta. (d) Postprocedure DSA image shows complete exclusion of the aneurysmal sac.

 

View larger version (123K): [in a new window]   Figure 1c.  Endovascular procedure. (a) Image from digital subtraction angiography (DSA) shows a saccular aneurysm of the descending thoracic aorta. (b) DSA image shows the delivery system positioned at the desired location. The outer sheath is withdrawn for deployment of the stent-graft. (c) DSA image obtained after deployment shows correct positioning of the stent-graft in the descending aorta. (d) Postprocedure DSA image shows complete exclusion of the aneurysmal sac.

 

View larger version (151K): [in a new window]   Figure 1d.  Endovascular procedure. (a) Image from digital subtraction angiography (DSA) shows a saccular aneurysm of the descending thoracic aorta. (b) DSA image shows the delivery system positioned at the desired location. The outer sheath is withdrawn for deployment of the stent-graft. (c) DSA image obtained after deployment shows correct positioning of the stent-graft in the descending aorta. (d) Postprocedure DSA image shows complete exclusion of the aneurysmal sac.

 

View larger version (121K): [in a new window]   Figure 2a.  Saccular aneurysm of the descending aorta. CT scans obtained before treatment (a) and 1 year after treatment (b) show shrinkage of the excluded aneurysmal space between the preprocedure and follow-up examinations.

 

View larger version (120K): [in a new window]   Figure 2b.  Saccular aneurysm of the descending aorta. CT scans obtained before treatment (a) and 1 year after treatment (b) show shrinkage of the excluded aneurysmal space between the preprocedure and follow-up examinations.

 

View larger version (44K): [in a new window]   Figure 3a.  Combined surgical-endovascular treatment. (a) Drawing shows a long aneurysm involving the entire thoracic aorta. (b) The ascending aorta and aortic arch are replaced by a surgical graft. (c) The proximal end of a stent-graft is anchored to the distal end of the surgical graft. (d) The thoracic aorta is reconstructed by combining surgical and endovascular procedures.

 

View larger version (42K): [in a new window]   Figure 3b.  Combined surgical-endovascular treatment. (a) Drawing shows a long aneurysm involving the entire thoracic aorta. (b) The ascending aorta and aortic arch are replaced by a surgical graft. (c) The proximal end of a stent-graft is anchored to the distal end of the surgical graft. (d) The thoracic aorta is reconstructed by combining surgical and endovascular procedures.

 

View larger version (61K): [in a new window]   Figure 3c.  Combined surgical-endovascular treatment. (a) Drawing shows a long aneurysm involving the entire thoracic aorta. (b) The ascending aorta and aortic arch are replaced by a surgical graft. (c) The proximal end of a stent-graft is anchored to the distal end of the surgical graft. (d) The thoracic aorta is reconstructed by combining surgical and endovascular procedures.

 

View larger version (55K): [in a new window]   Figure 3d.  Combined surgical-endovascular treatment. (a) Drawing shows a long aneurysm involving the entire thoracic aorta. (b) The ascending aorta and aortic arch are replaced by a surgical graft. (c) The proximal end of a stent-graft is anchored to the distal end of the surgical graft. (d) The thoracic aorta is reconstructed by combining surgical and endovascular procedures.

 

View larger version (157K): [in a new window]   Figure 4a.  Syphilitic aneurysm of the thoracic aorta. (a) DSA image shows aneurysmal involvement of the entire thoracic aorta. (b) CT scan obtained because the patient reported acute chest pain shows thickening of the aortic wall (arrowhead), which was not present at CT performed 2 weeks earlier. (c) Postprocedure CT scan shows a stent-graft inside the dilated aorta. (d) CT scan obtained at 1-year follow-up shows shrinkage of the aneurysmal space.

 

View larger version (91K): [in a new window]   Figure 4b.  Syphilitic aneurysm of the thoracic aorta. (a) DSA image shows aneurysmal involvement of the entire thoracic aorta. (b) CT scan obtained because the patient reported acute chest pain shows thickening of the aortic wall (arrowhead), which was not present at CT performed 2 weeks earlier. (c) Postprocedure CT scan shows a stent-graft inside the dilated aorta. (d) CT scan obtained at 1-year follow-up shows shrinkage of the aneurysmal space.

 

View larger version (136K): [in a new window]   Figure 4c.  Syphilitic aneurysm of the thoracic aorta. (a) DSA image shows aneurysmal involvement of the entire thoracic aorta. (b) CT scan obtained because the patient reported acute chest pain shows thickening of the aortic wall (arrowhead), which was not present at CT performed 2 weeks earlier. (c) Postprocedure CT scan shows a stent-graft inside the dilated aorta. (d) CT scan obtained at 1-year follow-up shows shrinkage of the aneurysmal space.

 

View larger version (95K): [in a new window]   Figure 4d.  Syphilitic aneurysm of the thoracic aorta. (a) DSA image shows aneurysmal involvement of the entire thoracic aorta. (b) CT scan obtained because the patient reported acute chest pain shows thickening of the aortic wall (arrowhead), which was not present at CT performed 2 weeks earlier. (c) Postprocedure CT scan shows a stent-graft inside the dilated aorta. (d) CT scan obtained at 1-year follow-up shows shrinkage of the aneurysmal space.

 

View larger version (132K): [in a new window]   Figure 5a.  Acute Stanford type A dissection. (a) Pretreatment DSA image shows dilatation of the ascending aorta and opacification of the true (arrows) and false (*) lumina through a wide entry site. (b) Postprocedure DSA image shows the ascending aorta replaced by an aortic graft. With stent-graft deployment in the descending aorta, only the true lumen is evident. (c) CT scan obtained before treatment shows an intimal flap in the ascending and descending aorta (arrows). The false lumen is dilated; the true lumen is compressed and has a crescentic shape. Note the presence of irregular strands (cobwebs) within the false lumen (*). (d) CT scan obtained 3 months after treatment shows the ascending aorta replaced by a graft and the descending aorta replaced by a stent-graft. The false lumen has regressed until it is no longer apparent.

 

View larger version (100K): [in a new window]   Figure 5b.  Acute Stanford type A dissection. (a) Pretreatment DSA image shows dilatation of the ascending aorta and opacification of the true (arrows) and false (*) lumina through a wide entry site. (b) Postprocedure DSA image shows the ascending aorta replaced by an aortic graft. With stent-graft deployment in the descending aorta, only the true lumen is evident. (c) CT scan obtained before treatment shows an intimal flap in the ascending and descending aorta (arrows). The false lumen is dilated; the true lumen is compressed and has a crescentic shape. Note the presence of irregular strands (cobwebs) within the false lumen (*). (d) CT scan obtained 3 months after treatment shows the ascending aorta replaced by a graft and the descending aorta replaced by a stent-graft. The false lumen has regressed until it is no longer apparent.

 

View larger version (128K): [in a new window]   Figure 5c.  Acute Stanford type A dissection. (a) Pretreatment DSA image shows dilatation of the ascending aorta and opacification of the true (arrows) and false (*) lumina through a wide entry site. (b) Postprocedure DSA image shows the ascending aorta replaced by an aortic graft. With stent-graft deployment in the descending aorta, only the true lumen is evident. (c) CT scan obtained before treatment shows an intimal flap in the ascending and descending aorta (arrows). The false lumen is dilated; the true lumen is compressed and has a crescentic shape. Note the presence of irregular strands (cobwebs) within the false lumen (*). (d) CT scan obtained 3 months after treatment shows the ascending aorta replaced by a graft and the descending aorta replaced by a stent-graft. The false lumen has regressed until it is no longer apparent.

 

View larger version (86K): [in a new window]   Figure 5d.  Acute Stanford type A dissection. (a) Pretreatment DSA image shows dilatation of the ascending aorta and opacification of the true (arrows) and false (*) lumina through a wide entry site. (b) Postprocedure DSA image shows the ascending aorta replaced by an aortic graft. With stent-graft deployment in the descending aorta, only the true lumen is evident. (c) CT scan obtained before treatment shows an intimal flap in the ascending and descending aorta (arrows). The false lumen is dilated; the true lumen is compressed and has a crescentic shape. Note the presence of irregular strands (cobwebs) within the false lumen (*). (d) CT scan obtained 3 months after treatment shows the ascending aorta replaced by a graft and the descending aorta replaced by a stent-graft. The false lumen has regressed until it is no longer apparent.

 

View larger version (120K): [in a new window]   Figure 6a.  Stanford type A dissection treated with endovascular completion of the elephant trunk technique. (a) DSA image shows the ascending aorta and aortic arch replaced by a graft, the elephant trunk (arrowheads), which mainly supplies the false lumen (*); the true lumen is compressed (arrows). (b) Oblique sagittal reformatted CT scan shows the elephant trunk (arrowheads) connected to the false lumen (*). Note the intimal flap and compression of the true lumen (arrows) by the dilated false lumen. (c) CT scan obtained before the endovascular procedure shows the end of the elephant trunk (arrowhead) connected to the dilated false lumen in the proximal descending aorta. (d) Follow-up CT scan shows complete thrombosis of the false lumen (*).

 

View larger version (124K): [in a new window]   Figure 6b.  Stanford type A dissection treated with endovascular completion of the elephant trunk technique. (a) DSA image shows the ascending aorta and aortic arch replaced by a graft, the elephant trunk (arrowheads), which mainly supplies the false lumen (*); the true lumen is compressed (arrows). (b) Oblique sagittal reformatted CT scan shows the elephant trunk (arrowheads) connected to the false lumen (*). Note the intimal flap and compression of the true lumen (arrows) by the dilated false lumen. (c) CT scan obtained before the endovascular procedure shows the end of the elephant trunk (arrowhead) connected to the dilated false lumen in the proximal descending aorta. (d) Follow-up CT scan shows complete thrombosis of the false lumen (*).

 

View larger version (141K): [in a new window]   Figure 6c.  Stanford type A dissection treated with endovascular completion of the elephant trunk technique. (a) DSA image shows the ascending aorta and aortic arch replaced by a graft, the elephant trunk (arrowheads), which mainly supplies the false lumen (*); the true lumen is compressed (arrows). (b) Oblique sagittal reformatted CT scan shows the elephant trunk (arrowheads) connected to the false lumen (*). Note the intimal flap and compression of the true lumen (arrows) by the dilated false lumen. (c) CT scan obtained before the endovascular procedure shows the end of the elephant trunk (arrowhead) connected to the dilated false lumen in the proximal descending aorta. (d) Follow-up CT scan shows complete thrombosis of the false lumen (*).

 

View larger version (144K): [in a new window]   Figure 6d.  Stanford type A dissection treated with endovascular completion of the elephant trunk technique. (a) DSA image shows the ascending aorta and aortic arch replaced by a graft, the elephant trunk (arrowheads), which mainly supplies the false lumen (*); the true lumen is compressed (arrows). (b) Oblique sagittal reformatted CT scan shows the elephant trunk (arrowheads) connected to the false lumen (*). Note the intimal flap and compression of the true lumen (arrows) by the dilated false lumen. (c) CT scan obtained before the endovascular procedure shows the end of the elephant trunk (arrowhead) connected to the dilated false lumen in the proximal descending aorta. (d) Follow-up CT scan shows complete thrombosis of the false lumen (*).

 

View larger version (164K): [in a new window]   Figure 7a.  Acute Stanford type B dissection. (a) DSA image shows a Stanford type B dissection with the false lumen (*) compressing the true lumen (arrows). (b) DSA image shows that the celiac trunk (C) and right renal artery (RRA) are supplied by the true lumen. Note the presence of a reentry tear (arrow) in the abdominal aorta. The left renal artery (LRA) is supplied by the false lumen. (c) Pretreatment CT scan shows that the dissection extends from the origin of the descending aorta, distal to the LSA origin. * = false lumen. (d) Pretreatment CT scan shows that the true lumen is compressed and gives rise to the superior mesenteric artery. * = false lumen. (e) CT scan obtained at 6-month follow-up shows complete regression of the dissection after exclusion of the entry site. (f ) CT scan obtained at 6-month follow-up shows repressurization of the true lumen and shrinkage of the thrombosed false lumen (*).

 

View larger version (114K): [in a new window]   Figure 7b.  Acute Stanford type B dissection. (a) DSA image shows a Stanford type B dissection with the false lumen (*) compressing the true lumen (arrows). (b) DSA image shows that the celiac trunk (C) and right renal artery (RRA) are supplied by the true lumen. Note the presence of a reentry tear (arrow) in the abdominal aorta. The left renal artery (LRA) is supplied by the false lumen. (c) Pretreatment CT scan shows that the dissection extends from the origin of the descending aorta, distal to the LSA origin. * = false lumen. (d) Pretreatment CT scan shows that the true lumen is compressed and gives rise to the superior mesenteric artery. * = false lumen. (e) CT scan obtained at 6-month follow-up shows complete regression of the dissection after exclusion of the entry site. (f ) CT scan obtained at 6-month follow-up shows repressurization of the true lumen and shrinkage of the thrombosed false lumen (*).

 

View larger version (93K): [in a new window]   Figure 7c.  Acute Stanford type B dissection. (a) DSA image shows a Stanford type B dissection with the false lumen (*) compressing the true lumen (arrows). (b) DSA image shows that the celiac trunk (C) and right renal artery (RRA) are supplied by the true lumen. Note the presence of a reentry tear (arrow) in the abdominal aorta. The left renal artery (LRA) is supplied by the false lumen. (c) Pretreatment CT scan shows that the dissection extends from the origin of the descending aorta, distal to the LSA origin. * = false lumen. (d) Pretreatment CT scan shows that the true lumen is compressed and gives rise to the superior mesenteric artery. * = false lumen. (e) CT scan obtained at 6-month follow-up shows complete regression of the dissection after exclusion of the entry site. (f ) CT scan obtained at 6-month follow-up shows repressurization of the true lumen and shrinkage of the thrombosed false lumen (*).

 

View larger version (178K): [in a new window]   Figure 7d.  Acute Stanford type B dissection. (a) DSA image shows a Stanford type B dissection with the false lumen (*) compressing the true lumen (arrows). (b) DSA image shows that the celiac trunk (C) and right renal artery (RRA) are supplied by the true lumen. Note the presence of a reentry tear (arrow) in the abdominal aorta. The left renal artery (LRA) is supplied by the false lumen. (c) Pretreatment CT scan shows that the dissection extends from the origin of the descending aorta, distal to the LSA origin. * = false lumen. (d) Pretreatment CT scan shows that the true lumen is compressed and gives rise to the superior mesenteric artery. * = false lumen. (e) CT scan obtained at 6-month follow-up shows complete regression of the dissection after exclusion of the entry site. (f ) CT scan obtained at 6-month follow-up shows repressurization of the true lumen and shrinkage of the thrombosed false lumen (*).

 

View larger version (95K): [in a new window]   Figure 7e.  Acute Stanford type B dissection. (a) DSA image shows a Stanford type B dissection with the false lumen (*) compressing the true lumen (arrows). (b) DSA image shows that the celiac trunk (C) and right renal artery (RRA) are supplied by the true lumen. Note the presence of a reentry tear (arrow) in the abdominal aorta. The left renal artery (LRA) is supplied by the false lumen. (c) Pretreatment CT scan shows that the dissection extends from the origin of the descending aorta, distal to the LSA origin. * = false lumen. (d) Pretreatment CT scan shows that the true lumen is compressed and gives rise to the superior mesenteric artery. * = false lumen. (e) CT scan obtained at 6-month follow-up shows complete regression of the dissection after exclusion of the entry site. (f ) CT scan obtained at 6-month follow-up shows repressurization of the true lumen and shrinkage of the thrombosed false lumen (*).

 

View larger version (167K): [in a new window]   Figure 7f.  Acute Stanford type B dissection. (a) DSA image shows a Stanford type B dissection with the false lumen (*) compressing the true lumen (arrows). (b) DSA image shows that the celiac trunk (C) and right renal artery (RRA) are supplied by the true lumen. Note the presence of a reentry tear (arrow) in the abdominal aorta. The left renal artery (LRA) is supplied by the false lumen. (c) Pretreatment CT scan shows that the dissection extends from the origin of the descending aorta, distal to the LSA origin. * = false lumen. (d) Pretreatment CT scan shows that the true lumen is compressed and gives rise to the superior mesenteric artery. * = false lumen. (e) CT scan obtained at 6-month follow-up shows complete regression of the dissection after exclusion of the entry site. (f ) CT scan obtained at 6-month follow-up shows repressurization of the true lumen and shrinkage of the thrombosed false lumen (*).

 

View larger version (104K): [in a new window]   Figure 8a.  Chronic Stanford type B dissection. (a) DSA image shows an entry tear (arrow) in the distal descending aorta and injected contrast material in the false lumen. The dissection extends distally into the abdominal aorta. The abdominal branch vessels are supplied by the compressed true lumen. C = celiac trunk, LRA = left renal artery, RRA = right renal artery, SMA = superior mesenteric artery. (b) DSA image obtained after stent-graft placement shows complete exclusion of the false lumen. The flow to all visceral vessels from the true lumen is maintained. (c) Pretreatment CT scan shows compression of the true lumen by the dilated false lumen (*) at the level of the entry site. (d) Pretreatment CT scan shows that the celiac trunk is supplied by the true lumen. Note the partial thrombosis of the false lumen (*). (e) CT scan obtained at 3-month follow-up shows that exclusion of the entry site has led to thrombosis of the thoracic component of the false lumen (*). (f) CT scan obtained at 3-month follow-up shows that the caliber of the abdominal aorta has been reestablished. The false lumen is completely thrombosed (*).

 

View larger version (92K): [in a new window]   Figure 8b.  Chronic Stanford type B dissection. (a) DSA image shows an entry tear (arrow) in the distal descending aorta and injected contrast material in the false lumen. The dissection extends distally into the abdominal aorta. The abdominal branch vessels are supplied by the compressed true lumen. C = celiac trunk, LRA = left renal artery, RRA = right renal artery, SMA = superior mesenteric artery. (b) DSA image obtained after stent-graft placement shows complete exclusion of the false lumen. The flow to all visceral vessels from the true lumen is maintained. (c) Pretreatment CT scan shows compression of the true lumen by the dilated false lumen (*) at the level of the entry site. (d) Pretreatment CT scan shows that the celiac trunk is supplied by the true lumen. Note the partial thrombosis of the false lumen (*). (e) CT scan obtained at 3-month follow-up shows that exclusion of the entry site has led to thrombosis of the thoracic component of the false lumen (*). (f) CT scan obtained at 3-month follow-up shows that the caliber of the abdominal aorta has been reestablished. The false lumen is completely thrombosed (*).

 

View larger version (84K): [in a new window]   Figure 8c.  Chronic Stanford type B dissection. (a) DSA image shows an entry tear (arrow) in the distal descending aorta and injected contrast material in the false lumen. The dissection extends distally into the abdominal aorta. The abdominal branch vessels are supplied by the compressed true lumen. C = celiac trunk, LRA = left renal artery, RRA = right renal artery, SMA = superior mesenteric artery. (b) DSA image obtained after stent-graft placement shows complete exclusion of the false lumen. The flow to all visceral vessels from the true lumen is maintained. (c) Pretreatment CT scan shows compression of the true lumen by the dilated false lumen (*) at the level of the entry site. (d) Pretreatment CT scan shows that the celiac trunk is supplied by the true lumen. Note the partial thrombosis of the false lumen (*). (e) CT scan obtained at 3-month follow-up shows that exclusion of the entry site has led to thrombosis of the thoracic component of the false lumen (*). (f) CT scan obtained at 3-month follow-up shows that the caliber of the abdominal aorta has been reestablished. The false lumen is completely thrombosed (*).

 

View larger version (117K): [in a new window]   Figure 8d.  Chronic Stanford type B dissection. (a) DSA image shows an entry tear (arrow) in the distal descending aorta and injected contrast material in the false lumen. The dissection extends distally into the abdominal aorta. The abdominal branch vessels are supplied by the compressed true lumen. C = celiac trunk, LRA = left renal artery, RRA = right renal artery, SMA = superior mesenteric artery. (b) DSA image obtained after stent-graft placement shows complete exclusion of the false lumen. The flow to all visceral vessels from the true lumen is maintained. (c) Pretreatment CT scan shows compression of the true lumen by the dilated false lumen (*) at the level of the entry site. (d) Pretreatment CT scan shows that the celiac trunk is supplied by the true lumen. Note the partial thrombosis of the false lumen (*). (e) CT scan obtained at 3-month follow-up shows that exclusion of the entry site has led to thrombosis of the thoracic component of the false lumen (*). (f) CT scan obtained at 3-month follow-up shows that the caliber of the abdominal aorta has been reestablished. The false lumen is completely thrombosed (*).

 

View larger version (121K): [in a new window]   Figure 8e.  Chronic Stanford type B dissection. (a) DSA image shows an entry tear (arrow) in the distal descending aorta and injected contrast material in the false lumen. The dissection extends distally into the abdominal aorta. The abdominal branch vessels are supplied by the compressed true lumen. C = celiac trunk, LRA = left renal artery, RRA = right renal artery, SMA = superior mesenteric artery. (b) DSA image obtained after stent-graft placement shows complete exclusion of the false lumen. The flow to all visceral vessels from the true lumen is maintained. (c) Pretreatment CT scan shows compression of the true lumen by the dilated false lumen (*) at the level of the entry site. (d) Pretreatment CT scan shows that the celiac trunk is supplied by the true lumen. Note the partial thrombosis of the false lumen (*). (e) CT scan obtained at 3-month follow-up shows that exclusion of the entry site has led to thrombosis of the thoracic component of the false lumen (*). (f) CT scan obtained at 3-month follow-up shows that the caliber of the abdominal aorta has been reestablished. The false lumen is completely thrombosed (*).

 

View larger version (120K): [in a new window]   Figure 8f.  Chronic Stanford type B dissection. (a) DSA image shows an entry tear (arrow) in the distal descending aorta and injected contrast material in the false lumen. The dissection extends distally into the abdominal aorta. The abdominal branch vessels are supplied by the compressed true lumen. C = celiac trunk, LRA = left renal artery, RRA = right renal artery, SMA = superior mesenteric artery. (b) DSA image obtained after stent-graft placement shows complete exclusion of the false lumen. The flow to all visceral vessels from the true lumen is maintained. (c) Pretreatment CT scan shows compression of the true lumen by the dilated false lumen (*) at the level of the entry site. (d) Pretreatment CT scan shows that the celiac trunk is supplied by the true lumen. Note the partial thrombosis of the false lumen (*). (e) CT scan obtained at 3-month follow-up shows that exclusion of the entry site has led to thrombosis of the thoracic component of the false lumen (*). (f) CT scan obtained at 3-month follow-up shows that the caliber of the abdominal aorta has been reestablished. The false lumen is completely thrombosed (*).

 

View larger version (169K): [in a new window]   Figure 9a.  Traumatic aortic rupture after an automobile accident. (a) DSA image shows enlargement of the aortic lumen distal to the LSA origin (arrows). A traumatic aortic rupture was suspected. (b) CT scan shows enlargement of the mediastinum (M), hemothorax (HT), and irregularity of the aortic contour. (c) DSA image obtained after stent-graft deployment shows exclusion of the aortic rupture. (d) CT scan obtained at 6-month follow-up shows the stent-graft covering the origin of the descending aorta. The mediastinum is normal, and the pleural effusion has disappeared.

 

View larger version (159K): [in a new window]   Figure 9b.  Traumatic aortic rupture after an automobile accident. (a) DSA image shows enlargement of the aortic lumen distal to the LSA origin (arrows). A traumatic aortic rupture was suspected. (b) CT scan shows enlargement of the mediastinum (M), hemothorax (HT), and irregularity of the aortic contour. (c) DSA image obtained after stent-graft deployment shows exclusion of the aortic rupture. (d) CT scan obtained at 6-month follow-up shows the stent-graft covering the origin of the descending aorta. The mediastinum is normal, and the pleural effusion has disappeared.

 

View larger version (185K): [in a new window]   Figure 9c.  Traumatic aortic rupture after an automobile accident. (a) DSA image shows enlargement of the aortic lumen distal to the LSA origin (arrows). A traumatic aortic rupture was suspected. (b) CT scan shows enlargement of the mediastinum (M), hemothorax (HT), and irregularity of the aortic contour. (c) DSA image obtained after stent-graft deployment shows exclusion of the aortic rupture. (d) CT scan obtained at 6-month follow-up shows the stent-graft covering the origin of the descending aorta. The mediastinum is normal, and the pleural effusion has disappeared.

 

View larger version (134K): [in a new window]   Figure 9d.  Traumatic aortic rupture after an automobile accident. (a) DSA image shows enlargement of the aortic lumen distal to the LSA origin (arrows). A traumatic aortic rupture was suspected. (b) CT scan shows enlargement of the mediastinum (M), hemothorax (HT), and irregularity of the aortic contour. (c) DSA image obtained after stent-graft deployment shows exclusion of the aortic rupture. (d) CT scan obtained at 6-month follow-up shows the stent-graft covering the origin of the descending aorta. The mediastinum is normal, and the pleural effusion has disappeared.

 

View larger version (122K): [in a new window]   Figure 10a.  Posttraumatic aortic pseudoaneurysm. (a) DSA image shows a posttraumatic pseudoaneurysm located close to the LSA (arrow). (b) DSA image obtained after stent-graft deployment shows that the origin of the LSA has been covered (arrow) to extend the proximal anchoring zone. A spontaneous subclavian steal was established (arrowhead) with no signs of vertebrobasilar or left arm ischemia. (c, d) CT scans obtained before treatment (c) and 1 year after treatment (d) show a decrease in the size of the pseudoaneurysm after exclusion. Note the significant calcifications in the aneurysm wall.

 

View larger version (130K): [in a new window]   Figure 10b.  Posttraumatic aortic pseudoaneurysm. (a) DSA image shows a posttraumatic pseudoaneurysm located close to the LSA (arrow). (b) DSA image obtained after stent-graft deployment shows that the origin of the LSA has been covered (arrow) to extend the proximal anchoring zone. A spontaneous subclavian steal was established (arrowhead) with no signs of vertebrobasilar or left arm ischemia. (c, d) CT scans obtained before treatment (c) and 1 year after treatment (d) show a decrease in the size of the pseudoaneurysm after exclusion. Note the significant calcifications in the aneurysm wall.

 

View larger version (117K): [in a new window]   Figure 10c.  Posttraumatic aortic pseudoaneurysm. (a) DSA image shows a posttraumatic pseudoaneurysm located close to the LSA (arrow). (b) DSA image obtained after stent-graft deployment shows that the origin of the LSA has been covered (arrow) to extend the proximal anchoring zone. A spontaneous subclavian steal was established (arrowhead) with no signs of vertebrobasilar or left arm ischemia. (c, d) CT scans obtained before treatment (c) and 1 year after treatment (d) show a decrease in the size of the pseudoaneurysm after exclusion. Note the significant calcifications in the aneurysm wall.

 

View larger version (121K): [in a new window]   Figure 10d.  Posttraumatic aortic pseudoaneurysm. (a) DSA image shows a posttraumatic pseudoaneurysm located close to the LSA (arrow). (b) DSA image obtained after stent-graft deployment shows that the origin of the LSA has been covered (arrow) to extend the proximal anchoring zone. A spontaneous subclavian steal was established (arrowhead) with no signs of vertebrobasilar or left arm ischemia. (c, d) CT scans obtained before treatment (c) and 1 year after treatment (d) show a decrease in the size of the pseudoaneurysm after exclusion. Note the significant calcifications in the aneurysm wall.

 

View larger version (156K): [in a new window]   Figure 11a.  Intramural hematoma. (a) DSA image shows external compression of the aortic lumen at the origin of the descending aorta (arrows). (b) CT scan obtained before treatment shows that the area of aortic wall thickening remains unenhanced after administration of contrast material. (c) DSA image obtained after stent-graft deployment to cover the extension of the intramural hematoma shows that the external compression has disappeared.

 

View larger version (156K): [in a new window]   Figure 11b.  Intramural hematoma. (a) DSA image shows external compression of the aortic lumen at the origin of the descending aorta (arrows). (b) CT scan obtained before treatment shows that the area of aortic wall thickening remains unenhanced after administration of contrast material. (c) DSA image obtained after stent-graft deployment to cover the extension of the intramural hematoma shows that the external compression has disappeared.

 

View larger version (137K): [in a new window]   Figure 11c.  Intramural hematoma. (a) DSA image shows external compression of the aortic lumen at the origin of the descending aorta (arrows). (b) CT scan obtained before treatment shows that the area of aortic wall thickening remains unenhanced after administration of contrast material. (c) DSA image obtained after stent-graft deployment to cover the extension of the intramural hematoma shows that the external compression has disappeared.

 

View larger version (139K): [in a new window]   Figure 12a.  Penetrating atherosclerotic ulcer. (a) CT scan shows a contrast material–filled outpouching in the distal thoracic aorta. The outpouching is surrounded by a thrombosed pseudoaneurysm. (b) DSA image shows the contrast material–filled structure (arrow) projecting beyond the expected confines of the aortic lumen. (c) DSA image obtained after stent-graft deployment shows successful exclusion of the penetrating ulcer and the pseudoaneurysm.

 

View larger version (129K): [in a new window]   Figure 12b.  Penetrating atherosclerotic ulcer. (a) CT scan shows a contrast material–filled outpouching in the distal thoracic aorta. The outpouching is surrounded by a thrombosed pseudoaneurysm. (b) DSA image shows the contrast material–filled structure (arrow) projecting beyond the expected confines of the aortic lumen. (c) DSA image obtained after stent-graft deployment shows successful exclusion of the penetrating ulcer and the pseudoaneurysm.

 

View larger version (123K): [in a new window]   Figure 12c.  Penetrating atherosclerotic ulcer. (a) CT scan shows a contrast material–filled outpouching in the distal thoracic aorta. The outpouching is surrounded by a thrombosed pseudoaneurysm. (b) DSA image shows the contrast material–filled structure (arrow) projecting beyond the expected confines of the aortic lumen. (c) DSA image obtained after stent-graft deployment shows successful exclusion of the penetrating ulcer and the pseudoaneurysm.

 

View larger version (152K): [in a new window]   Figure 13a.  Rupture of a penetrating atherosclerotic ulcer. (a) CT scan shows a large penetrating ulcer (*) that has progressed to a transmural aortic rupture. Note the intramural hematoma (H), large hemomediastinum (M), and bilateral hemothorax (HT). (b) Follow-up DSA image shows complete exclusion of the rupture site.

 

View larger version (169K): [in a new window]   Figure 13b.  Rupture of a penetrating atherosclerotic ulcer. (a) CT scan shows a large penetrating ulcer (*) that has progressed to a transmural aortic rupture. Note the intramural hematoma (H), large hemomediastinum (M), and bilateral hemothorax (HT). (b) Follow-up DSA image shows complete exclusion of the rupture site.

 

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