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DOI: 10.1148/rg.264055082
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MR Angiographic Evaluation of Complications in Surgically Treated Type A Aortic Dissection1

Àngela García, MD, Joaquín Ferreirós, MD, PhD, Mónica Santamaría, MD, Ana Bustos, MD, José Luis Abades, MD and Nuria Santamaría, MD

1 From the Department of Diagnostic Imaging, Hospital Clínico San Carlos, Universidad Complutense, c/o Profesor Martín Lagos s/n, 28040 Madrid, Spain. Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received April 4, 2005; revision requested June 20 and received August 22; accepted August 26. All authors have no financial relationships to disclose.

Figure 1
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  		Figure 1a.  Prosthetic replacement of the ascending aorta. (a) Diagram shows a prosthetic tube used to replace the supracoronary ascending aorta. (b) Maximum intensity projection image from gadolinium-enhanced 3D MR angiography shows the prosthetic replacement in a 50-year-old man.

 

Figure 1
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  		Figure 1b.  Prosthetic replacement of the ascending aorta. (a) Diagram shows a prosthetic tube used to replace the supracoronary ascending aorta. (b) Maximum intensity projection image from gadolinium-enhanced 3D MR angiography shows the prosthetic replacement in a 50-year-old man.

 

Figure 2
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  		Figure 2a.  Bentall procedure. (a) Schematic shows the replacement of the entire ascending aorta and aortic valve with a valve-equipped prosthesis and the reimplantation of the coronary arteries onto the graft. The native aorta is either resected or wrapped around the prosthesis. (b) Maximum intensity projection image from gadolinium-enhanced 3D MR angiography in a 60-year-old man after a Bentall procedure shows the anastomoses of the coronary arteries to the prosthesis (arrowheads).

 

Figure 2
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  		Figure 2b.  Bentall procedure. (a) Schematic shows the replacement of the entire ascending aorta and aortic valve with a valve-equipped prosthesis and the reimplantation of the coronary arteries onto the graft. The native aorta is either resected or wrapped around the prosthesis. (b) Maximum intensity projection image from gadolinium-enhanced 3D MR angiography in a 60-year-old man after a Bentall procedure shows the anastomoses of the coronary arteries to the prosthesis (arrowheads).

 

Figure 3
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  		Figure 3a.  Cabrol procedure. (a) Diagram shows a Cabrol-type interostial conduit, which is routed behind the aortic prosthesis and anastomosed to an opening in it (arrow). (b, c) Schematics show a direct Cabrol shunt (b) between the perigraft space (PS) and the right atrial appendage (RA) and an indirect shunt (c) created by using a prosthetic tube. AO = aortic graft, RV = right ventricle.

 

Figure 3
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  		Figure 3b.  Cabrol procedure. (a) Diagram shows a Cabrol-type interostial conduit, which is routed behind the aortic prosthesis and anastomosed to an opening in it (arrow). (b, c) Schematics show a direct Cabrol shunt (b) between the perigraft space (PS) and the right atrial appendage (RA) and an indirect shunt (c) created by using a prosthetic tube. AO = aortic graft, RV = right ventricle.

 

Figure 3
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  		Figure 3c.  Cabrol procedure. (a) Diagram shows a Cabrol-type interostial conduit, which is routed behind the aortic prosthesis and anastomosed to an opening in it (arrow). (b, c) Schematics show a direct Cabrol shunt (b) between the perigraft space (PS) and the right atrial appendage (RA) and an indirect shunt (c) created by using a prosthetic tube. AO = aortic graft, RV = right ventricle.

 

Figure 4
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  		Figure 4a.  Replacements of the aortic arch and descending aorta. (a, b) Schematics show a prosthetic replacement of the aortic arch (a) and an elephant trunk–like extension distal to a prosthetic replacement of the proximal descending aorta (b). (c) Sagittal gadolinium-enhanced 3D MR angiogram in a 47-year-old woman shows prosthetic replacements of the supracoronary aorta and aortic arch, with an elephant trunk–like extension (arrow) of the native descending thoracic aorta.

 

Figure 4
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  		Figure 4b.  Replacements of the aortic arch and descending aorta. (a, b) Schematics show a prosthetic replacement of the aortic arch (a) and an elephant trunk–like extension distal to a prosthetic replacement of the proximal descending aorta (b). (c) Sagittal gadolinium-enhanced 3D MR angiogram in a 47-year-old woman shows prosthetic replacements of the supracoronary aorta and aortic arch, with an elephant trunk–like extension (arrow) of the native descending thoracic aorta.

 

Figure 4
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  		Figure 4c.  Replacements of the aortic arch and descending aorta. (a, b) Schematics show a prosthetic replacement of the aortic arch (a) and an elephant trunk–like extension distal to a prosthetic replacement of the proximal descending aorta (b). (c) Sagittal gadolinium-enhanced 3D MR angiogram in a 47-year-old woman shows prosthetic replacements of the supracoronary aorta and aortic arch, with an elephant trunk–like extension (arrow) of the native descending thoracic aorta.

 

Figure 5
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  		Figure 5a.  Stenosis of a distal anastomosis in a 56-year-old-man 1 month after a Bentall procedure. (a) Axial gadolinium-enhanced 3D MR angiogram shows narrowing of the aortic lumen at the level of the distal anastomosis (*). (b) Sagittal 3D MR angiogram from the same examination shows a circumferential stenosis (white arrows) in the area of the distal anastomosis, a residual dissection that involves the brachio-cephalic artery (black arrows), and a hypointense periprosthetic hematoma (x).

 

Figure 5
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  		Figure 5b.  Stenosis of a distal anastomosis in a 56-year-old-man 1 month after a Bentall procedure. (a) Axial gadolinium-enhanced 3D MR angiogram shows narrowing of the aortic lumen at the level of the distal anastomosis (*). (b) Sagittal 3D MR angiogram from the same examination shows a circumferential stenosis (white arrows) in the area of the distal anastomosis, a residual dissection that involves the brachio-cephalic artery (black arrows), and a hypointense periprosthetic hematoma (x).

 

Figure 6
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  		Figure 6a.  Progression of a periprosthetic hematoma to a pseudoaneurysm in a 44-year-old woman. (a) Axial T1-weighted SE image obtained 2 months after prosthetic replacement of the aortic valve and the ascending aorta shows a large periprosthetic hematoma (*) and residual dissection of the descending aorta (arrow). (b) Axial T1-weighted SE image obtained 2 years later shows a hyperintense persistent hematoma (*) and an increased diameter of the false lumen (x) with partial thrombosis (arrowhead) in the descending aorta. (c) Axial gadolinium-enhanced 3D MR angiogram shows the unenhanced hematoma (*) and a small gadolinium-enhanced pseudoaneurysm (arrow) indicative of dehiscence of the proximal anastomosis. Moderate contrast enhancement at the center of the false lumen indicates slow flow (x), and a lack of enhancement at the periphery confirms partial thrombosis (arrowhead).

 

Figure 6
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  		Figure 6b.  Progression of a periprosthetic hematoma to a pseudoaneurysm in a 44-year-old woman. (a) Axial T1-weighted SE image obtained 2 months after prosthetic replacement of the aortic valve and the ascending aorta shows a large periprosthetic hematoma (*) and residual dissection of the descending aorta (arrow). (b) Axial T1-weighted SE image obtained 2 years later shows a hyperintense persistent hematoma (*) and an increased diameter of the false lumen (x) with partial thrombosis (arrowhead) in the descending aorta. (c) Axial gadolinium-enhanced 3D MR angiogram shows the unenhanced hematoma (*) and a small gadolinium-enhanced pseudoaneurysm (arrow) indicative of dehiscence of the proximal anastomosis. Moderate contrast enhancement at the center of the false lumen indicates slow flow (x), and a lack of enhancement at the periphery confirms partial thrombosis (arrowhead).

 

Figure 6
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  		Figure 6c.  Progression of a periprosthetic hematoma to a pseudoaneurysm in a 44-year-old woman. (a) Axial T1-weighted SE image obtained 2 months after prosthetic replacement of the aortic valve and the ascending aorta shows a large periprosthetic hematoma (*) and residual dissection of the descending aorta (arrow). (b) Axial T1-weighted SE image obtained 2 years later shows a hyperintense persistent hematoma (*) and an increased diameter of the false lumen (x) with partial thrombosis (arrowhead) in the descending aorta. (c) Axial gadolinium-enhanced 3D MR angiogram shows the unenhanced hematoma (*) and a small gadolinium-enhanced pseudoaneurysm (arrow) indicative of dehiscence of the proximal anastomosis. Moderate contrast enhancement at the center of the false lumen indicates slow flow (x), and a lack of enhancement at the periphery confirms partial thrombosis (arrowhead).

 

Figure 7
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  		Figure 7a.  Periprosthetic pseudoaneurysm in a 56-year-old man after a Bentall procedure. Axial T1-weighted SE image (a) and axial gadolinium-enhanced 3D MR angiogram (b) show a pseudoaneurysm anterior and lateral to the prosthesis, a finding suggestive of suture dehiscence at the proximal anastomosis (*).

 

Figure 7
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  		Figure 7b.  Periprosthetic pseudoaneurysm in a 56-year-old man after a Bentall procedure. Axial T1-weighted SE image (a) and axial gadolinium-enhanced 3D MR angiogram (b) show a pseudoaneurysm anterior and lateral to the prosthesis, a finding suggestive of suture dehiscence at the proximal anastomosis (*).

 

Figure 8
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  		Figure 8a.  Pseudoaneurysm in a 58-year-old man 6 months after prosthetic replacement of the aortic valve and the ascending aorta. Sagittal (a), axial (b), and coronal (c) gadolinium-enhanced 3D MR angiograms demonstrate a pseudoaneurysm (*) caused by disruption of the distal anastomosis. The pseudoaneurysm extends to the origin of the brachiocephalic artery. Follow-up MR angiography 5 months later showed no significant changes.

 

Figure 8
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  		Figure 8b.  Pseudoaneurysm in a 58-year-old man 6 months after prosthetic replacement of the aortic valve and the ascending aorta. Sagittal (a), axial (b), and coronal (c) gadolinium-enhanced 3D MR angiograms demonstrate a pseudoaneurysm (*) caused by disruption of the distal anastomosis. The pseudoaneurysm extends to the origin of the brachiocephalic artery. Follow-up MR angiography 5 months later showed no significant changes.

 

Figure 8
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  		Figure 8c.  Pseudoaneurysm in a 58-year-old man 6 months after prosthetic replacement of the aortic valve and the ascending aorta. Sagittal (a), axial (b), and coronal (c) gadolinium-enhanced 3D MR angiograms demonstrate a pseudoaneurysm (*) caused by disruption of the distal anastomosis. The pseudoaneurysm extends to the origin of the brachiocephalic artery. Follow-up MR angiography 5 months later showed no significant changes.

 

Figure 9
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  		Figure 9a.  Pseudoaneurysm around an aortic prosthesis wrapped in the native aorta in a 60-year-old man. (a) Axial T1-weighted SE image depicts blood flow (*) between the anterior native aorta and the prosthesis, as well as a hyperintense periprosthetic hematoma. (b, c) Axial (b) and sagittal (c) gadolinium-enhanced 3D MR angiograms show a partial rim of contrast enhancement (*) around the prosthesis, a finding indicative of pseudoaneurysm.

 

Figure 9
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  		Figure 9b.  Pseudoaneurysm around an aortic prosthesis wrapped in the native aorta in a 60-year-old man. (a) Axial T1-weighted SE image depicts blood flow (*) between the anterior native aorta and the prosthesis, as well as a hyperintense periprosthetic hematoma. (b, c) Axial (b) and sagittal (c) gadolinium-enhanced 3D MR angiograms show a partial rim of contrast enhancement (*) around the prosthesis, a finding indicative of pseudoaneurysm.

 

Figure 9
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  		Figure 9c.  Pseudoaneurysm around an aortic prosthesis wrapped in the native aorta in a 60-year-old man. (a) Axial T1-weighted SE image depicts blood flow (*) between the anterior native aorta and the prosthesis, as well as a hyperintense periprosthetic hematoma. (b, c) Axial (b) and sagittal (c) gadolinium-enhanced 3D MR angiograms show a partial rim of contrast enhancement (*) around the prosthesis, a finding indicative of pseudoaneurysm.

 

Figure 10
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  		Figure 10a.  False lumen thrombosis in a 44-year-old woman with a prosthetic replacement of the aortic valve and the ascending aorta. (a) Axial gadolinium-enhanced fast spoiled gradient-recalled image shows residual dissection with high signal intensity due to blood flow in both the true and the false lumen (*). (b) Axial gadolinium-enhanced fast spoiled gradient-recalled image obtained at the same level 1 year later shows a lack of enhancement in the false channel (*), a finding indicative of thrombosis. (c, d) Axial gadolinium-enhanced fast spoiled gradient-recalled image (c), at a lower level than a and b, and coronal gadolinium-enhanced 3D MR angiogram (d) show blood flow in the false lumen (arrows). The flow originated from a distal reentry point in the left common iliac artery.

 

Figure 10
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  		Figure 10b.  False lumen thrombosis in a 44-year-old woman with a prosthetic replacement of the aortic valve and the ascending aorta. (a) Axial gadolinium-enhanced fast spoiled gradient-recalled image shows residual dissection with high signal intensity due to blood flow in both the true and the false lumen (*). (b) Axial gadolinium-enhanced fast spoiled gradient-recalled image obtained at the same level 1 year later shows a lack of enhancement in the false channel (*), a finding indicative of thrombosis. (c, d) Axial gadolinium-enhanced fast spoiled gradient-recalled image (c), at a lower level than a and b, and coronal gadolinium-enhanced 3D MR angiogram (d) show blood flow in the false lumen (arrows). The flow originated from a distal reentry point in the left common iliac artery.

 

Figure 10
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  		Figure 10c.  False lumen thrombosis in a 44-year-old woman with a prosthetic replacement of the aortic valve and the ascending aorta. (a) Axial gadolinium-enhanced fast spoiled gradient-recalled image shows residual dissection with high signal intensity due to blood flow in both the true and the false lumen (*). (b) Axial gadolinium-enhanced fast spoiled gradient-recalled image obtained at the same level 1 year later shows a lack of enhancement in the false channel (*), a finding indicative of thrombosis. (c, d) Axial gadolinium-enhanced fast spoiled gradient-recalled image (c), at a lower level than a and b, and coronal gadolinium-enhanced 3D MR angiogram (d) show blood flow in the false lumen (arrows). The flow originated from a distal reentry point in the left common iliac artery.

 

Figure 10
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  		Figure 10d.  False lumen thrombosis in a 44-year-old woman with a prosthetic replacement of the aortic valve and the ascending aorta. (a) Axial gadolinium-enhanced fast spoiled gradient-recalled image shows residual dissection with high signal intensity due to blood flow in both the true and the false lumen (*). (b) Axial gadolinium-enhanced fast spoiled gradient-recalled image obtained at the same level 1 year later shows a lack of enhancement in the false channel (*), a finding indicative of thrombosis. (c, d) Axial gadolinium-enhanced fast spoiled gradient-recalled image (c), at a lower level than a and b, and coronal gadolinium-enhanced 3D MR angiogram (d) show blood flow in the false lumen (arrows). The flow originated from a distal reentry point in the left common iliac artery.

 

Figure 11
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  		Figure 11a.  True lumen collapse in a 26-year-old woman with Marfan syndrome who underwent a prosthetic replacement of the aortic valve and the ascending aorta in the 7th month of pregnancy. (a) Axial T1-weighted SE image shows residual dissection distal to the prosthesis (arrow). (b) Coronal T1-weighted SE image shows dilatation of the aortic sinuses (arrows). (c) Axial gadolinium-enhanced 3D MR angiogram at the level of the renal arteries shows a narrow true lumen, a wide false channel, and the site of communication between the two (*). (d) Maximum intensity projection image from the same examination as c shows the narrow true lumen (x).

 

Figure 11
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  		Figure 11b.  True lumen collapse in a 26-year-old woman with Marfan syndrome who underwent a prosthetic replacement of the aortic valve and the ascending aorta in the 7th month of pregnancy. (a) Axial T1-weighted SE image shows residual dissection distal to the prosthesis (arrow). (b) Coronal T1-weighted SE image shows dilatation of the aortic sinuses (arrows). (c) Axial gadolinium-enhanced 3D MR angiogram at the level of the renal arteries shows a narrow true lumen, a wide false channel, and the site of communication between the two (*). (d) Maximum intensity projection image from the same examination as c shows the narrow true lumen (x).

 

Figure 11
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  		Figure 11c.  True lumen collapse in a 26-year-old woman with Marfan syndrome who underwent a prosthetic replacement of the aortic valve and the ascending aorta in the 7th month of pregnancy. (a) Axial T1-weighted SE image shows residual dissection distal to the prosthesis (arrow). (b) Coronal T1-weighted SE image shows dilatation of the aortic sinuses (arrows). (c) Axial gadolinium-enhanced 3D MR angiogram at the level of the renal arteries shows a narrow true lumen, a wide false channel, and the site of communication between the two (*). (d) Maximum intensity projection image from the same examination as c shows the narrow true lumen (x).

 

Figure 11
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  		Figure 11d.  True lumen collapse in a 26-year-old woman with Marfan syndrome who underwent a prosthetic replacement of the aortic valve and the ascending aorta in the 7th month of pregnancy. (a) Axial T1-weighted SE image shows residual dissection distal to the prosthesis (arrow). (b) Coronal T1-weighted SE image shows dilatation of the aortic sinuses (arrows). (c) Axial gadolinium-enhanced 3D MR angiogram at the level of the renal arteries shows a narrow true lumen, a wide false channel, and the site of communication between the two (*). (d) Maximum intensity projection image from the same examination as c shows the narrow true lumen (x).

 

Figure 12
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  		Figure 12a.  Aneurysmatic dilatation of the false channel and collapse of the true lumen. (a, b) Axial T1-weighted SE MR image (a) and sagittal oblique gadolinium-enhanced 3D MR angiogram (b) in a 46-year-old man with a prosthetic replacement of the ascending aorta show dilatation and partial thrombosis of the aortic false channel (x). A point of communication between the true lumen and the false channel also is depicted (arrow in b). (c, d) Axial (c) and coronal oblique (d) gadolinium-enhanced 3D MR angiograms in a 58-year-old man (same patient as Figure 9) with true lumen collapse show dilatation of the false channel along the abdominal aorta (*). (e) Photograph of an autopsy specimen from a patient who died several years after aortic replacement shows aneurysmatic dilatation and endothelialization of the false channel (arrowheads).

 

Figure 12
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  		Figure 12b.  Aneurysmatic dilatation of the false channel and collapse of the true lumen. (a, b) Axial T1-weighted SE MR image (a) and sagittal oblique gadolinium-enhanced 3D MR angiogram (b) in a 46-year-old man with a prosthetic replacement of the ascending aorta show dilatation and partial thrombosis of the aortic false channel (x). A point of communication between the true lumen and the false channel also is depicted (arrow in b). (c, d) Axial (c) and coronal oblique (d) gadolinium-enhanced 3D MR angiograms in a 58-year-old man (same patient as Figure 9) with true lumen collapse show dilatation of the false channel along the abdominal aorta (*). (e) Photograph of an autopsy specimen from a patient who died several years after aortic replacement shows aneurysmatic dilatation and endothelialization of the false channel (arrowheads).

 

Figure 12
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  		Figure 12c.  Aneurysmatic dilatation of the false channel and collapse of the true lumen. (a, b) Axial T1-weighted SE MR image (a) and sagittal oblique gadolinium-enhanced 3D MR angiogram (b) in a 46-year-old man with a prosthetic replacement of the ascending aorta show dilatation and partial thrombosis of the aortic false channel (x). A point of communication between the true lumen and the false channel also is depicted (arrow in b). (c, d) Axial (c) and coronal oblique (d) gadolinium-enhanced 3D MR angiograms in a 58-year-old man (same patient as Figure 9) with true lumen collapse show dilatation of the false channel along the abdominal aorta (*). (e) Photograph of an autopsy specimen from a patient who died several years after aortic replacement shows aneurysmatic dilatation and endothelialization of the false channel (arrowheads).

 

Figure 12
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  		Figure 12d.  Aneurysmatic dilatation of the false channel and collapse of the true lumen. (a, b) Axial T1-weighted SE MR image (a) and sagittal oblique gadolinium-enhanced 3D MR angiogram (b) in a 46-year-old man with a prosthetic replacement of the ascending aorta show dilatation and partial thrombosis of the aortic false channel (x). A point of communication between the true lumen and the false channel also is depicted (arrow in b). (c, d) Axial (c) and coronal oblique (d) gadolinium-enhanced 3D MR angiograms in a 58-year-old man (same patient as Figure 9) with true lumen collapse show dilatation of the false channel along the abdominal aorta (*). (e) Photograph of an autopsy specimen from a patient who died several years after aortic replacement shows aneurysmatic dilatation and endothelialization of the false channel (arrowheads).

 

Figure 12
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  		Figure 12e.  Aneurysmatic dilatation of the false channel and collapse of the true lumen. (a, b) Axial T1-weighted SE MR image (a) and sagittal oblique gadolinium-enhanced 3D MR angiogram (b) in a 46-year-old man with a prosthetic replacement of the ascending aorta show dilatation and partial thrombosis of the aortic false channel (x). A point of communication between the true lumen and the false channel also is depicted (arrow in b). (c, d) Axial (c) and coronal oblique (d) gadolinium-enhanced 3D MR angiograms in a 58-year-old man (same patient as Figure 9) with true lumen collapse show dilatation of the false channel along the abdominal aorta (*). (e) Photograph of an autopsy specimen from a patient who died several years after aortic replacement shows aneurysmatic dilatation and endothelialization of the false channel (arrowheads).

 

Figure 13
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  		Figure 13a.  Distal residual dissection with involvement of visceral aortic branches. (a) Coronal gadolinium-enhanced 3D MR angiogram shows a supracoronary aortic prosthesis in a 56-year-old man. (b, c) Axial 3D MR angiograms from the same examination at the origin of the celiac trunk (b) and the superior mesenteric artery (c) show distal residual dissection that affects both vessels (arrow).

 

Figure 13
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  		Figure 13b.  Distal residual dissection with involvement of visceral aortic branches. (a) Coronal gadolinium-enhanced 3D MR angiogram shows a supracoronary aortic prosthesis in a 56-year-old man. (b, c) Axial 3D MR angiograms from the same examination at the origin of the celiac trunk (b) and the superior mesenteric artery (c) show distal residual dissection that affects both vessels (arrow).

 

Figure 13
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  		Figure 13c.  Distal residual dissection with involvement of visceral aortic branches. (a) Coronal gadolinium-enhanced 3D MR angiogram shows a supracoronary aortic prosthesis in a 56-year-old man. (b, c) Axial 3D MR angiograms from the same examination at the origin of the celiac trunk (b) and the superior mesenteric artery (c) show distal residual dissection that affects both vessels (arrow).

 

Figure 14
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  		Figure 14a.  Distal residual dissection with involvement of the supra-aortic vessels. Axial (a) and coronal (b) gadolinium-enhanced 3D MR angiograms in a 56-year-old man show residual dissection that extends into the brachiocephalic arterial trunk (arrow in b) and the left subclavian artery (arrow in a).

 

Figure 14
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  		Figure 14b.  Distal residual dissection with involvement of the supra-aortic vessels. Axial (a) and coronal (b) gadolinium-enhanced 3D MR angiograms in a 56-year-old man show residual dissection that extends into the brachiocephalic arterial trunk (arrow in b) and the left subclavian artery (arrow in a).

 

Figure 15
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  		Figure 15a.  Proximal residual dissection in a 70-year-old man with a prosthetic tube replacement of the ascending aorta. (a) Sagittal oblique gadolinium-enhanced 3D MR angiogram shows a short flap in the lumen at the aortic root (arrow), just below the prosthesis. (b) Axial CT image shows the dissection (arrow) proximal to the prosthesis. The finding also was con-firmed at transesophageal echocardiography (not shown).

 

Figure 15
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  		Figure 15b.  Proximal residual dissection in a 70-year-old man with a prosthetic tube replacement of the ascending aorta. (a) Sagittal oblique gadolinium-enhanced 3D MR angiogram shows a short flap in the lumen at the aortic root (arrow), just below the prosthesis. (b) Axial CT image shows the dissection (arrow) proximal to the prosthesis. The finding also was con-firmed at transesophageal echocardiography (not shown).

 




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