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Long-Term Imaging oftheAorta: Considerations andComparison ofModalities
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approach can lead to signicant measurement variability (on the order of 5–10mm)
related to the degree of aortic obliquity, particularly at the root and arch segments
[38]. With the advent of medical image analysis software, multi-planer reformats
(MPR) can be generated that allow for measurement of the aortic diameter orthogonal to the vessel axis (i.e. double-oblique plane), and these orthogonal measurement
planes can be generated either manually, or more recently with the assistance of
semi-automated image analysis software that rst generates a centerline through
geometric center of the vessel lumen (Fig.5). However, despite optimal centerline
assessment technique, measurement variability remains within the ±2mm range for
TAA even in the setting of highly standardized measurement protocols [39, 40].
Measurement variability is further increased when the aortic wall geometry is noncircular/ovoid or the aortic wall is difcult to clearly visualize, as is often the case
with aortic dissection. Measurement variability alone often precludes condent
determination of aortic enlargement considering that aortic growth rates commonly
fall within the range of 1–3mm per year.
Methods toImprove Quality ofImaging Surveillance
Considering that aortic diameter is the gold standard metric for assessment of aortic
disease, it is important for both imagers and surgeons to understand and utilize best
practices for aortic measurement in order to ensure the most reliable aortic growth
ab c
Fig. 5 Aortic Measurement Techniques: The simplest method of measurement involves measuring
the shortest dimension of the aorta on standard axial images (a), although this method can lead to
signicant measurement variability. Double-oblique measurement technique minimize inaccuracy
related to measurement plane obliquity and can either be performed manually using multi-planar
reformats (b) or using a semi-automated centerline approach (c)
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assessment possible. The key to minimizing measurement variability is to minimize
any differences in measurement technique between two different scans. Specically,
it is ideal to have both prior and current scans measured using the same measurement technique (e.g. centerline versus manual MPR versus axial), and using the
most comparable images in terms of contrast phase, slice thickness and gating
parameters. Any areas of maximal aortic dimension should be directly compared
between the prior and current scans by the same person, using the same software, at
as close to the same anatomic location as possible, and ideally in a side-by-side
fashion to allow for conrmation of the visual similarity of measurement planes.
Additionally, all readers should be instructed to use the same measurement landmarks along the length of the aorta, and diameter measurements should extend from
the outer aortic wall to outer aortic wall have been shown to be most reproducible in
TAA, although outer aortic wall can be difcult to locate in aortic dissection if the
false lumen enhancement is low [3, 15]. Furthermore, it important that if prior CT
images/measurements were obtained a different institution, that the measurements
on the external prior study be repeated by the current institution, as signicant interinstitutional measurement variability has been documented, mostly owing to differences in institutional specic measurement protocols [41]. Lastly, to maximize the
interpretability and comparability of documented aortic measurements, it is ideal to
utilize a standardized measurement reporting/storage format, and many image analysis programs currently support generation of standardized measurement reports.
N. S. Burris et al.
Advances andFuture Directions
While seemingly a simple task, long-term imaging surveillance of aortic disease
struggles with measurement inaccuracies and can be exceedingly time consuming,
particularly in the aortic dissection or post-endograft settings where patient-specic
considerations, and variations in aortic anatomy, image quality and measurement
technique are accentuated. There are two areas in which we believe ongoing
advancements in aortic imaging will have a signicant impact on the quality of
aortic imaging surveillance in the future. First, while MRA is clearly a secondary
modality to CTA in majority of institutions due to issues of time, cost and image
quality, given MRI’s inherent ability to resolve the aortic blood pool and aortic wall
without the need for radiation or contrast, and given its ability to provide a dynamic
assessment of aortic morphology, distensibility and blood ow, MRI/MRA may be
an ideal method to more fully characterize aortic disease. While further advancements are needed to shorten acquisition times for MRI/MRA and to establish the
clinical relevance of dynamic aortic parameters in aortic dissection (e.g., distensibility, blood ow, ap motion), active research in these areas has shown promising
results [42–44]. Secondly, there is a critical need to advance the speed and accuracy
of aortic size and growth assessment in long-term imaging surveillance. Advanced
computational methods in the elds of computer vision and machine learning may
ab
Long-Term Imaging oftheAorta: Considerations andComparison ofModalities
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Fig. 6 Future Directions to Improve Aortic Measurements and Imaging Surveillance: Software
exists that permits tabulation and graphical representation of aortic measurements along the length
of the aorta at each surveillance imaging study allowing for improved depiction of long-term
growth trends. A sample report is shown from a patient with acute type A aortic dissection treated
with ascending aortic repair, with residual dissection involving the arch and descending thoracoabdominal aorta. Five series follow-up studies demonstrate gradual increase in maximum diameter
of the proximal descending thoracic aorta over two years. Courtesy of Dominik Fleischman,
Stanford 3D/Quantitative Imaging Laboratory (a). Image analysis tools are being developed that
allow for a three-dimensional analysis of aortic growth in aortic dissection that overcomes many
of the limitations of diameter measurements, and an example of such a 3D analysis in a repaired
type A dissection patient with stable aortic dimensions is shown (b)
203
be ideal solutions. Preliminary studies have shown that automated segmentation and
classication of aortic aneurysms as well as three-dimensional deformation analysis
of aortic growth are both possible, and suggest the possibility that the future of aortic imaging surveillance may evolve from the hands of human readers to the servers
of medical imaging software companies (Fig.6) [45, 46].
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Part III
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Treatment of Acute Thoracic Aortic
Syndromes
Blunt Traumatic Aortic Injury: Etiology,
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Diagnosis, andManagement
BruceL.Tjaden andAnthonyL.Estrera
History
The rst report of a BTAI is widely attributed to Andreas Vesalius in 1557. However,
this is factually incorrect. The case was rst brought to Vesalius’ attention in 1555,
and it was not until 1609 when a report by Dr. Adolph Occo III (a friend and
colleague of Vesalius) was posthumously published describing the situation in detail.
While references to this famous injury abound, nding the actual text of the case
report can be challenging, due to its age. Thankfully, Drs. Suy and Fourneau of the
University of Leuven in Belgium recently provided an excellent English translation
of Dr. Occo III’s “Famous Case of an Aneurysm,” which is reproduced here with
permission:
Leonard Welser, a gentleman of Augsburg, [had] sustained a violent concussion when han-
dling an agitated horse. He became ill with pertinent sickness, whose principal symptom
was excruciating pain in the dorsal region. He failed to respond to any of the medicines
proposed by his physicians, and so the advice of Vesalius from Belgium, who then taught
anatomy, was sought. This illustrious man instantly recognised the symptoms of an aortic
aneurysm, which he predicted would be fatal. Immediately on discovering a small pulsating
tumour under the dorsal spine, he declared it to be an aneurysm caused by dilation of
the aorta.
Given that this resulted from a concussion, it was incurable. He also stated that he had
seen such a disease in the neck, the chest, the popliteal space, and the arm, and that it always
was associated with excruciating pain, and at the end, sideration [gangrene]. [Vesalius
stated that] this condition is incurable unless it is possible to remove it, and that these
aneurysms frequently contain a concrete uid resembling ice or the crystalline humour,
sometimes coagulated blood, or a polypous substance. [He also stated that] while alive, the
aneurysmal blood remains uid, but that is black and sidareted [sic] after death, [and that
the] patient dies suffering from exquisite pain, [and that] sometimes these vascular
B. L. Tjaden · A. L. Estrera (*)
Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at The
University of Texas Health Science Center at Houston (UTHealth), Houston, TX, USA
e-mail: Anthony.L.Estrera@uth.tmc.edu
J. S. Coselli et al. (eds.), Aortic Dissection and Acute Aortic Syndromes,
https://doi.org/10.1007/978-3-030-66668-2_14
209© Springer Nature Switzerland AG 2021
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dilatations form spontaneously, sometimes they are the results of an external cause, as in the
present case. Two years after the consultation, the patient nally ran out of patience in the
face of this pain, which had resisted all medical treatment. [The patient] ultimately threw
himself into the hands of an empiric [a charlatan], who administered certain catapotia
[internal remedies], the use of which was soon followed by expectoration of blood, causing
the patient to choke on his own blood, resulting in sudden death on June 25, 1557. From the
section of the body we found, as predicted by Vesalius, a very large, cavernous, eshy,
tumour protruding from the aorta, which was the source of the pain and the pulsations in the
back. As predicted by Vesalius, the good man died from this incurable disease [
B. L. Tjaden and A. L. Estrera
1].
While most patients with BTAI injuries now sustain their injury in motor
vehicle accidents rather than equestrian misadventures, this famous rst account of
the pathology sheds light on the timeless features of aortic trauma.
Epidemiology andTerminology
In general, penetrating trauma has accounted for the majority of historic aortic injuries (83% in one large trauma registry [2].) However, due to the predominance of
blunt traumatic mechanisms—along with the survivability of BTAI—most traumatic aortic injuries that surgeons encounter will be BTAI.
The vast majority of these BTAI involve the descending thoracic aorta [2]. This
has the potential to lead to confusion, as blunt traumatic aortic injury (which can
also include the abdominal aorta) and blunt thoracic aortic injury have both been
abbreviated BTAI. Authors have historically used these terms interchangeably in
the literature because, again, they are epidemiologically nearly synonymous. In
light of that, we will not draw distinctions in our review of the literature between the
two concepts. In our text, we will use the abbreviation BTAI to mean blunt thoracic
aortic injury, exclusive of abdominal injury.
Motor vehicle crashes account for the largest subset of BTAI cases [3]. While
BTAI are infrequent overall (incidence <0.5% of trauma patients in our registry [4]),
they carry a high mortality risk. They are the second-most common cause of blunt
traumatic fatalities [3]. In fact, nearly one-third of blunt trauma-related deaths were
associated with BTAI on in an autopsy study [5].
As trauma patients are younger on average than most other patients suffering
from acute aortic syndromes, it should come as no surprise that most patients with
BTAI are young. One 18-year institutional review found an average age of 38years
[6]. This has implications for device selection and treatment strategies [7], and will
be discussed later.
Diagnosis: Physical Exam andImaging Modality
Physical exam is not reliable in ruling in or ruling out BTAI [8]. For this reason,
virtually all patients with BTAI will be diagnosed by virtue of imaging. A widened
mediastinum on chest x-ray (CXR) may be present, though in isolation, this nding
Blunt Traumatic Aortic Injury: Etiology, Diagnosis, andManagement
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211
is not particularly useful. Even when considering multiple radiographic ndings in
aggregate, CXR is not an adequate test for diagnosing BTAI [9], and has been
shown to have a sensitivity as low as 41% [10]. A multicenter study found that the
constellation of several CXR ndings, in addition to other organ injury and clinical
criteria (“widened mediastinum, hypotension less than 90 mmHg, long bone
fracture, pulmonary contusion, left scapula fracture, hemothorax, and pelvic
fracture”) could be used to diagnose BTAI with a sensitivity of 92% and specicity
of 85% [11].
As early as 1996, contrast-enhanced CT of the chest was found to be 97% sensi-
tive and 99.8% specic for BTAI [12]. Over the ensuing decade, from 1997–2007,
there was a fundamental shift in the diagnosis of BTAI [13]. CT has become the new
gold standard for identifying this injury, and is the modality according to which
most diagnostic and treatment decisions are made [13]. Recent work also supports
the adequacy of CT with venous contrast instead of formal CT angiography (CTA)
in diagnosing BTAI [14]. CT allows for excellent visualization of the injury in axial,
coronal, and parasagittal projections, as well as 3D reconstruction of the injury and
accurate measurements of the aortic diameter and lengths along centerline, greater
curve, and lesser curve using specialized software. (Fig.1).
If the diagnosis of BTAI is equivocal, adjunctive tests can be performed to rule
aortic injury in or out. When comparing CTA, angiogram, and IVUS, IVUS has
been shown to be the least equivocal in cases of BTAI [15]. One observational study
suggested that IVUS has a sensitivity of 91.7% and specicity of 100% for
BTAI. The same publication found transesophageal echocardiography (TEE) to
have a 60% sensitivity and 66.7% specicity [16].
BTAI most often occurs in the proximal descending thoracic aorta at the level of
the aortic isthmus, but concomitant injury in other locations, such as the ascending,
arch, and distal descending thoracic aorta, may be present as well. The adoption of
the Ishimaru zones of the aorta may be used in order to more accurately categorize
the location of BTAI [17]. According to this schema, the common locations of BTAI
would be classied as zone 2 and 3 [7].
Fig. 1 From left: Axial, parasagittal, and reconstructed images from a computed tomographic
angiogram of the chest, demonstrating a severe (Grade IV) blunt thoracic aortic injury
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