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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3752_Библиотеки_им_академика_М_И_Перельмана
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this immunosuppressed population, necessitates further
investigation of the role of CCTA post-transplant [ 94 , 95 ].
CCTA Imaging Related to Surgery for Cardiac
Masses
While defi nitive diagnosis of cardiac tumors requires pathologic examination of the mass histology, CCTA can be used to
characterize masses and associated fi ndings important to diagnosis and pre-surgical work-up and planning (Fig. 22.43 ) [ 96 ,
97 ]. CCTA can defi ne morphology including 3-D shape, single
versus multiple masses, and wide-based versus narrow-based
connection to the myocardium. Tissue characteristics, including attenuation of the mass, homogeneity versus heterogeneity
of attenuation in different areas within the mass, presence and
pattern of calcifi cation, and presence and pattern of vascularity,
can be defi ned with CCTA. Descriptive features of the location
of the mass in relation to cardiovascular and thoracic structure
should be noted, including: intracameral, intramyocardial epicardial or pericardial location of the mass, invasion or involvement of other cardiac or thoracic structures by the mass from
its primary location, relationship of the mass to the coronary
arteries, pericardial studding or effusion, and presence of
lymphadenopathy or other thoracic masses within the fi eld of
view. CCTA can also provide coronary artery assessment for
obstructive coronary artery disease prior to surgery. All of
these factors are important to decisions as to resectability and
surgical approach once a histologic tissue diagnosis is made.
CCTA Imaging Related to Surgery
for Pericardial Disease
Assessment for constrictive pericarditis is challenging and
often involves multiple modalities of imaging including
echocardiography as well as invasive cardiac catheterization
to assess hemodynamic elements. CCTA can be helpful in
assessing pericardial thickness by cardiac region as well as
by the degree of calcifi cation [ 98 – 100 ]. Surgical complica-
tions can occur due to vascular damage related to dissecting
the pericardium away from the coronary arteries. CCTA can
defi ne the relationship between the pericardium and coronary arteries, including areas of pericardial thickening, pericardial calcifi cation, as well as tethering of coronary arteries
on dynamic images (Fig. 22.44 ).
Fig. 22.24 Normal coronary artery origins and anomalous coronary
artery courses. 3-D axial view reconstruction ( left panel ) demonstrates
normal coronary artery origins with the right coronary artery origin at
11 o’clock and the left main coronary artery origin at 3:30 on the aortic
clock face. Thick maximum intensity projection in the axial view shows
the four primary courses ( black circles ) for anomalous coronary arteries
arising from the contralateral sinus. CX circumfl ex coronary artery,
LAD left anterior descending coronary artery, LM left main coronary
artery, RCA right coronary artery (Reprinted from Shinbane et al. [ 35 ]
with permission from SAGE Publications)
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Decisions regarding percutaneous versus surgical
approaches to drain pericardial fl uid collections can be
facilitated by CT assessment of the location, extent, and
tissue characteristics of the pericardial effusion [ 101 ]. A
percutaneous approach may be limited by the complexity
of the effusion due to loculation of the effusion or effusion
tissue attenuation consistent with blood, proteinaceous
material, or thrombus. Accessibility by a sub-xiphoid
approach can be determined by the relation of the effusion
to skeletal and thoracic structures (Fig. 22.45 ). For poste-
rior effusions, particularly in the setting of post cardiothoracic surgery, a sub-xiphoid approach may not be feasible,
while a CT guided drainage may be achievable.
CCTA Imaging for Aortic Surgery
CCTA and CMR diagnosis of acute and chronic aortic disease is well-established. These technologies can visualize
dissection, intramural hematoma, penetrating ulcer, aortic
aneurysm, and aortic rupture. Details of a dissection fl ap
entry and exit site, location and extent of true and false
lumen, dissection into branch vessels, involvement of the
sinuses of Valsalva, dissection into the coronary arteries, and
dissection into the pericardium can be defi ned (Figs. 22.46
and 22.47 ) [ 102 – 104 ]. CCTA can assess coronary artery
anatomy when cardiac catheterization is high risk or
unachievable due to aortic pathology, such as severe atherosclerotic disease with large atheromas, thrombi, aneurysms,
or dissections. Similarly, in emergency department settings,
when rapid assessment for thoracic and coronary artery traumatic abnormalities are crucial and time dependent, CCTA
may be useful [ 105 – 107 ]. CCTA provides assessment of vas-
cular dimensions for endograft sizing and placement important to endovascular aneurysm repair [ 108 ]. The presence
and degree of atherosclerosis, calcifi cation, and thrombus
can be important to cross clamp decisions related to multiple
types of cardiothoracic procedures. CCTA can also be useful
in the assessment of infected aortic aneurysms, with fi ndings
including saccular structure, contiguous soft tissue masses,
Fig. 22.25 Left coronary artery arising from a shared ostium on the
right coronary sinus with a prepulmonic course and single-vessel right
coronary artery coronary artery disease. 3-D reconstructions ( upper and
lower left panels ) demonstrate a left coronary artery arising from a
separate ostium on the right coronary sinus with a prepulmonic course.
A curved multiplanar reformat ( lower right panel ) shows signifi cant
atherosclerotic disease of the right coronary artery. Cardiac catheteriza-
tion demonstrated proximal occlusion of the right coronary artery with
left to right collaterals. In this case, medical management of the diseased single vessel was chosen. AO aorta, CX circumfl ex coronary
artery, LAD left anterior descending coronary artery, LM left main coro-
nary artery, PA pulmonary artery, RCA right coronary artery (Reprinted
from Shinbane et al. [ 35 ] with permission from SAGE Publications)
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contrast enhancement, fl uid, gas, and adjoining bone destruction [ 109 ]. For other aortic abnormalities, such as coarctation
of the aorta, CCTA is useful for decision-making related to
percutaneous or surgical intervention. Characterization of
coarctation location, size, calcifi cation, collateral circulation,
as well as associated congenital anomalies, can be achieved.
Conclusions
The spectrum of cardiothoracic surgical options continues
to expand. CCTA can facilitate surgical procedures and
requires continued investigation to defi ne optimal proce-
dural approaches to coronary artery, valvular, and aortic
pathology. Although the cardiothoracic surgeon may not
necessarily be the CCTA reading physician, detailed
knowledge of the images and workstation software capabilities are essential in order to attain a 3-D understanding
of an individual patient’s pre-surgical cardiothoracic anatomy. Viewing modalities and presentations intuitive to the
surgical approach are being advanced with 3-D printing of
individualized heart models from CCTA data for surgical
planning [ 110 – 114 ]. A close working relationship between
the imager, interventional cardiologist and surgeon and
presentation of relevant pre- surgical images to the multidisciplinary team are import to the comprehensive utilization of data to defi ne approaches to particular cardiovascular
disease processes.
Fig. 22.26 Left coronary artery branches arising from the right coronary sinus with a prepulmonic left anterior descending coronary artery
arising from a separate ostium with a subsequent intramyocardial
course and a retroaortic circumfl ex arising off of the coronary artery.
3-D reconstructions ( upper panels ) demonstrate the left anterior
descending coronary artery arising just anterior and cranial to the right
coronary artery arising from a separate ostium off of the right coronary
sinus. The circumfl ex coronary artery arises off of the right coronary
artery and courses retroaortic, terminating in obtuse marginal branches.
2-D double oblique thick maximum intensity projection ( lower panel )
shows the separate right sinus ostium giving off a conus branch coursing anterior to the right ventricular outfl ow tract with the diminutive left
anterior descending coronary artery coursing intramyocardially via a
transseptal course as well as the retroaortic circumfl ex. Surgery was not
required due to lower risk anatomic features, and due to the lack of
obstructive coronary artery disease. AO aorta, CX circumfl ex coronary
artery, LAD left anterior descending coronary artery, LA left atrium, LM
left main coronary artery, RCA right coronary artery (Reprinted from
Shinbane et al. [
35 ] with permission from SAGE Publications)
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Fig. 22.27 Left coronary artery arising from a shared ostium on the
right coronary sinus with a retroaortic course and myocardial bridging
of the left anterior descending coronary artery. 3-D reconstructions
( upper panels ) demonstrate anomalous origin of the left main coronary
artery off of its own ostium of the right coronary sinus taking a retrograde aortic course between the aorta and the left atrium. A curved
multiplanar reformat ( lower left panel ) shows the separate ostia of the
left main and right coronary artery. A 2-D double oblique thick maxi-
mum intensity projection view ( lower right panel ) shows myocardial
bridging of the left anterior descending coronary artery. Given the lower
risk anatomy and lack of obstructive coronary artery disease, surgical
intervention was not required. CX circumfl ex coronary artery, LAD left
anterior descending coronary artery, LM left main coronary artery, RCA
right coronary artery (Reprinted from Shinbane et al. [ 35 ] with permis-
sion from SAGE Publications.)
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Fig. 22.28 Right coronary artery arising with a high takeoff from a
separate ostium on the left coronary sinus with an interarterial course.
3-D reconstructions ( upper panels ) demonstrate anomalous takeoff of
the right coronary artery from the superior portion of the left coronary
sinus with an interarterial course between the aorta and the pulmonary
artery. Two-D double oblique thick maximum intensity projection
views ( lower panels ) show the interarterial course and the slit-like ori-
fi ce of the right coronary artery. Due to symptoms of exertional syncope
and high risk anatomy, surgical treatment was recommended. A minimally invasive unroofi ng of the artery was performed, with the aorta
opened in an oblique fashion and incised following the track of the right
coronary artery as it coursed through the intramural portion of the aorta
for 1.5 cm, allowing correction of the slit like orifi ce and rerouting of
the interarterial course without the need for sternotomy in an athlete.
AO aorta, CX circumfl ex coronary artery, LAD left anterior descending
coronary artery, LM left main coronary artery, PA pulmonary artery,
RCA right coronary artery, RVOT right ventricular outfl ow tract
(Reprinted from Shinbane et al. [
35 ] with permission from SAGE
Publications)
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a
b
Fig. 22.29 Panel ( a ) Left main coronary artery arising from a separate
ostium within the right coronary sinus with an interarterial course. 3-D
reconstructions ( upper panels ) demonstrate an anomalous takeoff of the
left main coronary artery from its own ostium within the right coronary
sinus with an interarterial course between the aorta and the pulmonary
artery. 2-D double oblique thick maximum intensity projection views
( lower panels ) show the intraarterial course and left main coronary artery
with a slit-like orifi ce. Due to symptoms of exertional chest pain, positive
cardiac enzymes and high risk anatomy, surgical treatment was recom-
mended. A minimally invasive approach through a small 2nd intercostal
space incision was used in order to avoid sternotomy. As the slit-like
ostium had an extremely short course, re-implantation of the LM was
performed. Panel ( b ) The 3D views show the minimally invasive surgical
approach ( white dotted line ) through a small second intercostal space
incision perpendicular to sternum. AO aorta, CX circumfl ex coronary
artery, LAD left anterior descending coronary artery, LM left main coro-
nary artery, PA pulmonary artery, RCA right coronary artery (Reprinted
from Shinbane et al. [ 35 ] with permission from SAGE Publications)
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Fig. 22.30 Left main coronary artery ( LM ) arising from a separate
ostium within the right coronary sinus with an interarterial course and
multivessel coronary artery disease. 3-D reconstructions ( upper panels,
lower left panel ) demonstrate an anomalous takeoff of the LM from its
own ostium within the right coronary sinus with an interarterial course
between the aorta and the pulmonary artery. 2-D double oblique thick
maximum intensity projection view ( lower right panel ) shows the intra-
arterial course of the LM with a slit-like orifi ce. Due to presentation
with cardiogenic shock, intraaortic balloon pump placement and cardiac catheterization had been performed with subsequent CCTA to further characterize anomalous coronary anatomy. Given the presence of
multivessel coronary artery disease, standard coronary artery bypass
surgery was performed. AO aorta, LAD left anterior descending coro-
nary artery, LM left main coronary artery, PA pulmonary artery, RCA
right coronary artery (Reprinted from Shinbane et al. [ 35 ] with permis-
sion from SAGE Publications)
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Fig. 22.31 Left coronary artery arising from a separate ostium on the
right coronary sinus with an interarterial course with previous surgical
unroofi ng. 3-D reconstruction ( left panel ) demonstrates the left coro-
nary artery with the left main coronary artery originating from its own
ostium off of the right coronary sinus. There has been previous unroofing of the interarterial left main course with surgical widening and
extension to the commissure between the left and right coronary
sinuses. 2-D double oblique thick maximum intensity projection views
( right panel ) show the ostium has been surgically widened and extended
to the commissure between the left and the right coronary sinus. There
was no obstructive coronary artery disease within any of these vessels.
No further intervention was necessary. AO aorta, LM left main coronary
artery, RCA right coronary artery (Reprinted from Shinbane et al. [ 35 ]
with permission from SAGE Publications)
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Fig. 22.33 Anomalous coronary artery termination with a serpiginous
coronary artery fi stula from the proximal left anterior descending coronary artery to the main pulmonary artery. 3-D reconstructions ( upper
panels ) demonstrate an extremely serpiginous fi stula extended from the
proximal left anterior descending coronary artery to the main pulmonary artery. 2-D double oblique thick maximum intensity projection
views ( lower panels ) demonstrate the termination of the fi stula into the
left anterolateral aspect of the main pulmonary artery just distal to the
pulmonic valve. The remainder of the left anterior descending artery
followed a normal course without evidence of stenosis. The coronary
artery origins were normal. There was no evidence of obstructive coronary artery disease. An incidental wide- mouthed saccular aneurysm of
the descending thoracic aorta at the level of the left atrium is seen in the
lower right panel . Given the size and profound tortuosity of the fi stula
in the setting of exertional chest pain, surgical ligation of the fi stula via
a median sternotomy approach was performed. CX circumfl ex coronary
artery, Diag diagonal branch, LAD left anterior descending coronary
artery, LM left main coronary artery, PA pulmonary artery, RCA right
coronary artery (Reprinted from Shinbane et al. [
35 ] with permission
from SAGE Publications)
Fig. 22.32 Anomalous termination of a coronary artery with coronary
artery fi stula from the fi rst septal perforating branch of the left anterior
descending coronary artery to the right ventricular outfl ow tract with
history of Tetralogy of Fallot repair. 3-D reconstructions ( upper panels )
show a large caliber and tortuous left main coronary artery with a posterior and cranial takeoff. A fi stula from a septal branch of the left anterior
descending coronary artery terminates in the right ventricular infundibulum. After takeoff of the fi stula, the left anterior descending coronary
artery continues as a normal caliber vessel along the anterior interventricular groove. 2-D double oblique thick maximum intensity projection
views ( lower panels ) demonstrate the termination of the fi stula into the
posterior aspect of the right ventricular outfl ow tract. Portions of the
right coronary artery coursed immediately posterior to the sternum. No
signifi cant stenoses of the coronary arteries were present. Other fi ndings
included a prosthetic aortic valve with normal leafl et motion, a rightsided aortic arch and descending aorta, and evidence of a prior repair of
a ventricular septal defect. Given these fi ndings, a percutaneous left
anterior descending coronary artery to right ventricular outfl ow tract fi stula occlusion with a 4-mm vascular plug was performed. Diag diagonal
branch, LAD left anterior descending coronary artery, RVOT right ven-
tricular outfl ow tract (Reprinted from Shinbane et al. [
35 ] with permis-
sion from SAGE Publications)
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a
d
bc
Fig. 22.34 Arteriovenous fi stula due to anomalous right coronary
artery termination into the coronary sinus. The right coronary artery is
dilated throughout its course with a maximum dimension of 1.6 × 1.6 cm
and serpiginous in morphology. Panel ( a ) A 3-D reconstruction with
skeletal structure. Panel ( b ) A 3-D reconstruction with skeletal structure
removed. Panel ( c ) Posterior rotation of 3-D reconstruction. Panel ( d ) A
2-D double oblique view demonstrating the abnormal termination of
the right coronary artery with an arteriovenous connection to the coronary sinus, with the connection approximately 7 mm cm distal to the
coronary sinus ostium. Surgical closure was performed. RCA right
coronary artery
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