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An Image From the Dark Side of the Stomach
DIAGNOSTIC DILEMMAS Paul S. Pagel, MD, PhD Section Editor
An Image From the Dark Side of the Stomach Marc S. Eiseman, MD, Zafar Iqbal, MD, Sandeep Markan, MD, and Paul S. Pagel, MD, PhD
A
62-YEAR-OLD, 129-kg, 177-cm man was admitted to the authors’ institution for the evaluation of progressive chest tightness and dyspnea on exertion. A persantine-thallium stress test revealed a reversible perfusion defect in the left ventricular anterior wall. Coronary angiography showed the presence of a complete occlusion of the proximal left anterior descending coronary artery with extensive collateralization of the central ischemic region provided by branches of the left circumflex coronary artery. The left ventricular ejection fraction was estimated to be 60%. The patient was transported to the operating room for off-pump coronary artery bypass graft surgery
Fig 2. A color-flow Doppler mapping image of the proximal abdominal aorta obtained immediately below the diaphragm (the level of the midpapillary left ventricular short axis) showing laminar blood flow within the proximal aspect of the large blood vessel depicted in Figure 1.
Fig 1. A 2-dimensional short-axis image of the proximal abdominal aorta obtained immediately below the diaphragm (the level of the midpapillary left ventricular short axis) showing the origin and proximal course of a large blood vessel.
(the left internal mammary artery to the left anterior descending artery). After anesthetic induction, transesophageal echocardiography (TEE) was performed. Regional wall motion abnormalities were absent, and the remainder of the heart was normal. The transesophageal echocardiographic probe was rotated counterclockwise from the midpapillary transgastric plane to evaluate the aorta, and the structure depicted in Figures 1 and 2 was observed. What is the diagnosis?
From the Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI. Address reprint requests to Paul S. Pagel, MD, PhD, Clement J. Zablocki Veterans Affairs Medical Center, Anesthesia Service, 5000 W National Avenue, Milwaukee, WI 53295. E-mail: [email protected] © 2011 Elsevier Inc. All rights reserved. 1053-0770/2503-0030$36.00/0 doi:10.1053/j.jvca.2010.02.014 Key words: celiac artery, descending thoracic aorta, abdominal aorta, transesophageal echocardiography, normal anatomy Journal of Cardiothoracic and Vascular Anesthesia, Vol 25, No 3 (June), 2011: pp 565-566
565
566
EISEMAN ET AL
DIAGNOSIS: NORMAL CELIAC ARTERY
The transesophageal echocardiographic examination revealed the celiac artery arising from the proximal abdominal aorta (Fig 1). Blood flow within the artery was normal (Fig 2, pulse-wave Doppler echocardiography not shown). The esophagus is located directly behind the thoracic aorta immediately distal to the aortic arch. As the esophagus and thoracic aorta descend toward the abdomen, the esophagus gradually rotates 180° in a counterclockwise direction around the medial aspect of the aorta, such that the distal esophagus and the cardia of the stomach are transposed anterior to the proximal abdominal aorta. This anatomic orientation facilitates visualization of the origin of several abdominal blood vessels including the celiac, the superior mesenteric, and the right and left renal arteries1-4 unless the transesophageal echocardiographic probe fails to consistently contact the posterior gastric surface.5 Orihashi et al4 reported successful visualization of the celiac and superior mesenteric arteries in 12 consecutive patients undergoing TEE during aortic surgery. The left and right renal arteries also were observed in 59% and 83%, respectively, of patients in this small series.4 In a prospective study of 27
patients undergoing cardiac surgery, Royse et al6 concluded that routine assessment of the celiac axis and renal arteries was not always possible using TEE. Nevertheless, the authors reported that acceptable imaging of the celiac axis was feasible in the majority (81%) of their patients.6 The celiac artery is usually the first reproducibly identifiable landmark to appear arising from the descending aorta after the origin of the left subclavian artery.7 Imaging of the celiac artery may be an especially useful indicator of splanchnic blood flow6 in the presence of aortic pathology. For example, Frazin8 used TEE to detect the extension of a descending thoracic aortic dissection into the celiac artery in an elderly man presenting with severe back and abdominal pain. Similarly, López-Pardo et al9 also used TEE to identify a descending thoracic aortic dissection reentry site at the level of the celiac artery. Thus, the current case serves to emphasize that transesophageal echocardiographic evaluation of the major arterial branches of the proximal abdominal aorta may be feasible, and such assessment may yield potentially important information about the structural and functional integrity of these essential sources of splanchnic and renal blood supply.
REFERENCES 1. Chouinard MD, Pinheiro L, Nanda NC, et al: Transgastric ultrasonography: A new approach for imaging the abdominal structures and vessels. Echocardiography 8:397-403, 1991 2. Keen RR, Yao JS, Astleford P, et al: Feasibility of transgastic ultrasonography of the abdominal aorta. J Vasc Surg 24:834-842, 1996 3. Orihashi K, Matsuura Y, Sueda T, et al: Abdominal aorta and visceral arteries visualized by transgastric echocardiography: Technical considerations. Hiroshima J Med Sci 46:151-157, 1997 4. Orihashi K, Matsuura Y, Sueda T, et al: Abdominal aorta and visceral arteries visualized with transesophageal echocardiography during operations on the aorta. J Thorac Cardiovasc Surg 115:945-947, 1998 5. Frazin LJ, Siddiqui M, Venugopalan K, et al: Feasibility of transcolonic and transgastic abdominal vascular ultrasound. Am J Card Imaging 8:95-99, 1994
6. Royse CF, Bird H, Royse AG: Routine assessment of coeliac axis and renal blood flow is not feasible with transoesophageal echocardiography. Anaesthesia 64:103-104, 2009 7. Frazin LJ: Editorial: TEE of the descending aorta: Anatomic coherence provided by the celiac artery. Echocardiography 22:283, 2005 8. Frazin J: Transesophageal echocardiographic detection of thoracic aorta dissection extending into the celiac artery. J Am Soc Echocardiogr 16:1186-1187, 2003 9. López-Pardo F, Gomez-Navarro C, Peiro J, et al: Transesophageal echocardiographic detection of aortic dissection with reentry site at the level of the celiac artery. Echocardiography 22:279-281, 2005
An Image From the Dark Side of the Stomach Marc S. Eiseman, MD, Zafar Iqbal, MD, Sandeep Markan, MD, and Paul S. Pagel, MD, PhD
A
62-YEAR-OLD, 129-kg, 177-cm man was admitted to the authors’ institution for the evaluation of progressive chest tightness and dyspnea on exertion. A persantine-thallium stress test revealed a reversible perfusion defect in the left ventricular anterior wall. Coronary angiography showed the presence of a complete occlusion of the proximal left anterior descending coronary artery with extensive collateralization of the central ischemic region provided by branches of the left circumflex coronary artery. The left ventricular ejection fraction was estimated to be 60%. The patient was transported to the operating room for off-pump coronary artery bypass graft surgery
Fig 2. A color-flow Doppler mapping image of the proximal abdominal aorta obtained immediately below the diaphragm (the level of the midpapillary left ventricular short axis) showing laminar blood flow within the proximal aspect of the large blood vessel depicted in Figure 1.
Fig 1. A 2-dimensional short-axis image of the proximal abdominal aorta obtained immediately below the diaphragm (the level of the midpapillary left ventricular short axis) showing the origin and proximal course of a large blood vessel.
(the left internal mammary artery to the left anterior descending artery). After anesthetic induction, transesophageal echocardiography (TEE) was performed. Regional wall motion abnormalities were absent, and the remainder of the heart was normal. The transesophageal echocardiographic probe was rotated counterclockwise from the midpapillary transgastric plane to evaluate the aorta, and the structure depicted in Figures 1 and 2 was observed. What is the diagnosis?
From the Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI. Address reprint requests to Paul S. Pagel, MD, PhD, Clement J. Zablocki Veterans Affairs Medical Center, Anesthesia Service, 5000 W National Avenue, Milwaukee, WI 53295. E-mail: [email protected] © 2011 Elsevier Inc. All rights reserved. 1053-0770/2503-0030$36.00/0 doi:10.1053/j.jvca.2010.02.014 Key words: celiac artery, descending thoracic aorta, abdominal aorta, transesophageal echocardiography, normal anatomy Journal of Cardiothoracic and Vascular Anesthesia, Vol 25, No 3 (June), 2011: pp 565-566
565
566
EISEMAN ET AL
DIAGNOSIS: NORMAL CELIAC ARTERY
The transesophageal echocardiographic examination revealed the celiac artery arising from the proximal abdominal aorta (Fig 1). Blood flow within the artery was normal (Fig 2, pulse-wave Doppler echocardiography not shown). The esophagus is located directly behind the thoracic aorta immediately distal to the aortic arch. As the esophagus and thoracic aorta descend toward the abdomen, the esophagus gradually rotates 180° in a counterclockwise direction around the medial aspect of the aorta, such that the distal esophagus and the cardia of the stomach are transposed anterior to the proximal abdominal aorta. This anatomic orientation facilitates visualization of the origin of several abdominal blood vessels including the celiac, the superior mesenteric, and the right and left renal arteries1-4 unless the transesophageal echocardiographic probe fails to consistently contact the posterior gastric surface.5 Orihashi et al4 reported successful visualization of the celiac and superior mesenteric arteries in 12 consecutive patients undergoing TEE during aortic surgery. The left and right renal arteries also were observed in 59% and 83%, respectively, of patients in this small series.4 In a prospective study of 27
patients undergoing cardiac surgery, Royse et al6 concluded that routine assessment of the celiac axis and renal arteries was not always possible using TEE. Nevertheless, the authors reported that acceptable imaging of the celiac axis was feasible in the majority (81%) of their patients.6 The celiac artery is usually the first reproducibly identifiable landmark to appear arising from the descending aorta after the origin of the left subclavian artery.7 Imaging of the celiac artery may be an especially useful indicator of splanchnic blood flow6 in the presence of aortic pathology. For example, Frazin8 used TEE to detect the extension of a descending thoracic aortic dissection into the celiac artery in an elderly man presenting with severe back and abdominal pain. Similarly, López-Pardo et al9 also used TEE to identify a descending thoracic aortic dissection reentry site at the level of the celiac artery. Thus, the current case serves to emphasize that transesophageal echocardiographic evaluation of the major arterial branches of the proximal abdominal aorta may be feasible, and such assessment may yield potentially important information about the structural and functional integrity of these essential sources of splanchnic and renal blood supply.
REFERENCES 1. Chouinard MD, Pinheiro L, Nanda NC, et al: Transgastric ultrasonography: A new approach for imaging the abdominal structures and vessels. Echocardiography 8:397-403, 1991 2. Keen RR, Yao JS, Astleford P, et al: Feasibility of transgastic ultrasonography of the abdominal aorta. J Vasc Surg 24:834-842, 1996 3. Orihashi K, Matsuura Y, Sueda T, et al: Abdominal aorta and visceral arteries visualized by transgastric echocardiography: Technical considerations. Hiroshima J Med Sci 46:151-157, 1997 4. Orihashi K, Matsuura Y, Sueda T, et al: Abdominal aorta and visceral arteries visualized with transesophageal echocardiography during operations on the aorta. J Thorac Cardiovasc Surg 115:945-947, 1998 5. Frazin LJ, Siddiqui M, Venugopalan K, et al: Feasibility of transcolonic and transgastic abdominal vascular ultrasound. Am J Card Imaging 8:95-99, 1994
6. Royse CF, Bird H, Royse AG: Routine assessment of coeliac axis and renal blood flow is not feasible with transoesophageal echocardiography. Anaesthesia 64:103-104, 2009 7. Frazin LJ: Editorial: TEE of the descending aorta: Anatomic coherence provided by the celiac artery. Echocardiography 22:283, 2005 8. Frazin J: Transesophageal echocardiographic detection of thoracic aorta dissection extending into the celiac artery. J Am Soc Echocardiogr 16:1186-1187, 2003 9. López-Pardo F, Gomez-Navarro C, Peiro J, et al: Transesophageal echocardiographic detection of aortic dissection with reentry site at the level of the celiac artery. Echocardiography 22:279-281, 2005