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Patent Ductus Arteriosus Masquerading as Traumatic Aortic Rupture at Aortography: The Complementary Role of Transesophageal Echocardiography
nterventional Radiologist at Work
1
Patent Ductus Arteriosus Masquerading as Traumatic Aortic Rupture at Aortography: The Complementary Role of Transesophageal ~chocardiogra~h~' Jason C. Smith, MD Douglas C. Smith, MD Kamran Ahrar, MD Ramesh C. Bansal, MD
.
Index terms: Aorta, injuries Aortography Ductus arteriosus Echocardiography, transesophageal Trauma
JVIR 1999; 10:169-171
' From the Department of Radiology (J.C.S., D.C.S., K.A.) and the Cardiology Section, Department of Internal Medicine (R.C.B.), Loma Linda University Medical Center, 11234 Anderson St., 2605 Schuman Pavilion, Lorna Linda, CA 92354. Received April 13, 1998; revision requested May 21; final revision received and accepted June 16. Address correspondence to J.C.S. O SCVIR, 1999
IN recent years, there has been increasing debate regarding the appropriate work-up of suspected traumatic aortic rupture. Whereas aortography has traditionally been accepted as the gold standard, some have proposed that transesophageal echocardiography (TEE) can more efficiently and just as effectively image aortic rupture ( 1 3 . The relative advantages and disadvantages of each modality have been discussed in the literature, but no clear consensus has been reached as to the relative efficacy of each (1-4). The ideal modality should accurately detect suspected aortic injuries rapidly and with as few false-negative diagnoses as possible, which could lead to disastrous consequences. Although aortography remains the gold standard, occasional false-positive results have been reported (5-7), leading to unnecessary surgery. The major limitation of TEE is its inability to consistently evaluate the distal ascending aorta and the aortic arch branches (4).We present a case of a patent ductus arteriosus (PDA) in a 17-year-oldboy who was involved in a motor vehicle accident, and who was initially thought at aortography to have aortic rupture. We discuss the complementary role that TEE may have when aortographic findings are indeterminate. CASE REPORT
A 17-year-old boy was involved in a high-speed motor vehicle acci-
dent and was ejected from the back of a pick-up truck. On initial evaluation in the emergency department, the patient was alert but combative, had a flail right chest, and was normotensive. The chest radiograph showed thickening of the right paratracheal stripe, displacement of the left paravertebral line, and bilateral lung contusions; also, the aortic knob was not well seen (Fig 1). A contrast-enhanced computed tomographic (CT) scan of the chest was obtained, which showed bilateral hemopneumothoraces and pulmonary contusions, compression fractures of T-8 through L-2 vertebral bodies, fractures of the right 8th-12th posterior ribs, and extensive hemorrhage surrounding the descending thoracic aorta. A right chest tube was inserted, and shortly thereafter he became progressively unresponsive and hypotensive. He was then intubated. An emergent conventional left anterior oblique thoracic aortogram was obtained with use of a 7-F pigtail catheter. The aortogram demonstrated an abrupt, tubular projection of contrast material from the aorta at the level of the ligamentum arteriosum (Fig 2). This projection of contrast material was diagnosed as a traumatic pseudoaneurysm of the aorta. Because of the extensive hemorrhage adjacent to the descending thoracic aorta demonstrated on CT scans and contrast enhancement in the periaortic region on the thoracic aortogram, a
170
Interventional Radiologist at Work
February 1999 JVIR
Nine months after his injury, telephone inquiry revealed that the patient was in a convalescent facility because of paraplegia, but was otherwise doing well.
1 DISCUSSION Figure 3. Black and white print of a color TEE image of the distal aortic
Figure 1. Initial chest radiograph
shows thickening of the right paratracheal stripe, displacement of the left paravertebral line (arrow), and bilateral lung contusions. The aortic knob is not well seen.
Figure 2. Conventional left anterior oblique thoracic aortogram reveals a tubular projection of contrast material from the aorta (arrow).
digital subtraction descending thoracic aortogram, a s well a s selective catheterization of intercostal and lumbar arteries, was performed. Extravasation of contrast material from the right 9th-11th and left 9th and 10th posterior intercostal arteries, a s well a s the right 1st lumbar artery, was identified and transcatheter coil embolization with use
arch obtained with a multiplane probe with sectioning plane set at 0" showing a left-to-right shunt (arrows) through a small PDA emanating from the aorta (AO).
of a 3-F coaxial catheter was successfully performed in all six arteries. Selective catheterization and embolization added 65 minutes to the duration of angiography, during which time the operating suite was being readied for surgery. On arrival to the operating room, the patient was noted to be severely hypoxic, acidotic, and coagulopathic. Because of his critically compromised status, surgical intervention was postponed, and the patient was transferred to the surgical intensive care unit for stabilization. His respiratory status deteriorated, leading to adult respiratory distress syndrome. Two weeks later, while waiting for the patient to stabilize, further review of the aortogram was performed. Because of the unusual tubular configuration of the aortic projection of contrast material, the diagnosis of a n aortic rupture was believed to be less certain. Accordingly, on the next day (1day prior to proposed thoracotomy), a TEE was requested for clarification, which revealed no evidence of a n intimal flap or pseudoaneurysm. Instead, a small-sized, left-to-right shunt through a patent ductus arteriosus was shown (Fig 3). Continuous wave Doppler examination did not allow for determination of the flow velocity. Surgery was averted, the patient's clinical course began to improve, and on the 18th hospital day he was transferred in stable condition to the rehabilitation unit.
Aortic r u ~ t u r eis one of the most severe complications of blunt chest trauma and affects approximately 8,000 people annually (8). While the classic 1958 article by Parmley et a1 states that only 15% of patients with aortic rupture arrived alive a t the hospital (91, a more recent article states that with recent improvements in prehospital transport and treatment, many more patients with aortic rupture reach the hospital alive (10). Prompt and accurate diagnosis of aortic rupture and aortic arch branch injury is essential to give the patient a n optimal chance for survival. For many years, aortography has been considered the gold standard in the diagnosis of aortic rupture. Recently, a number of publications have promoted the use of TEE for this purpose (1,2). Proponents of TEE report that it can be performed portably and more rapidly than aortography, typically detects subclinical lesions that are missed by angiography such a s limited intimal tears, concurrently evaluates myocardial and hemodynamic abnormalities, is minimally invasive, and costs less than aortography (1,2). Critics point out that TEE cannot image the distal ascending aorta and most aortic arch branches well, and aortography is just a s sensitive and specific a s TEE and is more readily available a t most institutions (3,4,11,12). Minard et a1 reviewed the literature and combined their data with those of previously reported results and noted that the overall sensitivity for detecting aortic injuries is 85% for TEE versus 77%-92% for aortography, while the specificity reaches 93% and 99% for TEE and aortography, respectively (3). If subclinical, isolated intimal tears diagnosed with TEE alone are excluded, the sensitivity of aortography reached 92%. These authors stated t h a t
Smith et a1 a 171 Volume 10 Number 2
TEE is not ready to replace aortography as the standard diagnostic modality in suspected aortic rupture (3). Relative contraindications to performing TEE include difficulties commonly encountered in the trauma patient, such as maxillofacia1 fractures, unstable cervical spines, and nonintubated patients requiring sedation (where aspiration and airway compromise is a risk). Aortography, on the other hand, can be performed safely in almost all hemodynamically stable patients. The classical aortic ductus bump has been reported to be present in 9%-26% of patients (7,13) and usually presents no difficulty in differentiation from a pseudoaneurysm of aortic rupture. However, when an atypical ductus does not demonstrate the usual sloping, obtuse caudal and cranial margins, differentiating it from a pseudoaneurysm is more difficult (6,7,13). In studying the aortographic appearance of ductus bumps in 51 patients, Morse et a1 found that the angle between the caudal end of the bump and the aorta was obtuse in all 51, while the cranial angle was acute in six of 51 (7). The appearance of the abnormal projection of contrast material from the aorta in our case was initially believed to be similar to that seen by us in several surgically confirmed cases of aortic rupture. It is also somewhat similar to a case of atypical aortic rupture illustrated recently by Fisher et a1 (14) in which a small projection of contrast material was somewhat tubular. However, further review 2 weeks later with a second radiologist cast doubt on the initial diagnosis of traumatic aortic rupture, thus prompting the need to obtain TEE prior to surgery. It was the unusual tubular configuration of this projection, not the fact that the patient survived 2 weeks, that caused this uncertainty. Flow through the PDA into the
pulmonary artery was readily apparent at TEE but not at aortography. We believe that this occurred because the flow through PDA was very minimal and the sensitivity to detect a small left-to-right shunt is much greater with color flow Doppler using TEE than is contrast aortography. Although PDA usually resolves andlor is detected in early life, it occasionally persists into adulthood. It is readily demonstrated with TEE (15). The most common presenting symptoms are dyspnea and exercise intolerance, and the most serious complications are pulmonary hypertension and infective endarteritis of the pulmonary artery. In our patient, the PDA was asymptomatic and only discovered incidentally at the time of trauma.
I CONCLUSION We present a case of blunt deceleration injury to the thorax in which aortic rupture was initially thought to be present a t aortography. Subsequent TEE revealed this outpouching of contrast material to be a PDA. We believe that aortography remains the optimal imaging modality in suspected injury of the thoracic aorta and the aortic arch branches. However, TEE has a complimentary role in evaluating indeterminate angiographic lesions. References 1. Smith MD, Cassidy JM, South S, et
al. Transesophageal echocardiography in the diagnosis of traumatic rupture of the aorta. N Engl J Med 1995; 332~356-362. 2. Goarin J P , Catoire P, Jacquens Y, et al. Use of transesophageal echocardiography for diagnosis of traumatic aortic injury. Chest 1997; 112: 71-80. 3. Minard G, Schurr MJ, Croce MA, et al. Prospective analysis of transesophageal echocardiography in the diagnosis of traumatic disruption of the aorta. J Trauma 1996; 40:225230.
Ahrar K, Smith DC, Bansal RC, Razzouk A, Catalano RD. Angiography in blunt thoracic aortic injury. J Trauma 1997; 42:665-669. Orron DE, Porter DH, Kim D, Tortella B. False-positive aortography following blunt chest trauma: case report. Cardiovasc Intervent Radiol 1998; 11:132-135. Fisher RG, Sanchez-Torres M, Whigham CJ, Thomas JW. "Lumps" and "bumps" that mimic acute aortic and brachiocephalic vessel injury. RadioGraphics 1997; 17:825-834. Morse SS, Glickman MG, Greenwood LH, et al. Traumatic aortic rupture: false-positive aortographic diagnosis due to atypical ductus diverticulum. AJR 1998; 150:793-796. Mattox KL. Fact and fiction about management of aortic transection. Ann Thorac Surg 1989; 48:l-2. Parmley LF, Mattingly TW, Manion WC, Jahnke E J Jr. Nonpenetrating traumatic injury of the aorta. Circulation 1958; 17:1086-1101. Townsend RN, Colella J J , Diamond DL. Traumatic rupture of the aorta: critical decisions for trauma surgeons. J Trauma 1990; 30:11691174. Creasy JD, Chiles C, Routh WD, Dyer RB. Overview of traumatic injury of the thoracic aorta. RadioGraphics 1997; 17:27-45. Vignon P, Ostyn E, Francois B, Hojeij H, Gastinne H, Lang RM. Limitation of transesophageal echocardiography for the diagnosis of traumatic injuries to aortic branches. J Trauma 1997; 42:960963. Goodman PC, Jeffrey RB, Minagi H, Federle MP, Thomas AN. Angiographic evaluation of the ductus diverticulum. Cardiovasc Intervent Radiol 1982; 5:l-4. Fisher RG, Sanchez-Torres M, Thomas JW, Whigham CJ. Subtle or atypical injuries of the thoracic aorta and brachiocephalic vessels in blunt thoracic trauma. RadioGraphics 1997; 172335-849. Andrade A, Vargas-Barron J , Rijlaarsdam M, Romero-Cardenas A, Keirns C, Espinola N. Utility of transesophageal echocardiography in the examination of adult patients with ductus arteriosus. Am Heart J 1995; 130:543-546.
1
Patent Ductus Arteriosus Masquerading as Traumatic Aortic Rupture at Aortography: The Complementary Role of Transesophageal ~chocardiogra~h~' Jason C. Smith, MD Douglas C. Smith, MD Kamran Ahrar, MD Ramesh C. Bansal, MD
.
Index terms: Aorta, injuries Aortography Ductus arteriosus Echocardiography, transesophageal Trauma
JVIR 1999; 10:169-171
' From the Department of Radiology (J.C.S., D.C.S., K.A.) and the Cardiology Section, Department of Internal Medicine (R.C.B.), Loma Linda University Medical Center, 11234 Anderson St., 2605 Schuman Pavilion, Lorna Linda, CA 92354. Received April 13, 1998; revision requested May 21; final revision received and accepted June 16. Address correspondence to J.C.S. O SCVIR, 1999
IN recent years, there has been increasing debate regarding the appropriate work-up of suspected traumatic aortic rupture. Whereas aortography has traditionally been accepted as the gold standard, some have proposed that transesophageal echocardiography (TEE) can more efficiently and just as effectively image aortic rupture ( 1 3 . The relative advantages and disadvantages of each modality have been discussed in the literature, but no clear consensus has been reached as to the relative efficacy of each (1-4). The ideal modality should accurately detect suspected aortic injuries rapidly and with as few false-negative diagnoses as possible, which could lead to disastrous consequences. Although aortography remains the gold standard, occasional false-positive results have been reported (5-7), leading to unnecessary surgery. The major limitation of TEE is its inability to consistently evaluate the distal ascending aorta and the aortic arch branches (4).We present a case of a patent ductus arteriosus (PDA) in a 17-year-oldboy who was involved in a motor vehicle accident, and who was initially thought at aortography to have aortic rupture. We discuss the complementary role that TEE may have when aortographic findings are indeterminate. CASE REPORT
A 17-year-old boy was involved in a high-speed motor vehicle acci-
dent and was ejected from the back of a pick-up truck. On initial evaluation in the emergency department, the patient was alert but combative, had a flail right chest, and was normotensive. The chest radiograph showed thickening of the right paratracheal stripe, displacement of the left paravertebral line, and bilateral lung contusions; also, the aortic knob was not well seen (Fig 1). A contrast-enhanced computed tomographic (CT) scan of the chest was obtained, which showed bilateral hemopneumothoraces and pulmonary contusions, compression fractures of T-8 through L-2 vertebral bodies, fractures of the right 8th-12th posterior ribs, and extensive hemorrhage surrounding the descending thoracic aorta. A right chest tube was inserted, and shortly thereafter he became progressively unresponsive and hypotensive. He was then intubated. An emergent conventional left anterior oblique thoracic aortogram was obtained with use of a 7-F pigtail catheter. The aortogram demonstrated an abrupt, tubular projection of contrast material from the aorta at the level of the ligamentum arteriosum (Fig 2). This projection of contrast material was diagnosed as a traumatic pseudoaneurysm of the aorta. Because of the extensive hemorrhage adjacent to the descending thoracic aorta demonstrated on CT scans and contrast enhancement in the periaortic region on the thoracic aortogram, a
170
Interventional Radiologist at Work
February 1999 JVIR
Nine months after his injury, telephone inquiry revealed that the patient was in a convalescent facility because of paraplegia, but was otherwise doing well.
1 DISCUSSION Figure 3. Black and white print of a color TEE image of the distal aortic
Figure 1. Initial chest radiograph
shows thickening of the right paratracheal stripe, displacement of the left paravertebral line (arrow), and bilateral lung contusions. The aortic knob is not well seen.
Figure 2. Conventional left anterior oblique thoracic aortogram reveals a tubular projection of contrast material from the aorta (arrow).
digital subtraction descending thoracic aortogram, a s well a s selective catheterization of intercostal and lumbar arteries, was performed. Extravasation of contrast material from the right 9th-11th and left 9th and 10th posterior intercostal arteries, a s well a s the right 1st lumbar artery, was identified and transcatheter coil embolization with use
arch obtained with a multiplane probe with sectioning plane set at 0" showing a left-to-right shunt (arrows) through a small PDA emanating from the aorta (AO).
of a 3-F coaxial catheter was successfully performed in all six arteries. Selective catheterization and embolization added 65 minutes to the duration of angiography, during which time the operating suite was being readied for surgery. On arrival to the operating room, the patient was noted to be severely hypoxic, acidotic, and coagulopathic. Because of his critically compromised status, surgical intervention was postponed, and the patient was transferred to the surgical intensive care unit for stabilization. His respiratory status deteriorated, leading to adult respiratory distress syndrome. Two weeks later, while waiting for the patient to stabilize, further review of the aortogram was performed. Because of the unusual tubular configuration of the aortic projection of contrast material, the diagnosis of a n aortic rupture was believed to be less certain. Accordingly, on the next day (1day prior to proposed thoracotomy), a TEE was requested for clarification, which revealed no evidence of a n intimal flap or pseudoaneurysm. Instead, a small-sized, left-to-right shunt through a patent ductus arteriosus was shown (Fig 3). Continuous wave Doppler examination did not allow for determination of the flow velocity. Surgery was averted, the patient's clinical course began to improve, and on the 18th hospital day he was transferred in stable condition to the rehabilitation unit.
Aortic r u ~ t u r eis one of the most severe complications of blunt chest trauma and affects approximately 8,000 people annually (8). While the classic 1958 article by Parmley et a1 states that only 15% of patients with aortic rupture arrived alive a t the hospital (91, a more recent article states that with recent improvements in prehospital transport and treatment, many more patients with aortic rupture reach the hospital alive (10). Prompt and accurate diagnosis of aortic rupture and aortic arch branch injury is essential to give the patient a n optimal chance for survival. For many years, aortography has been considered the gold standard in the diagnosis of aortic rupture. Recently, a number of publications have promoted the use of TEE for this purpose (1,2). Proponents of TEE report that it can be performed portably and more rapidly than aortography, typically detects subclinical lesions that are missed by angiography such a s limited intimal tears, concurrently evaluates myocardial and hemodynamic abnormalities, is minimally invasive, and costs less than aortography (1,2). Critics point out that TEE cannot image the distal ascending aorta and most aortic arch branches well, and aortography is just a s sensitive and specific a s TEE and is more readily available a t most institutions (3,4,11,12). Minard et a1 reviewed the literature and combined their data with those of previously reported results and noted that the overall sensitivity for detecting aortic injuries is 85% for TEE versus 77%-92% for aortography, while the specificity reaches 93% and 99% for TEE and aortography, respectively (3). If subclinical, isolated intimal tears diagnosed with TEE alone are excluded, the sensitivity of aortography reached 92%. These authors stated t h a t
Smith et a1 a 171 Volume 10 Number 2
TEE is not ready to replace aortography as the standard diagnostic modality in suspected aortic rupture (3). Relative contraindications to performing TEE include difficulties commonly encountered in the trauma patient, such as maxillofacia1 fractures, unstable cervical spines, and nonintubated patients requiring sedation (where aspiration and airway compromise is a risk). Aortography, on the other hand, can be performed safely in almost all hemodynamically stable patients. The classical aortic ductus bump has been reported to be present in 9%-26% of patients (7,13) and usually presents no difficulty in differentiation from a pseudoaneurysm of aortic rupture. However, when an atypical ductus does not demonstrate the usual sloping, obtuse caudal and cranial margins, differentiating it from a pseudoaneurysm is more difficult (6,7,13). In studying the aortographic appearance of ductus bumps in 51 patients, Morse et a1 found that the angle between the caudal end of the bump and the aorta was obtuse in all 51, while the cranial angle was acute in six of 51 (7). The appearance of the abnormal projection of contrast material from the aorta in our case was initially believed to be similar to that seen by us in several surgically confirmed cases of aortic rupture. It is also somewhat similar to a case of atypical aortic rupture illustrated recently by Fisher et a1 (14) in which a small projection of contrast material was somewhat tubular. However, further review 2 weeks later with a second radiologist cast doubt on the initial diagnosis of traumatic aortic rupture, thus prompting the need to obtain TEE prior to surgery. It was the unusual tubular configuration of this projection, not the fact that the patient survived 2 weeks, that caused this uncertainty. Flow through the PDA into the
pulmonary artery was readily apparent at TEE but not at aortography. We believe that this occurred because the flow through PDA was very minimal and the sensitivity to detect a small left-to-right shunt is much greater with color flow Doppler using TEE than is contrast aortography. Although PDA usually resolves andlor is detected in early life, it occasionally persists into adulthood. It is readily demonstrated with TEE (15). The most common presenting symptoms are dyspnea and exercise intolerance, and the most serious complications are pulmonary hypertension and infective endarteritis of the pulmonary artery. In our patient, the PDA was asymptomatic and only discovered incidentally at the time of trauma.
I CONCLUSION We present a case of blunt deceleration injury to the thorax in which aortic rupture was initially thought to be present a t aortography. Subsequent TEE revealed this outpouching of contrast material to be a PDA. We believe that aortography remains the optimal imaging modality in suspected injury of the thoracic aorta and the aortic arch branches. However, TEE has a complimentary role in evaluating indeterminate angiographic lesions. References 1. Smith MD, Cassidy JM, South S, et
al. Transesophageal echocardiography in the diagnosis of traumatic rupture of the aorta. N Engl J Med 1995; 332~356-362. 2. Goarin J P , Catoire P, Jacquens Y, et al. Use of transesophageal echocardiography for diagnosis of traumatic aortic injury. Chest 1997; 112: 71-80. 3. Minard G, Schurr MJ, Croce MA, et al. Prospective analysis of transesophageal echocardiography in the diagnosis of traumatic disruption of the aorta. J Trauma 1996; 40:225230.
Ahrar K, Smith DC, Bansal RC, Razzouk A, Catalano RD. Angiography in blunt thoracic aortic injury. J Trauma 1997; 42:665-669. Orron DE, Porter DH, Kim D, Tortella B. False-positive aortography following blunt chest trauma: case report. Cardiovasc Intervent Radiol 1998; 11:132-135. Fisher RG, Sanchez-Torres M, Whigham CJ, Thomas JW. "Lumps" and "bumps" that mimic acute aortic and brachiocephalic vessel injury. RadioGraphics 1997; 17:825-834. Morse SS, Glickman MG, Greenwood LH, et al. Traumatic aortic rupture: false-positive aortographic diagnosis due to atypical ductus diverticulum. AJR 1998; 150:793-796. Mattox KL. Fact and fiction about management of aortic transection. Ann Thorac Surg 1989; 48:l-2. Parmley LF, Mattingly TW, Manion WC, Jahnke E J Jr. Nonpenetrating traumatic injury of the aorta. Circulation 1958; 17:1086-1101. Townsend RN, Colella J J , Diamond DL. Traumatic rupture of the aorta: critical decisions for trauma surgeons. J Trauma 1990; 30:11691174. Creasy JD, Chiles C, Routh WD, Dyer RB. Overview of traumatic injury of the thoracic aorta. RadioGraphics 1997; 17:27-45. Vignon P, Ostyn E, Francois B, Hojeij H, Gastinne H, Lang RM. Limitation of transesophageal echocardiography for the diagnosis of traumatic injuries to aortic branches. J Trauma 1997; 42:960963. Goodman PC, Jeffrey RB, Minagi H, Federle MP, Thomas AN. Angiographic evaluation of the ductus diverticulum. Cardiovasc Intervent Radiol 1982; 5:l-4. Fisher RG, Sanchez-Torres M, Thomas JW, Whigham CJ. Subtle or atypical injuries of the thoracic aorta and brachiocephalic vessels in blunt thoracic trauma. RadioGraphics 1997; 172335-849. Andrade A, Vargas-Barron J , Rijlaarsdam M, Romero-Cardenas A, Keirns C, Espinola N. Utility of transesophageal echocardiography in the examination of adult patients with ductus arteriosus. Am Heart J 1995; 130:543-546.