Surgical and Endovascular Repair of Aortic Coarctation: Normal Findings and Appearance of Complications on CT Angiography and MR Angiography
Ming-Chen Paul Shih1,2,
Ashok Tholpady3,
Christopher M. Kramer1,4,
Malcolm K. Sydnor1,5 and
Klaus D. Hagspiel1
1 Division of Noninvasive Cardiovascular Imaging, Department of Radiology,
University of Virginia Health System, 1215 Lee St., PO Box 800170,
Charlottesville, VA 22908.
2 Department of Medical Imaging, Kaohsiung Medical University Hospital,
Kaohsiung, Taiwan.
3 University of Virginia Medical School, Charlottesville, VA.
4 Division of Cardiology, Department of Medicine, University of Virginia Health
System, Charlottesville, VA.
5 Present address: Department of Radiology, Virginia Commonwealth University
Health System, Richmond, VA.
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Fig. 1 —Surgical techniques for repair of aortic coarctation. Top row
shows end-to-end anastomosis. Segment containing coarctation is resected, and
proximal and distal aortic segments are apposed directly end to end. Second
row shows subclavian flap procedure. Distal subclavian artery is divided, and
flap of proximal portion of vessel is used to widen segment with coarctation.
Third row shows patch aortoplasty. Elliptic woven Dacron (DuPont) patch is
inserted to expand diameter of lumen. Fourth row shows interposition grafting.
If resected segment of coarctation is too long to allow end-to-end
anastomosis, interposition graft is inserted, creating proximal and distal
anastomoses. Bottom row shows extraanatomic bypass graft. Extraanatomic
ascending aorta-to-descending thoracic aorta bypass grafting is created
through median sternotomy and posterior pericardial approach.
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Fig. 2 —39-year-old man after operative repair of aortic coarctation
using end-to-end anastomosis technique in early childhood. Oblique sagittal
multiplanar reformatted CT angiogram shows normal postoperative appearance of
repaired coarctation; arrowheads point to site of anastomosis. Note relatively
distal origin of left subclavian artery close to repair (arrow).
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Fig. 3 —3-year-old girl after surgical repair using end-to-end
anastomosis technique for aortic coarctation. Oblique sagittal
maximum-intensity-projection 3D contrast-enhanced MR angiography shows normal
end-to-end anastomosis features (arrowheads).
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Fig. 4 —27-year-old man who underwent interposition graft repair of
aortic coarctation in early infancy. Oblique sagittal
maximum-intensity-projection 3D contrast-enhanced MR angiography shows
postoperative condition with residual hypoplastic arch (single
arrowhead) and coarctation treated with interposition graft. Arrows show
proximal and distal anastomoses. Note ascending aortic ectasia (double
arrowhead).
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Fig. 5A —3-week-old girl born with preductal coarctation of aorta and
patent ductus arteriosus (PDA) treated with pulmonary homograft repair of
coarctation and ligation of PDA. Maximum-intensity-projection (MIP) oblique
sagittal MDCT angiography shows aortic coarctation (arrow) and PDA
(arrowhead).
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Fig. 5B — 3-week-old girl born with preductal coarctation of aorta and
patent ductus arteriosus (PDA) treated with pulmonary homograft repair of
coarctation and ligation of PDA. Postsurgical MIP (B) and thin-slab MIP
(C) contrast-enhanced MR angiography show appearance after successful
ligation of PDA and proximal and distal anastomoses of pulmonary homograft
(arrows). Note hypoplasia of right lung and right pulmonary artery
with extralobar sequestration (star, B), with afferent blood
supply from infradiaphragmatic abdominal aorta (single arrowhead,
B) and venous drainage to suprahepatic inferior vena cava (double
arrowhead, B). Also note aberrant right subclavian artery
origin.
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Fig. 5C — 3-week-old girl born with preductal coarctation of aorta and
patent ductus arteriosus (PDA) treated with pulmonary homograft repair of
coarctation and ligation of PDA. Postsurgical MIP (B) and thin-slab MIP
(C) contrast-enhanced MR angiography show appearance after successful
ligation of PDA and proximal and distal anastomoses of pulmonary homograft
(arrows). Note hypoplasia of right lung and right pulmonary artery
with extralobar sequestration (star, B), with afferent blood
supply from infradiaphragmatic abdominal aorta (single arrowhead,
B) and venous drainage to suprahepatic inferior vena cava (double
arrowhead, B). Also note aberrant right subclavian artery
origin.
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Fig. 6 —15-year-old girl after subclavian flap surgical repair 11
years earlier. Maximum-intensity-projection MR angiography shows
pseudoaneurysm formation (star) at operative repair site. Note
postsurgical occlusion of proximal left subclavian artery (arrow)
whose distal portion is reconstituted by way of vertebral artery
(arrowhead).
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Fig. 7 —53-year-old man who underwent repair of aortic coarctation 20
years earlier. Maximum-intensity-projection 3D contrast-enhanced MR
angiography shows normal appearance of extraanatomic bypass graft from
ascending to descending thoracic aorta (arrows). Aortic arch distal
to left common carotid artery and proximal descending thoracic aorta is
surgically absent.
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Fig. 8A —36-year-old man with medical history of familial non-Williams
supravalvular aortic stenosis and coarctation who had patch repair of
coarctation at age of 7 years. He returns now for endovascular treatment of
aortic recoarctation. Oblique sagittal maximum-intensity-projection
contrast-enhanced MR angiography (A) and right posterior oblique arch
aortogram (B), done for persistent hypertension, show recoarctation of
aorta (arrows) at site of patch repair with associated left carotid
and left subclavian artery orifice stenoses (arrowheads). A 40-mm
gradient is present across lesion.6
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Fig. 8B —36-year-old man with medical history of familial non-Williams
supravalvular aortic stenosis and coarctation who had patch repair of
coarctation at age of 7 years. He returns now for endovascular treatment of
aortic recoarctation. Oblique sagittal maximum-intensity-projection
contrast-enhanced MR angiography (A) and right posterior oblique arch
aortogram (B), done for persistent hypertension, show recoarctation of
aorta (arrows) at site of patch repair with associated left carotid
and left subclavian artery orifice stenoses (arrowheads). A 40-mm
gradient is present across lesion.6
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Fig. 8C —36-year-old man with medical history of familial non-Williams
supravalvular aortic stenosis and coarctation who had patch repair of
coarctation at age of 7 years. He returns now for endovascular treatment of
aortic recoarctation. Follow-up aortogram after stent placement (C),
oblique sagittal multiplanar reconstruction (D), and volume-rendered
MDCT angiogram (E) show complete resolution of stenosis after balloon
dilatation and stent placement (arrows) in region of coarctation. No
pressure gradient is seen at end of procedure.
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Fig. 8D —36-year-old man with medical history of familial non-Williams
supravalvular aortic stenosis and coarctation who had patch repair of
coarctation at age of 7 years. He returns now for endovascular treatment of
aortic recoarctation. Follow-up aortogram after stent placement (C),
oblique sagittal multiplanar reconstruction (D), and volume-rendered
MDCT angiogram (E) show complete resolution of stenosis after balloon
dilatation and stent placement (arrows) in region of coarctation. No
pressure gradient is seen at end of procedure.
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Fig. 8E —36-year-old man with medical history of familial non-Williams
supravalvular aortic stenosis and coarctation who had patch repair of
coarctation at age of 7 years. He returns now for endovascular treatment of
aortic recoarctation. Follow-up aortogram after stent placement (C),
oblique sagittal multiplanar reconstruction (D), and volume-rendered
MDCT angiogram (E) show complete resolution of stenosis after balloon
dilatation and stent placement (arrows) in region of coarctation. No
pressure gradient is seen at end of procedure.
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Fig. 9A —2-day-old girl with critical coarctation of aorta at birth
complicated by thrombosis of distal arch and proximal descending thoracic
aorta underwent aortotomy, thrombectomy, and coarctation repair with pulmonary
homograft insertion. This was complicated by development of membranous
anastomotic stenosis, which was treated with percutaneous transluminal
angioplasty. Since then, she has undergone repeated balloon angioplasties for
residual obstruction. Maximum-intensity-projection (MIP) contrast-enhanced MR
angiography shows initial appearance of thrombosed arch (arrow)
distal to left common carotid artery and proximal descending thoracic aorta
(arrowhead).
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Fig. 9B —2-day-old girl with critical coarctation of aorta at birth
complicated by thrombosis of distal arch and proximal descending thoracic
aorta underwent aortotomy, thrombectomy, and coarctation repair with pulmonary
homograft insertion. This was complicated by development of membranous
anastomotic stenosis, which was treated with percutaneous transluminal
angioplasty. Since then, she has undergone repeated balloon angioplasties for
residual obstruction. MIP contrast-enhanced MR angiography after surgical
revision and percutaneous transluminal angioplasty for recoarctation shows
membranous stenosis (arrow).
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Fig. 9C —2-day-old girl with critical coarctation of aorta at birth
complicated by thrombosis of distal arch and proximal descending thoracic
aorta underwent aortotomy, thrombectomy, and coarctation repair with pulmonary
homograft insertion. This was complicated by development of membranous
anastomotic stenosis, which was treated with percutaneous transluminal
angioplasty. Since then, she has undergone repeated balloon angioplasties for
residual obstruction. Oblique sagittal cine MR angiography shows jet caused by
membrane proving its hemodynamic significance (arrowhead).
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Fig. 10A —29-year-old woman who underwent patch aortoplasty repair of
aortic coarctation and closure of patent ductus arteriosus (PDA) that occurred
at age 3 years. Three-dimensional contrast-enhanced MR angiography maximum
intensity projection shows trilobed pseudoaneurysms of proximal descending
aorta (arrowhead) just distal to left subclavian artery
(arrow) and between origins of left carotid and subclavian
arteries.
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Fig. 10B —29-year-old woman who underwent patch aortoplasty repair of
aortic coarctation and closure of patent ductus arteriosus (PDA) that occurred
at age 3 years. Axial multiplanar reconstruction of contrast-enhanced MR
angiography shows two of three aneurysms (arrows) protruding from
each side of aortic arch (star).
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Fig. 11A —34-year-old man with history of aortic coarctation operated
on at age 14 years with placement of a Dacron (DuPont) patch. Right posterior
oblique digital subtraction angiogram (A) and
maximum-intensity-projection contrast-enhanced MR angiogram (B) show
pseudoaneurysm (arrows) in region of aortic isthmus where coarctation
was repaired.
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Fig. 11B —34-year-old man with history of aortic coarctation operated
on at age 14 years with placement of a Dacron (DuPont) patch. Right posterior
oblique digital subtraction angiogram (A) and
maximum-intensity-projection contrast-enhanced MR angiogram (B) show
pseudoaneurysm (arrows) in region of aortic isthmus where coarctation
was repaired.
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Fig. 12 —28-year-old man after repair of transposition of great
vessels that occurred as infant and patch repair of aortic coarctation that
occurred at age 6 years. Maximum-intensity-projection contrast-enhanced MR
angiography shows large aneurysm in proximal descending thoracic aorta.
Patient subsequently underwent uneventful surgical tube graft repair.
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Fig. 13A —29-year-old man with aortic coarctation patch repair that
occurred at age 6 years presents with abrupt onset of left chest pain.
Maximum-intensity-projection (A) and volume-rendered (B) MDCT
angiograms show acute rupture of descending thoracic aortic pseudoaneurysm
(B) (star, B) at site of previously repaired aortic
coarctation.
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Fig. 13B —29-year-old man with aortic coarctation patch repair that
occurred at age 6 years presents with abrupt onset of left chest pain.
Maximum-intensity-projection (A) and volume-rendered (B) MDCT
angiograms show acute rupture of descending thoracic aortic pseudoaneurysm
(B) (star, B) at site of previously repaired aortic
coarctation.
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Fig. 13C —29-year-old man with aortic coarctation patch repair that
occurred at age 6 years presents with abrupt onset of left chest pain. Axial
MDCT source image shows site of leak (arrowhead) and hemothorax.
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Fig. 14A —21-year-old woman with history of three previous aortic
coarctation repairs, most recent of which was 8 years earlier and consisted of
interposition Dacron (DuPont) graft. She presented emergently with massive
hemoptysis. Oblique sagittal volume-rendered CT angiography reveals large
pseudoaneurysm at proximal descending thoracic aorta.
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Fig. 14B —21-year-old woman with history of three previous aortic
coarctation repairs, most recent of which was 8 years earlier and consisted of
interposition Dacron (DuPont) graft. She presented emergently with massive
hemoptysis. Axial contrast-enhanced CT image shows hemomediastinum,
hemothorax, and site of leak (arrow).
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Fig. 14C —21-year-old woman with history of three previous aortic
coarctation repairs, most recent of which was 8 years earlier and consisted of
interposition Dacron (DuPont) graft. She presented emergently with massive
hemoptysis. Postoperative maximum-intensity-projection CT angiography reveals
extraanatomic Dacron Hemashield (Meadox Medicals) bypass (arrowheads)
from ascending aorta to intraabdominal supraceliac aorta and surgical
occlusion of arch distal to left common carotid artery and proximal descending
thoracic aorta. Also note extraanatomic graft from aortic graft to left
subclavian artery (arrow).
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Fig. 15A —46-year-old woman with long history of hypertension and
recent diagnosis of congenital coarctation of aorta presented for balloon
angioplasty of coarctation. Angioplasty was performed with near-complete
resolution of initial pressure gradient of 37 mm Hg, but was complicated by
type B aortic dissection. Oblique sagittal maximum-intensity-projection (MIP)
contrast-enhanced MR angiogram shows type B dissection (arrowheads),
which extends from just below coarctation (arrow) to level of celiac
axis. She subsequently underwent stent placement.
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Fig. 15B —46-year-old woman with long history of hypertension and
recent diagnosis of congenital coarctation of aorta presented for balloon
angioplasty of coarctation. Angioplasty was performed with near-complete
resolution of initial pressure gradient of 37 mm Hg, but was complicated by
type B aortic dissection. Axial (B) and sagittal (C) (MIP) CT
angiograms images performed 6 years later show descending thoracic aortic
stent in true lumen (arrowheads) with stable descending thoracic
aortic and abdominal aortic dissection. Dissecting membrane (arrows,
C) terminates between celiac artery and superior mesenteric artery.
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Fig. 15C —46-year-old woman with long history of hypertension and
recent diagnosis of congenital coarctation of aorta presented for balloon
angioplasty of coarctation. Angioplasty was performed with near-complete
resolution of initial pressure gradient of 37 mm Hg, but was complicated by
type B aortic dissection. Axial (B) and sagittal (C) (MIP) CT
angiograms images performed 6 years later show descending thoracic aortic
stent in true lumen (arrowheads) with stable descending thoracic
aortic and abdominal aortic dissection. Dissecting membrane (arrows,
C) terminates between celiac artery and superior mesenteric artery.
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