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Two-Step Postmortem Angiography with a Modified Heart–Lung Machine: Preliminary Results

Silke Grabherr1,2, Erich Gygax3, Barbara Sollberger3, Steffen Ross1, Lars Oesterhelweg1, Stephan Bolliger1, Andreas Christe1,4, Valentin Djonov5, Michael J. Thali1 and Richard Dirnhofer1

1 Center of Forensic Imaging and Virtopsy, Institute of Forensic Medicine, University of Bern, Bern, Switzerland.
2 Institute of Forensic Medicine, University of Lausanne, Rue du Bugnon 21, CH-1005 Lausanne, Switzerland.
3 Department of Cardiovascular Surgery, University of Bern, Inselspital, Bern, Switzerland.
4 Institute of Diagnostic Radiology, University of Bern, Inselspital, Bern, Switzerland.
5 Institute of Anatomy, University of Bern, Bern, Switzerland.


Figure 1
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  		Fig. 1A —Methodologic setup. Photographs show delivery of oily perfusate (A) via modified heart–lung machine (B) to human cadaver on CT table (C). Perfusate leaves vascular system (D) together with remaining blood and postmortem clots (arrow, D). Minutes after perfusion is established, iodized oil is injected either indirectly through three-way stopcock attached to tube system or directly into vein.

 

Figure 2
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  		Fig. 1B —Methodologic setup. Photographs show delivery of oily perfusate (A) via modified heart–lung machine (B) to human cadaver on CT table (C). Perfusate leaves vascular system (D) together with remaining blood and postmortem clots (arrow, D). Minutes after perfusion is established, iodized oil is injected either indirectly through three-way stopcock attached to tube system or directly into vein.

 

Figure 3
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  		Fig. 1C —Methodologic setup. Photographs show delivery of oily perfusate (A) via modified heart–lung machine (B) to human cadaver on CT table (C). Perfusate leaves vascular system (D) together with remaining blood and postmortem clots (arrow, D). Minutes after perfusion is established, iodized oil is injected either indirectly through three-way stopcock attached to tube system or directly into vein.

 

Figure 4
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  		Fig. 1D —Methodologic setup. Photographs show delivery of oily perfusate (A) via modified heart–lung machine (B) to human cadaver on CT table (C). Perfusate leaves vascular system (D) together with remaining blood and postmortem clots (arrow, D). Minutes after perfusion is established, iodized oil is injected either indirectly through three-way stopcock attached to tube system or directly into vein.

 

Figure 5
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  		Fig. 2A —Cadaver of man who died with signs of peripheral arterial occlusion. Angiogram of leg shows typical signs of peripheral arterial occlusion disease, such as cyanosis, hair loss, and glabrous shiny skin, and of venous insufficiency, such as hyperpigmentation (inset). Three-dimensional model of lower extremities affords overview of angiographic findings. Cannula, which is connected to tube (arrows), has been inserted into right femoral artery. Perfused vessels of entire leg are visible.

 

Figure 6
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  		Fig. 2B —Cadaver of man who died with signs of peripheral arterial occlusion. Angiogram shows large number of perfused thigh vessels. In leg, only large supplying arteries, such as dorsalis pedis (bottom arrow), are apparent. Vessels of foot are intricately depicted. Top arrows indicate cannulas and parts of tube.

 

Figure 7
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  		Fig. 2C —Cadaver of man who died with signs of peripheral arterial occlusion. High-magnification image of foot shows branches of dorsalis pedis artery (arrow), which supply sole and heel.

 

Figure 8
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  		Fig. 2D —Cadaver of man who died with signs of peripheral arterial occlusion. Lateral angiogram of 3D model shows vascular supply to right knee. Occlusion (arrow) of main vessel is evidenced by abrupt interruption of contrast agent.

 

Figure 9
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  		Fig. 2E —Cadaver of man who died with signs of peripheral arterial occlusion. Angiogram of popliteal space shows occluded vessel to be posterior tibial artery (single arrow). Second great artery divides short distance from its origin into two main branches (double arrow) proximal to further anastomosis into many smaller branches.

 

Figure 10
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  		Fig. 3A —Cadaver of 39-year-old man with drug overdose as probable cause of death. Three-dimensional reconstructions of left upper extremity show superficial (A) and deep (B) veins. Top arrow (B) indicates brachial vein; middle arrow, medial cubital vein; bottom arrow, cephalic vein.

 

Figure 11
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  		Fig. 3B —Cadaver of 39-year-old man with drug overdose as probable cause of death. Three-dimensional reconstructions of left upper extremity show superficial (A) and deep (B) veins. Top arrow (B) indicates brachial vein; middle arrow, medial cubital vein; bottom arrow, cephalic vein.

 

Figure 12
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  		Fig. 3C —Cadaver of 39-year-old man with drug overdose as probable cause of death. Three-dimensional reconstruction of left hand at higher magnification than A and B shows entire venous system and part of arterial system. Single arrow indicates ulnar artery; double arrows, ulnar veins.

 

Figure 13
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  		Fig. 3D —Cadaver of 39-year-old man with drug overdose as probable cause of death. Maximum-intensity-projection reconstruction of elbow shows site of injection mark in left cubital space, medial cubital vein in longitudinal plane (left arrow), and contrast agent (right arrows) exuding from vessel. At same level, surface of skin is raised (arrowhead).

 

Figure 14
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  		Fig. 3E —Cadaver of 39-year-old man with drug overdose as probable cause of death. Three-dimensional reconstruction of affected region shows extravascular accumulation of contrast agent (arrow).

 

Figure 15
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  		Fig. 3F —Cadaver of 39-year-old man with drug overdose as probable cause of death. Photograph shows macroscopic view of hematoma in left cubital fossa. In center of hematoma, fresh injection mark (arrow) is visible. Blood and oily perfusate were pressed out of lesion.

 

Figure 16
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  		Fig. 4A —Cadaver of 29-year-old woman with history of IV drug abuse. Three-dimensional reconstruction obtained after additional IV injection of contrast agent into cephalic vein shows surface of skin and superficial veins of left forearm. Extravasation of contrast agent (dotted line) around injection mark (arrow) is apparent.

 

Figure 17
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  		Fig. 4B —Cadaver of 29-year-old woman with history of IV drug abuse. Three-dimensional reconstruction obtained after virtual removal of soft tissue shows veins with greater clarity than in A. Fragility and poor condition of veins is evidenced by laminar extravasation of contrast agent (small thin arrows) and by almost periodic narrowing of vessel lumina (large thin arrows). Thick arrow denotes site at which contrast agent was injected.

 

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