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Aortic Arch Abnormalities
NHS.
Norman H Silverman MD, D Sc.(Med.). FACC, FAHA.
Stanford University & Lucile Packard Children’s Hospital
IPOK
.
E mail: [email protected]
www.MD1World.com
Abnormalities • Supravalvar Aortic Stenosis• The Aortic Root in Marfan’s Syndrome
• Interruption• Hypoplasia
• High Aortic Arch • Arch Laterality• Coarctation
• Vascular Rings
Examination Technique
• A variety views should be used including :-• Suprasternal coronal and sagittal imaging,• Parasternal and• Subcostal views of the aorta and its relations.• The Imaging should be complemented by
various Doppler modalities including Color flow imaging.
Normal Aortic Arch Echo
Normal Aortic ArchSSN Sagittal
AAo
RPA
IV
RBr
D Ao
Aortic Arch Laterality• Transducer alignment
– The arch direction follows the plane of the array• Innominate Artery
– The innominate artery always bifurcates on the opposite side to the aortic arch.
– Lack of bifurcation may indicate that there is an anomalous subclavian artery
• Tracheal Rings or Esophagus – The descending aorta can be recognized by the examiner
either to the left (in left aortic arch) or to the right (in right aortic arch)
Innominate Artery Shows Arch Position
NHS.
Right Innominate, therefore left arch
Left innominate, therefore right arch
Arch Laterality
A Left Arch
A
R Arch Trachea
Tracheal Rings
Arch Laterality
Right Arch
Left Arch
Routine Arch Sweep
LA
IV
LSA
DAoRPA
TAO
AAo
THYMUS
LCA
Normal Aorta: Color Imaging
Supravalvar Aortic Stenosis
Supravalvar Aortic Stenosis
William’s Syndrome
William’s Syndrome
Supravalvar Aortic Stenosis
L Ax
Ao
LA
RV
LV
Supravalvar Aortic Stenosis
Ao
LVRV
Ao
Subcost.Coronal
P L Ax
Bicuspid Aortic Valve & Multiple Dissections
Aortic Dissection, Coarctation & Bicuspid Aortic Valve
Bicuspid Aortic Valve: Post Stenotic DilatationAAo
LV
AAo
Marfan’s Syndrome
Marfan’s Syndrome
Mariska Kemna
Marfan’s Syndrome: Dilated Aortic Root
P Sax.RV
LA
RA
Ao
DAo
LXRV
Ao
LALA
Marfan’s Syndrome: Dilated Aortic Root
Aortic Regurgitation
Marfan’s Syndrome: Dilated Aortic Root
Marfan’s Syndrome: Dilated Aortic Root
Coarctation
Coarctation
Courtesy Diane Spicer
Coarctation
Pathological Varieties of Coarctation &Techniques of Display
NHS.
DUCTUS SLING IN COARCTATION
Doppler ∆ ofCoarctation
Coarctation
PA Shelf
DAo
Duct Beak
A Ao
NHS.
Color Angiogram in Coarctation
RPA
DAO
Coarctation
Tr Ao Arch
Innominate Artery
L Subclavian
HYPOPLASTIC ISTHMUS
Ductus & ? Coarctation: On Prostaglandin
NHS.
MPA
Duct
Isthmus
? CoarctDAo
LPALA
Coarctation of the Aorta
NHS.
TAO
DAO
PA
OFF PGE1On PGE1
Taussig- Bing Malformation and Coarctation
PA
LA
IV
AAo
TAO
Coarct
D Ao
The Diversity of Coarctation
Coarctation-MRI 3 D Reconstruction
Courtesy of Dr. KerenHasbani
Coarctation: End - to - Side Anastomosis
SSN Cor.
Suture Line
IV
PA
D Ao
Fifth Aortic Arch
PMW ‘07
Interrupted Aortic Arch: Associations
• Ventricular septal defect• Catch 22 Syndrome • Truncus arteriosus• Aortopulmonary Window• Taussig Bing Malformation
Aortic Arch Interruption
C B A
Found with:- 22 Q-Truncus ArteriosusTaussig Bing Aortopulmonary Window VSD
Aortic Arch Interruption
Type B InterruptionAAo
PAD
LSA
Type B Interruption: Ductus & Descending Aorta
MPAAAo
LSA
Duct O AD
LA
NHS.
MPA
RL D
DA
O
LA
Interrupted Aortic Arch Sagittal Plane Imaging
INTERRUPTED ARCH TYPE B
AAo
Duct
LSA
D Ao
In. VnIn. A
Interrupted Arch: 2 Different Doppler Signals
NHS.
a
Truncus with Interrupted Aortic Arch
RVLV
*
A Ao
Tr
LPAD
The VSD in Interruption & Coarctation
Ao
LVRV
A4Ch.
P Lx
RV
Ao
LA
LV
In Coarctation and interruption of the aortic arch, all the woe, lies below!Richard Van Praagh.
Arch Embryology
Arch Embryology
Right Aortic Arch
Left Arch: Cervical Arch and Right Ductus
High ( Cervical ) Arch
Right PA
High ( Cervical ) Arch
Right PA
RAA- LPDAALSCA
DAA
BronchoscopyRT Mainstem Bronchus Compression
LT RT
Coronal Scan
Double Aortic Arch
R L
AAO
Double Aortic Arch
Fetal Double Aortic Arch
Double Aortic Arch
L Duct, Right Ao Arch
Interrupted Aortic Arch, R Desc. Ao & R Duct- Another Bronchial Vise
CP1281387-6
Right Arch with Aberrant Left Subclavian
Diverticulum of Kommerell's
Left ductus
Left subclavian
RING
CP1281387-6
Left ductus From innominate
Right ArchMirror Image Branching
Right Arch Mirror-image Branching and No Ring
NO RING
Right Aortic Arch – Aberrant L subclavian artery and L arterial duct
CP1281387-9
Left Aortic Arch with Aberrant Right Subclavian
Aberrant
RT SCA
Left Duct with Right Aortic Arch
EJCTS 2002
10 Reoperations
7 Primary operations
Resection of Kommerell’s diverticulum and left subclavian artery transfer for recurrent symptoms after vascular ring division
C.L. Backer, N. Hillman, C. Mavroudis, L.D. Holinger
Kommerell’s Diverticulum
Aortic diverticulum
Kommerell’s Diverticulum
Left Ductus: Right Arch
NHS.
Potentially Isolated L subclav.Art
BILATERAL DUCTS WITH ABSENT CENTRAL PA ‘S
Bilateral Ductus
Bilateral Ducts & Absent Central PA’s
Right Arch and Duct
Left Innominate and Duct
MAPCA’s
D A OLA
S Cost Sagittal
S SostCoronal
P Sx
Pulmonary Artery SlingFront
Back
CT Bronchial Tomography
Pulmonary artery Sling ECHO
LPA
PA Sling
Pulmonary Artery Sling
LPA
RPA
Pulmonary Artery Sling
AO
MPA
PSX
RPALPA
AOMPA
RPA
LPA
Thank You!