Three-Dimensional Echocardiographic Evaluation of the Celiac Trunk and Superior Mesenteric Artery in Aortic Dissection

P0348 

Abstract Submission 

Jamie Bloom (1), Audrey Spelde (1), Waseem Lutfi (2), Kendall Lawrence (2), Edward Percy (1), Chase Brown (3), Joseph Bavaria (1), Asad Usman (1)

(1) Hospital of the University of Pennsylvania, Philadelphia, PA, (2) University of Pennsylvania, Philadelphia, PA, (3) University of Pennsylvania, PHILADELPHIA, PA

Jamie Bloom    -  Contact Me
Hospital of the University of Pennsylvania

Audrey Spelde    -  Contact Me
Hospital of the University of Pennsylvania

Waseem Lutfi    -  Contact Me
University of Pennsylvania

Kendall Lawrence    -  Contact Me
University of Pennsylvania

Edward Percy    -  Contact Me
Hospital of the University of Pennsylvania

Chase Brown    -  Contact Me
University of Pennsylvania

*Joseph Bavaria    -  Contact Me
Hospital of the University of Pennsylvania

Asad Usman    -  Contact Me
Hospital of the University of Pennsylvania

Jamie Bloom    -  Contact Me
N/A

Introduction

Two-dimensional (2D) TEE enables echocardiographers to dynamically evaluate the anatomy of an aortic dissection and assess blood flow through branch vessels.1 Mesenteric ischemia has an associated mortality rate of 63.2%. Abdominal pain, lactic acidosis, evidence of liver dysfunction, or findings of celiac trunk or superior mesenteric artery occlusion on imaging may prompt further evaluation for visceral malperfusion.2 The optimal timing of direct surgical or endovascular stabilization of mesenteric blood flow remains controversial,2 although preventing or reversing visceral malperfusion seems crucial to reducing postoperative morbidity and mortality.

TEE can be used to diagnose visceral malperfusion in the OR or at the bedside for patients who are too unstable for computed tomographic angiography (CTA).2,3 TEE has particular utility when visceral malperfusion is dynamic, due to intermittent occlusion of visceral lumina or changes in regional blood flow after blood pressure reduction.3 TEE findings indicating reduced blood flow to the celiac trunk or superior mesenteric artery should prompt intervention on the dissected portions of the descending thoracic or abdominal aorta.

Methods

Philips 7CVxi echocardiography machines and X8-2T transducers were used to obtain celiac, SMA and abdominal aortic imaging between 0 – 30 degrees in the transgastric view. The celiac trunk and superior mesenteric artery were interrogated for patency, origin from the true aortic lumen, and extension of any dissection into these arteries.

Results

3D images show dynamic aortic flap motion impacting the celiac trunk and SMA. Patency is assessed structurally and color doppler proves blood flow.

Conclusion

TEE assess blood flow to the celiac trunk and SMA. Though static obstruction physiology is better diagnosed on CTA, dynamic obstruction mechanistically explains up to 80% of malperfusion syndromes.3 The ability to consistently view the celiac trunk and superior mesenteric artery with TEE has been demonstrated in case reports and single center case series; the attempts to characterize the celiac trunk have a high reported success rate (99-100%), although there is greater reported variability in the success rate of visualization of the orifice of the SMA (may be as low as 66%).3,4

3D-TEE for assessment of cardiac function and valvular disease is recommended by the ASE/SCA/STS guidelines as an adjunct to 2D TEE for intraoperative imaging of the heart and aorta.5 Published benefits of 3D TEE in evaluation of aortic dissections include a superior illustration of a dissection flap's architecture if the dissection has a helical course, and superior evaluation of entry tear size, coronary involvement, or interface with the aortic valve.6,7,8 No direct comparative studies have assessed 3D vs 2D imaging of the celiac trunk or SMA, but the value of 3D images of abdominal aortic dissection anatomy is easily extrapolated.

We advocate for standardization of routine 3D TEE evaluation of mesenteric vascular involvement in the dissected aorta as a method to best assess the impact of the aortopathy on visceral perfusion dynamically.

Descending/Thoracoabdominal Aorta