Angiography has gained traction in the hybrid operating-room approach to acute type A aortic dissection, in which diagnostic and interventional angiography techniques are combined with open surgical repair [63]. Catheter angiography allows for assessment of luminal size of the iliofemoral system but is limited in its ability to assess for atherosclerotic plaque burden [56]. Additionally, digital subtraction angiography remains the gold standard for preintervention visualization of the artery of Adamkiewicz, an important consideration when there is high concern for spinal cord ischemia [64]. TEE and TTE In hemodynamically unstable patients, transthoracic echocardiography (TTE) is a useful imaging study for rapid evaluation of valvular function, aortic root dilation, and thoracic aortic dissection. This can be further supplemented with TEE, which allows for comparatively superior anatomic evaluation and can be left in place for intraoperative monitoring [61,65]. Although offering comparable sensitivities to CT and MRI for detection of thoracic aortic dissection, TEE is limited in its sensitivity for detection of branch vessel involvement and delineation of pathology below the gastroesophageal junction [59]. Echocardiography can also evaluate for concomitant cardiovascular disease and identify patients in whom coronary revascularization or valvular repair may be indicated [54,66]. Thoracic Aorta Interventional Planning and Follow-Up IVUS Similar to intraprocedural TEE, intravascular US (IVUS) is an additional adjunctive imaging tool that can aid in optimal visualization of intimal tears, ideal endograft positioning, assessment of branch vessel patency, and detection of abnormal flow within the false lumen and excluded aneurysm sac after endograft placement [67].
Thoracic Aortic Aneurysm or Dissection Treatment Planning and Follow Up. Angiography has gained traction in the hybrid operating-room approach to acute type A aortic dissection, in which diagnostic and interventional angiography techniques are combined with open surgical repair [63]. Catheter angiography allows for assessment of luminal size of the iliofemoral system but is limited in its ability to assess for atherosclerotic plaque burden [56]. Additionally, digital subtraction angiography remains the gold standard for preintervention visualization of the artery of Adamkiewicz, an important consideration when there is high concern for spinal cord ischemia [64]. TEE and TTE In hemodynamically unstable patients, transthoracic echocardiography (TTE) is a useful imaging study for rapid evaluation of valvular function, aortic root dilation, and thoracic aortic dissection. This can be further supplemented with TEE, which allows for comparatively superior anatomic evaluation and can be left in place for intraoperative monitoring [61,65]. Although offering comparable sensitivities to CT and MRI for detection of thoracic aortic dissection, TEE is limited in its sensitivity for detection of branch vessel involvement and delineation of pathology below the gastroesophageal junction [59]. Echocardiography can also evaluate for concomitant cardiovascular disease and identify patients in whom coronary revascularization or valvular repair may be indicated [54,66]. Thoracic Aorta Interventional Planning and Follow-Up IVUS Similar to intraprocedural TEE, intravascular US (IVUS) is an additional adjunctive imaging tool that can aid in optimal visualization of intimal tears, ideal endograft positioning, assessment of branch vessel patency, and detection of abnormal flow within the false lumen and excluded aneurysm sac after endograft placement [67].