Femoral access is typically preferred for endovascular repair, although access vessels must typically be suitable in size, tortuosity, and calcification of the iliac vessels to permit device delivery to the aorta. In patients with inappropriate iliofemoral vessels, groin cutdown with conduit, direct aortoiliac access, or brachial access can be used. Before open or endovascular repair of a thoracoabdominal aneurysm or dissection, some authors have advocated for imaging for identification of the artery of Adamkiewicz, because preoperative identification could potentially reduce the risk of spinal cord ischemia [68,69]. Given the variability of the origin of this artery, preoperative identification of the origin of this vessel allows for operative planning that minimizes the risk of damage and can reduce surgical times [69]. Multiple studies evaluating the ability of CT and MRI to identify the artery of Adamkiewicz show that the artery can be identified and traced in >75% of patients, with some studies finding >90% identification [68,70-72]. CTA Chest and Abdomen With IV Contrast Compared with CTA of the chest, abdomen, and pelvis, exclusion of the pelvis carries the drawback of precluding evaluation of the iliofemoral access vessels if endovascular repair is considered. Furthermore, if the thoracoabdominal dissection or aneurysm extends into the pelvis, a lack of pelvis evaluation could result in incomplete evaluation of the aortic pathology. In select cases with recent imaging of the pelvis or in cases of planned open repair without extension into the pelvic vasculature, further imaging of the pelvis vasculature may not be needed. MRA Chest, Abdomen, and Pelvis Without and With IV Contrast Although the spatial resolution of MRA without and with IV contrast is less than the spatial resolution of CTA with IV contrast, MRA provides good evaluation of the aorta and branch vessels to allow for procedural or operative planning [38,62,67].
Thoracoabdominal Aneurysm or Dissection Treatment Planning and Follow Up. Femoral access is typically preferred for endovascular repair, although access vessels must typically be suitable in size, tortuosity, and calcification of the iliac vessels to permit device delivery to the aorta. In patients with inappropriate iliofemoral vessels, groin cutdown with conduit, direct aortoiliac access, or brachial access can be used. Before open or endovascular repair of a thoracoabdominal aneurysm or dissection, some authors have advocated for imaging for identification of the artery of Adamkiewicz, because preoperative identification could potentially reduce the risk of spinal cord ischemia [68,69]. Given the variability of the origin of this artery, preoperative identification of the origin of this vessel allows for operative planning that minimizes the risk of damage and can reduce surgical times [69]. Multiple studies evaluating the ability of CT and MRI to identify the artery of Adamkiewicz show that the artery can be identified and traced in >75% of patients, with some studies finding >90% identification [68,70-72]. CTA Chest and Abdomen With IV Contrast Compared with CTA of the chest, abdomen, and pelvis, exclusion of the pelvis carries the drawback of precluding evaluation of the iliofemoral access vessels if endovascular repair is considered. Furthermore, if the thoracoabdominal dissection or aneurysm extends into the pelvis, a lack of pelvis evaluation could result in incomplete evaluation of the aortic pathology. In select cases with recent imaging of the pelvis or in cases of planned open repair without extension into the pelvic vasculature, further imaging of the pelvis vasculature may not be needed. MRA Chest, Abdomen, and Pelvis Without and With IV Contrast Although the spatial resolution of MRA without and with IV contrast is less than the spatial resolution of CTA with IV contrast, MRA provides good evaluation of the aorta and branch vessels to allow for procedural or operative planning [38,62,67].