Info

Modified from Cigarroa JE, Isselbacher EM, DeSantis RW, Eagle KA. Diagnostic imaging in the evaluation of suspected aortic dissection: old standards and new directions. N Engl J Med 1993;328:35. +++ excellent; ++ good; + fair; - not detected

Modified from Cigarroa JE, Isselbacher EM, DeSantis RW, Eagle KA. Diagnostic imaging in the evaluation of suspected aortic dissection: old standards and new directions. N Engl J Med 1993;328:35. +++ excellent; ++ good; + fair; - not detected

Table 6

Utility of Transesophageal Echocardiography in Aortic Dissection

Advantages

Accurate (sensitivity 97-100%; specificity 95-98%) Rapid diagnosis

Portable (bedside or operating room)

Real-time intra-operative monitoring and evaluation

Safe—low complication rate

Inexpensive

Disadvantages

Blind spots in thoracic aorta (distal ascending aorta and aortic arch)

No visualization of abdominal aorta Intravenous conscious sedation; topical oropharyngeal anesthesia

Relative contraindication in certain cervicofacial and esophageal injuries involves the ostia and proximal segments of the coronary arteries.

Pitfalls in the Diagnosis of Aortic Dissection

Reverberations and beam-width artifacts can cause false linear echodensities within the aortic lumen that mimic aortic dissection. This is not an uncommon finding in aortas with extensive plaque formation or in dilated ectatic vessels (Fig. 4A; see Chapter 1, Fig. 8). TEE-derived M-mode echocardiography can help to identify reverberation artifacts originating from the posterior wall of the aorta or adjacent venous structures, and to differentiate these artifacts from dissection. Artifacts are located at a distance from the source that is predicted by ultrasound physical principles; and they have similar motion patterns with the suspected source. In one study, the use of M-mode echocardiography significantly improved the sensitivity and specificity of TEE from 87-93.5% to 93.5-96.8% and from 85.1-94.1% to 99-100%, respectively, suggesting that M-mode echocardiography should be performed in indeterminate cases of aortic dissection.

On the other hand, small dissections limited to the distal ascending aorta and proximal aortic arch could be missed because of interference from the air-filled trachea. Sometimes, intimal thickening with minor distortion of the aortic wall may be the only sign of a localized dissection when the false lumen is throm-bosed and the flap is relatively immobile.

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