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Indications for Thoracic Aortography by Walther Falholt, Gregers Thomsen, and H

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Indications for Thoracic Aortography by Walther Falholt, Gregers Thomsen, and H Thorax: first published as 10.1136/thx.10.1.23 on 1 March 1955. Downloaded from Thorax (1955), 10, 23. INDICATIONS FOR THORACIC AORTOGRAPHY BY WALTHER FALHOLT, GREGERS THOMSEN, AND H. GOSTA DAVIDSEN From the Medical Clinic B and Radiological Department, Rigshospitalet, University of Copenhagen, Denmark (RECEIVED FOR PUBLICATION OCTOBER 4, 1954) The recent advances in thoracic surgery have During the last two years we have performed necessitated a considerable development of diag- thoracic aortographies by the technique, introduced nostic methods in cardiovascular disease. The by Radner (1948) and further developed by Jons- introduction of cardiac catheterization as a routine son and his colleagues (Broden, Hanson, and method of examination has made it possible to Karnell, 1948; Broden, Jonsson, and Karnell, diagnose malformations of the great veins of the 1949; Jonsson, Broden, and Karnell, 1951; thorax, the right side of the heart, and the pul- Falholt, Thomsen, and Davidsen, 1954). By monary artery with accuracy. Pressure measure- their method a catheter is introduced through ments and the deterioration of arterio-venous shunts the right or left radial artery to the aorta and within the heart give evidence of abnormal com- the dye is injected through the catheter. This munications between the heart chambers or great technique has proved satisfactory in those cases in vessels. However, there are still difficulties in the which we have found it indicated. diagnosis of diseases exclusively localized to the To begin with, the aortographies were per- left side of the heart and the aorta and of mal- formed under nitrous oxide-oxygen-ether anaes- formations where the abnormal communication thesia. Lately we have used pentothal-curare between the arterial and venous side is so small anaesthesia, and this has been satisfactory. that its presence could not be proved by pressure Aortography is only fully profitable when a http://thorax.bmj.com/ measurements or blood analyses. casette changer, able to expose at least one picture Angiocardiography after injecting dye into an in two planes per second, is employed. In single arm vein is generally inconclusive in the diagnosis cases it may be of interest to obtain exposures with of these diseases, as the dye after its passage considerably shorter intervals in order to observe through the lungs is so diluted that the contrast the filling of the aorta and possible malformations filling of the left side of the heart and the aorta in the different phases of the cardiac cycle. is insufficient. During the two years in which we have been able A more detailed study of the anatomy of the to perform thoracic aortography we have only aorta in vivo has been made possible by the intro- found it indicated as a supplementary examination on September 29, 2021 by guest. Protected copyright. duction of thoracic aortography. As early as in 20 out of 700 catheterized cases of congenital 1939 Castellanos and Pereiras performed thoracic and acquired heart disease. In no case have aortographies by injecting dye retrogradely through serious complications developed. In spite of being the left brachial artery. Gomez Del Campo and ligated, the radial artery was generally palpable Meneses Hoyos (1947) developed a technique of immediately after the examination, giving evidence direct puncture of the aorta through the left second of sufficient collaterals. Frequently respiratory intercostal space and have performed aortographies paresis was observed for a few seconds to a few by injecting dye through a cannula. Several minutes after the injection of the dye (70% authors have made aortographies through the left diodone, 1 g. per kg., maximal 60 g.). Artificial carotid artery by percutaneous puncture or by respiration was given during this period. Fre- direct insertion of a needle or catheter into the quently the patients complained of a headache the artery after exposing the vessel (Burford and Car- first day after the aortography was performed, but son, 1948 ; Jonsson, 1949). In order to obtain suffi- we have never seen oedema of the brain such as ciently good filling of the aorta by these methods, has been reported by a few authors. Cases of it is necessary to use a heavy needle, which in- temporary hemiplegia have been reported after volves the risk of thrombosis of the artery or the performance of thoracic aortography (Jonsson perforation of the aorta and periarterial injection and others, 1952; Pierce, 1953). These last com- of the dye. plications are, according to Broman and Olsson Thorax: first published as 10.1136/thx.10.1.23 on 1 March 1955. Downloaded from 24 WALTHER FALHOLT, GREGERS THOMSEN, and H. GOSTA DAVIDSEN (1949), due partly to a toxic, partly an osmotic, effect of the hypertonic diodone solution on the blood-brain barrier. INDICATIONS PATENT DucTUs ARTERIoSUS.-The clinical pic- ture of this disease, in which the continuous mur- mur maximum in the second left intercostal space is so characteristic that neither cardiac catheteri- zation nor thoracic aortography is indicated when the electrocardiograms or radiographs do not show complicating anomalies of the heart. However, in cases of small patent ducts or very great ducts the murmurs are frequently atypical. In the first instance the continuous murmur is often displaced by separated systolic-diastolic murmurs. In cases of voluminous patent ducts, possibly with equalization of the pressures in the aorta and pulmonary artery, one may find a pure, rough, systolic murmur, which is louder and of lower frequency than the typical murmur. As we con- sider cardiac catheterization less risky than aorto- FIG. 1.-Patent ductus arteriosus. The aorta is visualized, and early graphy, these cases have been catheterized, and in filling of the pulmonary artery together with irregularities in the all we have succeeded in proving the presence of outline of the aorta indicate the presence of the patent duct. the duct by passing the catheter through it into the aorta. artery, hilar dance, and increased vascularization In the case of very small ducts, where the of the lung fields. The physiological conditions arterio-venous shunt to the pulmonary artery is may likewise be identical: pulmonary hyperten- so small that it cannot be demonstrated by the sion and an arterio-venous shunt to the pulmonary http://thorax.bmj.com/ analyses of blood samples or by pulmonary hyper- artery, which is shown by cardiac catheterization. tension, and where it has not been possible to pass The differential diagnosis between these malforma- the catheter through the duct, we have considered tions is thus only possible by direct catheteriza- thoracic aortography to be indicated. The duct tion of the patent duct, or the aortic septal defect is then so small that it is not visualized directly, itself, and, if this is not managed, by thoracic but early filling of the pulmonary artery, possibly aortography. displacement of the pulmonary artery towards the COARCTATION OF THE AORTA.-The murmurs with aorta, and irregularities in the outline of the aorta projection to the arteries of the neck, the decreased on September 29, 2021 by guest. Protected copyright. are evidence (Fig. 1) of the patent duct (Steinberg, or missing pulsation of the femoral artery, and the Grishman, and Sussman, 1943). notches in the ribs shown on radiographs are AoRTIc SEPTAL DEFECT.-This disease is a generally sufficient to establish the diagnosis of differential diagnostic problem to patent ductus coarctation of the aorta. Thoracic aortography arteriosus. It originates in a defective development is seldom indicated from a diagnostic point of of the septum between the aorta and the pul- view. monary artery. It is of practical importance to Certain authors (Jonsson and others, 1952) have establish the differential diagnosis before operation. maintained that aortography ought to be performed In aortic septal defect cyanosis is often present in any case of coarctation of the aorta before from early childhood, but, apart from this, it gives operation in order to obtain information of the the same symptoms as a patent duct. The mur- anatomy of the stenosis, its localization, its grade, murs are highly variable, varying from a pure and its length. In this hospital 45 cases of co- systolic murmur to systolic-diastolic murmurs arctation of the aorta have been operated upon. maximum in the lower precordium. Because The stenotic part of the aorta is resected and an pulmonary hypertension develops early these anastomosis established between the aorta above patients seldom survive the age of 20 years. and below the portion resected (Crafoord and Radiologically the picture is identical with that of Nylin, 1945). In all of the cases operated upon patent ductus arteriosus: uncharacteristic enlarge- here it was possible to perform this direct anasto- ment of the heart, dilatation of the pulmonary mosis. As long strictures are apparently extremely Thorax: first published as 10.1136/thx.10.1.23 on 1 March 1955. Downloaded from INDICATIONS FOR THORACIC AORTOGRAPH Y 25 rare, we do not consider thoracic aortography in- dicated as a routine method of examination in coarctation of the aorta, the risks of aortography being taken into consideration. We have thus only performed aortography in cases where we had a suspicion that there were complicating anomalies of the heart, such as aortic insufficiency or patent ductus arteriosus. If experiments with homologue transplantation in operations for coarctation of the aorta become fully satisfactory, thoracic aorto- graphy may become a routine before operation. The different congenital malformations of the aorta, double aortic arch, aortic ring, left circum- flex arch, etc., are rare. In the even rarer instances, where they are the cause of symptoms by com- pression of the oesophagus or trachea and opera- tion is contemplated, thoracic aortography may be indicated (Thomsen, Vesterdal, and Husfeldt, 1953). ACQUIRED DISEASES Acquired diseases of the aorta or aortic valves can generally be diagnosed by the combination of FIG.
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