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J Thorac Cardiovasc Surg 1998;115:945-947
© 1998 Mosby, Inc.

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Abdominal aorta and visceral arteries visualized with transesophageal echocardiography during operations on the aorta

Hiroshima, Japan

From the First Department of Surgery, Hiroshima University School of Medicine, Hiroshima, Japan.

Received for publication Oct. 13, 1997. Accepted for publication Oct. 29, 1997. Address for reprints: Kazumasa Orihashi, MD, First Department of Surgery, Hiroshima University School of Medicine, Kasumi 1-2-3, Minami-ku, Hiroshima, 734 Japan.

Despite possible complications of the abdominal aorta and visceral arteries during operations on the aorta, there has not been a satisfactory imaging modality of these arteries. We evaluated the feasibility and drawbacks of transesophageal echocardiography (TEE) for visualizing these vessels.

Methods

The 12 consecutive patients undergoing operations on the aorta (7 men and 5 women, ages ranging from 28 to 82) were examined. A 5 MHz biplane TEE system (EUB-555, EUP-ES322, Hitachi Co. Inc., Tokyo, Japan) was used. The incidence of successful visualization of the celiac artery (CEA), superior mesenteric artery (SMA), and right and left renal artery (RRA and LRA), as well as to the distance from the transducer to the artery and the angle of correction were examined.

As the probe was advanced into the stomach, an appropriate rotation and upward flexion was applied to keep the image of aorta on the screen. CEA and SMA serially appeared at the 1 to 3 o'clock position of the aorta (Fig. 1). The former soon divided into branches and moved away from the aorta, whereas the latter stayed adjacent to the aorta. As the probe was further advanced, the left renal vein appeared between the SMA and the aorta. At this level, the RRA and LRA appeared at approximately the 4 and 10 o'clock positions, respectively (Fig. 1). A lateral flexion of the probe was helpful for minimizing the angle of correction. In the longitudinal scan, the long-axis view of the aorta, CEA, and SMA was depicted.

View larger version (30K): [in this window] [in a new window]   Fig. 1. Scanning planes and images at the level of (A) celiac artery (CEA), (B) superior mesenteric artery (SMA), (C) right and left renal arteries (RRA and LRA), and (L) in the longitudinal scan. AO, Aorta, LRV, left renal vein; IVC, inferior vena cava; SV, splenic vein; DUO, duodenum.

The CEA and SMA were visualized in every case before bypass. Both LRA and RRA could be seen in 7 and 10 cases (59.3% and 83.3%), respectively. With further attempts, they were visualized in 11 (91.7%) and 12 cases (100%), respectively, by the end of the operation. The angle correction was within 30 degrees in 12 cases (100%), 11 cases (91.7%), 9 cases (75.0%), and 8 cases (72.7%), respectively. Whereas the CEA and the SMA were near the transducer (24.6 and 27.6 mm on average, respectively), the LRA and RRA were farther away (44.3 and 43.9 mm on average, respectively). Specific findings obtained by TEE included (1) occlusion of the CEA orifice after an aortic anastomosis, (2) reduced CEA flow caused by a narrowed orifice from an aortic dissection and improved flow after construction with a saphenous vein graft, and (3) an altered perfusion pattern in the SMA with dissection after surgical repair (false lumen dominant compared to true lumen). In case 7, TEE showed a thickened aortic wall below the SMA. After crossclamping of the aorta below the SMA, forward flow in the renal arteries showed a to-and-fro pattern (Fig. 2, A), followed by a marked decrease in urinary output. TEE showed an atheroma-like echo at the orifice of the renal artery (Fig. 2, B). Aortotomy revealed the squeezed atheroma at the orifice.

View larger version (95K): [in this window] [in a new window]   Fig. 2. Echocardiograms demonstrating (A) to-and-fro pattern of blood flow in the right renal artery after crossclamping of the aorta and (B) atheroma that fills the aortic lumen in case 7. AO, Aorta; RRA, right renal artery.

Several modalities have been used for visualizing the abdominal vessels. Surface ultrasonography ¹ provides an excellent image but necessitates an exposure of the abdominal aorta and thus was feasible in only 5 cases (41.7%) in our series. Frazin and colleagues ² first reported use of TEE for visualizing abdominal vessels, in which the probe in the stomach was manipulated by the surgeon. Although laparotomy is mandatory with this method, this report encouraged us to use TEE as "transgastric echoangiography" without manipulation by the surgeon. Intravascular ultrasonography ³ is invasive and necessitates another system and operator in the operative field. TEE visualizes abdominal vessels in nearly every case, is noninvasive, and necessitates no additional system; thus it saves both cost and space. Although no gastric complications developed in this series, manipulation of the probe against resistance may cause mucosal damage. Further investigation in a larger series is mandatory for evaluating the safety and clinical significance of this method.

References

1. Okuhn SP, Reilly LM, Bennett JB, Hughes L III, Goldstone J, Ehrenfeld WK, et al. Intraoperative assessment of renal and visceral artery reconstruction: the role of duplex scanning and spectral analysis. J Vasc Surg 1987;5:137-47.[Medline]
   
2. Frazin LJ, Siddiqui M, Venugopalan K, Pop P, Vonesh MJ, McPherson DD. Feasibility of transcolonic and transgastric abdominal vascular ultrasound. Am J Card Imaging 1994;8:95-9.
   
3. Yamada E, Matsumura M, Kyo S, Omoto R. Usefulness of a prototype intravascular ultrasound imaging in evaluation of aortic dissection and comparison with angiographic study, transesophageal echocardiography, computed tomography, and magnetic resonance imaging. Am J Cardiol 1995;75:161-5.[Medline]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kazumasa Orihashi Yuichiro Matsuura Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Orihashi, K. Articles by Okada, K. Search for Related Content PubMed PubMed Citation Articles by Orihashi, K. Articles by Okada, K.