Angiography

• Angiography is traditionally cited as the gold standard in the diagnosis of thoracic aortic trauma.

• Digital subtraction angiography (DSA) is preferred and intravenous examinations should be avoided because it produces poor-quality studies in one-third of cases.

• When performed adequately, intra-arterial DSA can detect thoracic aortic injury with a sensitivity of 9599% and a specificity of 94-100% [39].

• False-positive results are most frequently related to a prominent ductus diverticulum or large ulcerated ath-eromas just distally to the left subclavian artery [18].

• False-negative results may be due to incomplete series, misinterpretation or inadequate projections (Fig. 4.3.5).

• Left anterior oblique projections (15-20°) should be included in every examination in order to avoid missing the diagnosis!

• Thoracic aortic injury might present itself angiograph-ically most frequently as an intimal irregularity or filling defect caused by an intimal flap.

• Pseudoaneurysm formation is demonstrated by contained extravasation of contrast outside the aortic lumen (Fig. 4.3.6).

• Apart from the high sensitivity and specificity, aortography is also capable of showing associated lesions of the supra-aortic vessels. In addition, endovascular stent-grafting can follow it immediately.

Fig. 4.3.5a,b Angiography after blunt thoracic trauma. a Lesion at aortic isthmus was considered to be ductus diverticulum. b Angiography after 2 years showed typical pseudoaneurysm formation

• The major disadvantage of angiography is that it is time consuming and the patient must be transferred for a prolonged period to the vascular suite. In addition, it is invasive and it requires iodinated contrast material.

• Although there are no reports on the guidewire/cath-eter penetrating the injured aortic wall, full rupture of the aorta has been reported after high volume dye injection [14].

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