Transesophageal echocardiography evaluation of the thoracic aorta

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2 Review Artile Trnsesophgel ehordiogrphy evlution of the thori ort T. A. Ptil, Arno Nierih 1 Seniore Consultnt, Deprtment of Anesthesi, Fortis Hospitl, Bengluru, Krntk, Indi, 1 Crdiothori Anesthesiologist Intensivist, Isl Sophi, Zwolle, Netherlnds ABSTRACT Reeived: Aepted: Trnsesophgel ehordiogrphy (TEE) n e used to identify risk ftors suh s orti theroslerosis [2] efore ny sort of surgil mnipultions involving ort nd its relted strutures. TEE hs eome n importnt noninvsive tool to dignose ute thori orti pthologies. TEE evlution of endoleks helps erly detetion nd immedite orretive interventions. TEE is n invlule imging modlity in the mngement of orti pthology. TEE hs to lrge extent improved the ptient outomes. Key words: Bedside; Mortlity; Proximl Aess this rtile online Wesite: PMID: *** DOI: / Quik Response Code: INTRODUCTION Atheroslerosis of the sending ort (AA) nd orti rh is reognized s one of the importnt preditors of postopertive stroke fter rdi surgery. Aorti dissetion nd rupture re emergent situtions requiring rpid nd urte dignosis to redue the moridity nd mortlity. [1] Trnsesophgel ehordiogrphy (TEE) n e used to identify risk ftors suh s orti theroslerosis [2] efore ny sort of surgil mnipultions involving ort nd its relted strutures. TEE hs eome n importnt noninvsive tool to dignose ute thori orti pthologies. Epiorti snning (EAS) [3] is idel in high risk ptients to identify the sites of severe theroslerosis on the distl AA nd the proximl orti rh. A novel TEE tehnique, so lled TEE A view, y vn Zne et l., [4] overomes the lind spot of TEE. This llows edside imging of the distl AA, the orti rh, nd ererl rnh vessels. With this dditionl TEE informtion, pproprite modifitions of the surgil tehniques n e mde to redue moridity nd mortlity. ANATOMY OF THORACIC AORTA The thori ort is divided into four segments surgilly: Aorti root, AA, orti rh, nd desending thori ort. Aorti root onsists of the orti nnulus, orti usps, sinuses of vlslv, nd sinotuulr juntion (STJ). The dimeter of the ort vries etween 33 nd 35 mm with wll thikness of out 2 mm. The AA with length of out 7 11 m origintes from the orti nnulus t the level of STJ rossing eneth the min pulmonry rtery, then ourses in n nterior nd rightwrd diretion over the origin of the right pulmonry rtery, whih termintes nd ontinues s the orti rh t the origin of the innominte rtery. The orti rh ourses in posterior nd leftwrd diretion giving rise to the innominte (rhioephli), left ommon rotid (LCC), nd left sulvin rteries (LSAs). The underlying trhe mkes Address for orrespondene: Dr. T. A. Ptil, Fortis Hospitl, Bengluru, Krntk, Indi. E mil: nesthesiptil@yhoo.o.uk This is n open ess rtile distriuted under the terms of the Cretive Commons Attriution NonCommeril ShreAlike 3.0 Liense, whih llows others to remix, twek, nd uild upon the work non ommerilly, s long s the uthor is redited nd the new retions re liensed under the identil terms. For reprints ontt: reprints@medknow.om Cite this rtile s: Ptil TA, Nierih A. Trnsesophgel ehordiogrphy evlution of the thori ort. Ann Crd Anesth 2016;19:S S Annls of Crdi Anesthesi Pulished y Wolters Kluwer - Medknow

3 it diffiult to visulize the distl AA nd the proximl orti rh. The desending thori ort egins distl to the LSA t the level of the ligmentum rteriosum nd ourses nteriorly nd udlly towrd the diphrgmti hitus. At the site of the ligmentum rteriosum is reltively fixed nrrowing lled the orti isthmus whih is the most ommon site of trumti deelerting injury. The ort ourses in smooth urved fshion from the nterolterl side of the 4 th thori verter to the nterior surfe of the 11 th verterl ody. At distl level, the desending thori ort lies diretly posterior to the esophgus [Figure 1]. ECHOCARDIOGRAPHIC EVALUATION OF THE THORACIC AORTA Figure 1: Antomil ourse of the ort from the orti root down to its ifurtion (illustrtions y Srinivs Holl) Primrily insertion of the TEE proe must e performed gently with due onsidertion to ndon the proedure if resistne is enountered, more so in ptients with suspeted orti pthology. As per the SCA/ASE guidelines, the following imging plnes re reommended for imging the thori ort. [5] Mid esophgel (ME) orti vlve (AV) long xis view, ME sending (ASC) orti short xis (SAX) nd long xis (LAX) view, desending orti short nd long xis views, upper esophgel (UE) orti rh long nd SAX views. The tehniques of imging hve een delt with in the erlier hpter. Figure 2: Mid esophgel AV LAX view mesurements ross root. LV: Left ventrile, RV: Right ventrile, ASC AO: Asending ort ME AV LAX view [Figure 2] is importnt in evluting the AV nd the proximl AA. Mesurements n e mde of the left ventriulr outflow trt, the orti nnulus, sinuses of vlslv, STJ, nd AA if vlve replement nd/or root reonstrution is eing plnned. ME ASC orti SAX nd LAX views [Figure 3] re ruil to exlude dissetions in the ort. Artifts re ommonly enountered within the AA in this view, hene the priority to distinguish rtifts from true dissetions to prevent needless, expensive interventions. At the mid esophgel level from the four hmer view, rotting the proe in ounterlokwise diretion or to the left posteriorly nd optimizing the depth to 4 6 m result in desending orti SAX view. Inresing the multiplne ngle to 90, the desending orti Figure 3: Mid esophgel ASC AO SAX, LAX views. RPA: Right pulmonry rtery, MPA: Min pulmonry rtery, SVC: Superior ven v, ASC AO: Asending ort, SAX: Short xis, LAX: Long xis LAX view is otined. This is n importnt view to evlute mny dignosti issues suh s the presene of n theromtous plque, dissetion, neurysm, left pleurl effusion, nd position of intr orti lloon [Figures 4 nd 5]. The presene of pthologil lesion in the desending orti view neessittes dditionl proedures suh s Annls of Crdi Anesthesi Otoer 2016 Vol 19 Speil Issue 1 S45

4 Figure 4: () Desending orti short xis view, () long xis view proximl, distl end TEE A view nd/or EAS of the distl AA nd orti rh, espeilly in the presene of n theromtous plque to lter the surgil pln. A disdvntge of EAS is, however, tht it n only e pplied during surgery fter sternotomy nd nnot e used in losed hest proedures (trnstheter orti vlve implnttion [TAVI]) or preopertive sreening. Sine the guidelines do not desrie the views of this innovtive tehnique, short explntion is neessry. TRANSESOPHAGEAL ECHOCARDIOGRAPHY A VIEW METHOD A reently introdued modifition of onventionl TEE, known s the A view method, hs proven ple of inspeting the distl AA nd orti rh. Assessment of the distl AA sign TEE is distured y the interposition of the ir filled trhe etween the esophgus nd the AA, the so lled lind spot. [6] Reently, the A view (orti view) method, [7] modifition of onventionl TEE, ws introdued to overome this limittion. The A view method uses n intrtrhel lloon (the A view theter developed y Stroke2prevent [Figure 6], Hilversum, the Netherlnds) filled with sline to reple the ir in the distl trhe nd left min ronhus [Figure 6]. It, therefore, eomes possile to ssess the distl AA nd orti rh for the presene nd severity of theroslerosis efore rdi surgery, whih provides the surgeon with min of dditionl plnning time. Figure 6 shows the TEE A view distl AA long xis view with moile plque nd Figure 6d shows the Digrmmti representtion of the imge. Sine visuliztion will only led to n improved outome, if the informtion is trnslted to n djusted surgil pproh, further linil implementtion nd trining is ongoing, ut preliminry linil outome dt re promising. [8] A view theter A view theter in situ. Figure 5: () Desending orti long xis view olor flow Doppler, () Spetrl Doppler t the proximl nd () distl end of the ort depited s ove nd elow the seline, respetively, inditing the flow towrd nd wy from the trnsduer Withdrwing the TEE proe nd mintining the desending orti SAX view on the sreen, the ort hnges its pperne from irulr to longitudinl t the level of the orti rh, UE orti rh LAX view, nd inresing the multiplne ngle to 90, the UE orti rh SAX view is otined. The dignosti issues relted to this view inlude reognition of ptent dutus rteriosus, spetrl Doppler ssessment of the pulmonry rtery, nd presene of theromtous plques in the orti rh. The origins of the left sulvin, LCC, nd rhioephli rteries n e visulized frequently y miniml rottion of the TEE proe [Figure 7]. THORACIC AORTIC DISEASES The primry diseses of the ort re theroslerosis, orti neurysm, nd orti dissetion. Atheroslerosis Atheroslerosis of the AA nd orti rh is n importnt preditor of stroke fter rdi surgery ourring in 1% 6% of the ptients. [9] The est tretment option is prevention. TEE should e used to identify orti theroslerosis efore ntiipted surgil mnipultions. Identifition of signifint disese y TEE permits ltertions in the surgil proedure, suh s dopting femorl rteril nnultion, ltering the S46 Annls of Crdi Anesthesi Otoer 2016 Vol 19 Speil Issue 1

5 Figure 6: () The A view theter. () The A view theter in the trhe nd left min ronhus. () The A view distl sending ort long xis view. An imge of the trhe nd the sending ort s imged with the A view method with plque formtion on the posterior nd nterior wll (1: A view theter in the trhe, 2: The posterior wll of the distl sending ort, 3: The nterior wll of the distl sending ort, 4: A moile protruding therom indited y the rrow). (d) Digrmmti representtion of the imge site of orti ross lmp, hnging the type of nnule used for extrorporel irultion, off pump oronry rtery ypss oronry rtery surgery with no touh tehnique of the ort, using firilltory or hypothermi irultory rrest, ltertion of the site of grft nstomoses, nd voiding ntegrde rdioplegi. [10] Lesions of the AA nd rh hve een identified s risk ftors for stroke, peripherl emoliztion, periopertive stroke, s well s neuropsyhologil dysfuntion fter open hert surgery. Atheroemoli, thromoemoli, nd plque thikness >4 mm orrelte with signifint emoli risk. Although TEE evlution of the lesions is sensitive nd speifi, one of the importnt limittions is n indequte visuliztion of distl AA nd proximl orti rh euse of the interposed ir filled trhe. TEE A view overomes this prolem nd gives dequte therosleroti informtion efore surgery or during losed hest proedures suh s TAVIs. EAS or TEE A view imging should e performed in high risk ptients to further delinete the sites of severe theroslerosis so tht surgil modifitions n e mde to redue the moridity nd mortlity. Royse et l. [11] divided the thori ort into six zones in reltion to the res of surgil mnipultions whih simplified the inditions for EAS. Zones 1 3 re the proximl, mid, nd distl AA. Zones 1 nd 2 d Figure 7: () Upper esophgel orti rh long xis view, () spetrl Doppler orti rh proximl end, () upper esophgel orti rh short xis view PV: Pulmonry vlve, MPA: Min pulmonry rtery, Left CCA: Left ommon rotid rtery, AO: Aorti rh re the sites of inision for AV replement, proximl oronry grft nstomosis, nd ntegrde rdioplegi nnultion. Zone 3 is the site of orti ross lmp, Zone 4 inludes the proximl orti rh whih is the site of orti nnul plement, Zones 5 nd 6 inlude distl orti rh nd proximl desending ort, respetively, nd re not mnipulted during rdi surgery. Atheromtous emolism n our during orti nnultion or due to the presene of n intr orti lloon. In the study of Royse et l., [11] Zone 3 ws imged y TT only in 58% of the ses. Mnul surgil plption detets only 50% of those theroms identified y EAS [11] nd might even e dngerous y dislodging the therom. [12] When moderte to severe therom is identified in Zones 5 nd 6 y TEE, the inidene of therom in Zones 1 4 is very high. Hene, EAS is reommended. If Zones 1, 2, 3, 5, nd 6 re negtive, then EAS of Zones 3 nd 4 is not reommended in this pulition. A reent met nlysis y Vn Zne et l. [13] studied the dignosti ury of TEE for estimting AA theroslerosis. The sensitivity nd speifiity were 21% (95% onfidene intervl 13% 32%) nd 99% (96% 99%), respetively. Beuse of the low sensitivity of TEE for the detetion of AA theroslerosis, negtive test result requires verifition y dditionl tests suh s TEE A view nd EAS. In se of positive test result, AA theroslerosis n e onsidered s present, nd less mnipultive strtegies might e indited. Annls of Crdi Anesthesi Otoer 2016 Vol 19 Speil Issue 1 S47

6 Ktz et l. [14] reommended five point grding system for orti therom. Ptients with moile therom hd 45% inidene of stroke, while the inidene of stroke ws only 5% with Grde 3 therom [Figures 8 nd 9]. Grding of orti therom Grde Desription Perentge of inidene of stroke (%) 1 Norml ort 0 2 Extensive intiml thikening <3 mm 3 Protrudes <5 mm into orti lumen 4 Protrudes >5 mm into orti lumen Moile therom 46.5 In omprison to EAS, TEE hs een found to e superior for plque identifition in the desending ort nd rh ut hs poor preditive vlue in deteting disese in the AA. A omintion of tehniques, using EAS, A view theter tehnique nd TEE, is reommended in ptients t high risk for disese in the distl AA. Aorti neurysms An neurysm is defined s diltion of ort more thn 50% of norml orti dimeter involving ll the three lyers of the vessel wll. The ort is onsidered to e dilted if its dimeter vries etween 3.7 m nd 5.0 m, neurysml if the dimeter is more thn 5.0 m nd disseted if it presents with n intiml flp. An orti neurysm is either sulr or fusiform. A fusiform neurysm hs uniform shpe with symmetril dilttion tht involves the entire irumferene of the orti wll whiles sulr neurysm is lolized outpouhing of the orti wll. Aneurysms re primrily diseses of ging s result of degenertion nd theroslerosis. Aging leds to intiml thikening, lipid deposition, nd lifition resulting in diltion nd wekening of the orti wll. Connetive tissue disorders suh s Mrfn syndrome, Ehlers Dnlos syndrome trum, nd hypertension re some of the other uses of neurysms. Thori orti neurysms re divided into three groups depending on lotion: AA, orti rh, nd desending thori neurysms or thorodominl neurysms [Figure 10]. Thorodominl neurysms re grouped into four types sed on the Crwford lssifition. [15] Thorodominl neurysms [Figure 11] Type 1: Involves the desending ort just distl to the origin of LSA to the dominl ort ove the renl rteries Type 2: Involves the desending ort terminting distl to the renl rteries Figure 8: () Upper esophgel orti rh xis view demonstrting (rrow) Grde 2 plque. () Upper esophgel orti rh long xis view with (rrow) Grde 3 plque. () Desending orti long xis view with (rrow) Grde 4 plque Figure 9: () Short xis epiorti snning demonstrting the sending ort, min pulmonry rtery, right pulmonry rtery, pulmonry rtery theter in the right pulmonry rtery. () Long xis epiorti snning demonstrting the sending ort nd the pulmonry rtery. () Long xis epiorti snning demonstrting n theromtous 4 mm plque (rrow) on the wll of the sending ort S48 Annls of Crdi Anesthesi Otoer 2016 Vol 19 Speil Issue 1

7 d Figure 10: () Mid esophgel orti vlve long xis view demonstrting mesurements of dilted orti root. () The sme view with n neurysml sending ort. () Mid esophgel sending orti long xis view with n neurysml sending ort. (d) Mid esophgel orti vlve long xis view demonstrting Dron grft in situ (rrow) t the orti rh level. (e) upper esophgel orti vlve long xis view demonstrting Dron grft in situ (rrow) e lterntive for omplex ses is the hyrid pproh in whih n open surgil tehnique is omined with endovsulr orti repir whih hs the enefit of omplete repir simultneously reduing the risk of open tehnique. Figure 11: Types of thorodominl neurysms (illustrtions y Srinivs Holl) Type 3: Involves the distl hlf of the desending ort nd the dominl ort to its ifurtion Type 4: Involves the dominl ort to its ifurtion. As per the reommendtions y the Soiety of Thori Surgeons, neurysms with dimeter twie tht of the norml ort need to e surgilly orreted. [16] Surgery is indited if the sinuses re more thn 40 mm, AA is more thn 50 mm with ortopthy, nd more thn 60 mm without ortopthy. Ptients with onnetive tissue disorders, strong fmily history of orti neurysms, nd symptomti ptients should e onsidered for erly opertive therpy euse of inresed risk of dissetion or rupture. Another Annls of Crdi Anesthesi Otoer 2016 Vol 19 Speil Issue 1 TEE n e used to define the size, lotion, nd extent of the orti neurysm s well s the presene of hemtom or thromus. TEE my lso e used to evlute the pteny orti rh rnhes to onfirm the presene of orgn mlperfusion. It is n importnt monitoring tool of rdi funtion during orti neurysm surgeries. Aorti dissetion Aorti dissetion is formed y n intiml ter whih is ontined y the medi leding to the development of true nd flse lumen. The flse lumen my extend into rnhes of the ort in the hest or domen, using mlperfusion, ishemi, or olusion with resultnt omplitions. The dissetion n lso progress proximlly involving the orti sinus, AV leding to orti insuffiieny, nd my lso involve the oronry rteries resulting in ishemi events. Aorti dissetion is the most ommon use of deth involving the ort. The mortlity rte is extremely high t the rte of 1%/h 3%/h [17] during the first 48 h. Erly nd rpid dignosis is essentil to redue mortlity. S49

8 TEE hs 98% sensitivity nd 100% speifiity [18] for dignosing dissetions, hene it is n idel imging modlity in unstle ptients euse of its ury, low ost, miniml invsiveness, elimintes the prolems ssoited with short time. One of the mjor limittions of TEE is the inility to visulize the distl AA nd the proximl orti rh whih n overome y the usge of A view theter t edside or EAS during surgery. The DeBkey et l. lssifition [19] nd the Stnford lssifition [20] systems re used to desrie orti dissetions. DISSECTIONS [FIGURE 12] DeBkey lssifition Type 1: Origintes in the AA extending distlly up to the orti ifurtion Type 2: Origintes in the AA up to the rhioephli trunk Type 3: Origintes distl to the LSA terminting just ove the diphrgm Type 3: Origintes distl to the LSA up to the orti ifurtion [Figure 12]. The Stnford lssifition is divided into two types: Type A involving the AA (DeBkey Type 1 nd 2), Type B the AA is spred (DeBkey Type 3 nd 3). This lssifition is simple nd linilly importnt. Type A inludes ll types of dissetions involving the AA no mtter where the intiml ter is loted nd how fr the dissetion. Hene, surgery is reommended for Type A dissetions. Mortlity rtes for medil nd surgil mngement re similr for Type B dissetions. given ge nd ody surfe re, for ptients ove 40 yers predited sinus dimension (m) = J 0.74 BSA (m 2 ). Ptients with n orti root dimeter of 50 mm undergoing oronry revsulriztion re t inresed of orti dissetion. Aorti dissetions n e evluted y TEE using the stndrd views mentioned erlier. The presene of n intiml flp is the most importnt evidene of n orti dissetion. The presene of n intiml flp, true nd flse lumen, nd forwrd systoli flow in the true lumen re sensitive fetures of dissetion. [22] Other findings re omplete thromosis of the flse lumen, entrl displement of intiml lifition, nd seprtion of intiml lyers form the thromus [23] [Figure 13]. ENTRY AND EXIT SITES TEE is vlule imging modlity to lote the intiml ter site whih is of extreme importne to determine the type of dissetion nd the suess of surgil repir. Resetion of the primry site dereses the inidene of omplitions nd redo surgeries. Intiml ter ours in the AA, 1 3 m ove the right or left sinus of vlslv in out 70% of the ses nd t the site of ligmentum rteriosum in out 30% of the ses. [24] In the sending nd orti rh, the dissetion plne is long the greter urvture, ut in the desending ort, it is loted lterl to the true lumen. Ptients with Mrfn syndrome re t n inresed risk of orti dissetion. An orti rtio (AO) <1.3 indites low risk group. [21] The AO rtio is the sinus of vlslv dimeter divided y the predited sinus dimeter for Figure 12: Types of orti dissetion (illustrtions y Srinivs Holl) Figure 13: () Mid esophgel orti vlve long xis view demonstrting the intiml flp rising t the sinotuulr juntion (rrows). () Upper esophgel orti rh long xis view (rrow) inditing the presene of n intiml ter in the orti wll. () Stnford Type B dissetion with the intiml flp t the level of desending ort. TL: True lumen, FL: Flse lumen S50 Annls of Crdi Anesthesi Otoer 2016 Vol 19 Speil Issue 1

9 TEE plys n importnt role in the identifition of the true nd flse lumen. True lumen expnded during systole nd ompressed during distole. M mode pled through the dissetion helps in identifying the systoli expnsion of the true lumen. True lumen is smller thn the flse lumen, [25] exhiits forwrd systoli flow pttern, hs less ehogeni thin lyer ompred to the flse lumen whih hs right ehogeni lyer. Thikening of the orti wll more thn 15mm is onsidered to e sign of dissetion, [26] inditing mssive thromosis of the flse lumen mking it diffiult to identify the intiml flp [Figure 14]. It is importnt to exmine the ME AV LAX view refully to detet proximl AA dissetions. It is in this view Swn Gnz theter ppers s n rtift. Hene, it is importnt to differentite n rtift from true dissetion, lest the ptient my e sujeted to needless expensive surgil proedure therey inresing the moridity. A liner rtift of the AA n e distinguished from n intiml flp y its indistint orders, lk of rpid osilltory movements, extension of the rtift through the orti wll s stright line, [27] nd the presene of olor flow on oth sides of the rtift. Artifts n lso our in the desending ort. These re mirror imge rtifts used y highly refletive ort whih our t twie the distne from the trnsduer ppering s doule lumen ort [Figure 15]. COMPLICATIONS Complitions ssoited with dissetions re orti insuffiieny ourring in out 50% 70% of the ses, oronry dissetions in 10% 20% [18] of the ses, pleurl nd perirdil effusion, nd glol left ventriulr dysfuntion. TEE n e used to determine the use of orti insuffiieny in the presene of dissetion in the ME AV SAX view. LV dysfuntion my e seondry to ishemi following oronry dissetion or due to severe orti insuffiieny presenting in out 10% 15% of the ses. Perirdil effusion is due to trnsudtion of fluid from the wll of the flse lumen into the perirdil vity. [28] Another routine finding is the presene of left pleurl effusion using hemothorx [Figure 16]. INTRAMURAL HEMATOMA Intrmurl hemtoms re hrterized y thikened orti wlls without n intiml flp involving the sending or the desending ort, proly due to rupture of the vs vsorum leding to hemorrhgi vessel wll. Hemtoms involving the AA need emergent surgil therpy, while those involving the desending ort n e mnged medilly. Intrmurl hemtoms s desried y Mohr Khly et l. [22] re hrterized y intiml ter [Figure 17]. Figure 14: () Desending orti long xis view with the systoli olor flow Doppler in the true lumen. FL: Flse lumen. () M mode ehordiogrphy (rrow) inditing the systoli expnsion of the true lumen towrd the flse lumen. () Desending orti short xis view inditing the flow of lood y olor flow Doppler from the true lumen to the flse lumen in the lte systoli phse. Note the trer (red) on the eletrordiogrm t the end of systole Figure 15: Mid esophgel orti vlve long xis view demonstrting n rtift (red rrow) in the sending ort due to the presene of pulmonry rtery theter in the right ventrile (yellow rrow) Annls of Crdi Anesthesi Otoer 2016 Vol 19 Speil Issue 1 S51

10 GIANT PENETRATING ULCER This disese ours in elderly ptients with hypertension, hyperlipidemi, nd therosleroti disese. It ommonly ffets the desending ort in the form of n uler, whih t lter stge my result in n neurysm formtion. COARCTATION OF AORTA This is ongenitl nrrowing of the ort t the level of the orti isthmus. It n e predutl, dutl, or postdutl. This ondition is ommonly ssoited with iuspid AV nd ptent dutus rteriosus. Upper esophgel orti rh shot nd LAX views re the reommended views for evluting this ondition y TEE. Findings inlude nrrowing of the ort distl to LSA nd turulent flow on the olor flow Doppler. Trnsthori ehordiogrphy is more fvorle due to its ntomil lotion [Figure 18]. TRAUMATIC AORTIC DISEASE This disese is ssoited with high mortlity rte of out 30%, deelertion injury eing the most ommon use [29] nd orti isthmus eing the most ommon site of injury prt from desending ort, orti rh, nd dominl ort. TEE with its speifiity of 100% remins the imging modlity of hoie. Three types of lesions re seen su dventitil orti rupture, orti intiml ter, medistinl hemtom. [30] The sudventitil rupture n e prtil or omplete (trnsetion) with thikened highly moile flp, sene of ter, similr lood flow veloities on oth sides of the flp, mosi olor flow Doppler in the re of disruption, nd presene of medistinl hemtoms. Medistinl hemtoms pper s n inresing spe etween the TEE proe nd the orti wll nd right ehogeni spe etween the orti wll nd the pleur [Figure 19]. TRANSESOPHAGEAL ECHOCARDIOGRAPHY ASSESSMENT OF ENDOVASCULAR REPAIR OF AORTIC ANEURYSMS Endovsulr repir is gining populrity s n lterntive to open surgil repir of orti neurysms, therey minimizing the risk of surgery. TEE is n invlule tool for identifition of orti pthology, onfirmtion of plement of the guide wire within the Figure 16: () Desending orti short xis view demonstrting the intiml flp with mssive left sided pleurl effusion, TL: True lumen, FL: Flse lumen. () Mid esophgel orti vlve long xis view demonstrting severe orti insuffiieny following the Stnford Type A dissetion Figure 17: () Three dimensionl (zoom) imge of the desending orti short xis view showing 5 mm intrmurl hemtom in the wll of the desending ort. () X plne olor Doppler imging of the desending ort showing the intrmurl hemtom Figure 18: () Upper esophgel orti rh short xis view demonstrting the nrrowing (rrow) of the ort elow the level of left sulvin rtery. () Turulent flow ross the nrrowed segment Figure 19: () Desending orti short xis view demonstrting the thikened medil flp with n symmetril orti ontour inditing omplete sudventitil rupture of the ort. () Similr lood flow veloities with mosi pperne on oth sides of the disruption re seen S52 Annls of Crdi Anesthesi Otoer 2016 Vol 19 Speil Issue 1

11 true lumen, helps in stent grft positioning, deteting endoleks, nd evluting the rdi funtion. The min im of stent deployment in neurysms is to exlude the neurysml s so s to prevent further diltion. While in dissetions, the im would e to exlude the intiml ter preventing its evolution. An endolek is ommon omplition fter endovsulr repir of the ort. It is hrterized y persistent lood flow within the neurysml s ourring in out 20% of the ptient. [31] Endoleks re lssified into four types. [32] They my e primry endoleks usully deteted within 30 dys or seondry endoleks ourring fter 30 dys. Most of the endoleks n e deteted using olor flow Doppler. Another ehordiogrphi sign of endolek is the development of spontneous eho ontrst within the neurysml s fter deployment of the stent. If ontrst is eing used swirling of ontrst within the s indites the presene of endolek, stti ontrst indites the sene of endolek. TEE evlution of endoleks helps erly detetion nd immedite orretive interventions [Figures 20 nd 21]. SUMMARY TEE is n invlule imging modlity in the mngement of orti pthology. TEE hs to lrge extent improved the ptient outomes. Finnil support nd sponsorship Nil. Conflits of interest There re no onflits of interest. Clssifition of endoleks Type Atthment site lek Brnh lek Grft defet Grft wll porosity Desription Proximl lek Distl lek Lili olude To nd fro flow into the neurysml s Complex flow from more rnh vessels into the s Mid grft hole Juntionl lek or grft disonnetion Filure from suture holes Figure 20: () Desending orti short xis view demonstrting olor flow Doppler in the true lumen, rrow (lk) pointing towrd the guide wire in the enter. () Desending orti long xis view demonstrting the true lumen with the two guide wires (yellow rrows) in situ. () Desending orti long xis view demonstrting (rrow) the Medtroni tlent endovsulr stent in situ Figure 21: () Upper esophgel orti rh short xis view demonstrting the (red rrow) endovsulr stent in the orti rh proximl to the origin of the left sulvin rtery. () Aortogrphy demonstrting Type 2A endolek (lk rrow) into the neurysml s from the inferior mesenteri rtery. Red rrow is inditing the endovsulr stent. () Trnsdominl ultrsound olor flow Doppler demonstrting Type 4 (yellow rrow) endolek Annls of Crdi Anesthesi Otoer 2016 Vol 19 Speil Issue 1 S53

12 REFERENCES 1. Olsson C, Thelin S, Ståhle E, Ekom A, Grnth F. Thori orti neurysm nd dissetion: Inresing prevlene nd improved outomes reported in ntionwide popultion sed study of more thn 14,000 ses from 1987 to Cirultion 2006;114: Nihoynnopoulos P, Joshi J, Athnsopoulos G, Okley CM. Detetion of therosleroti lesions in the ort y trnsesophgel ehordiogrphy. Am J Crdiol 1993;71: Rosenerger P, Shernn SK, Löffler M, Shekr PS, Fox JA, Tuli JK, et l. The influene of epiorti ultrsonogrphy on intropertive surgil mngement in 6051 rdi surgil ptients. Ann Thor Surg 2008;85: vn Zne B, Nierih AP, Buhre WF, Brndon Brvo Bruinsm GJ, Moons KG. Resolving the lind spot of trnsoesophgel ehordiogrphy: A new dignosti devie for visulizing the sending ort in rdi surgery. Br J Anesth 2007;98: Shnewise JS, Cheung AT, Aronson S, Stewrt WJ, Weiss RL, Mrk JB, et l. ASE/SCA guidelines for performing omprehensive intropertive multiplne trnsesophgel ehordiogrphy exmintion: Reommendtions of the Amerin Soiety of Ehordiogrphy Counil for Intropertive Ehordiogrphy nd the Soiety of Crdiovsulr Anesthesiologists Tsk Fore for Certifition in Periopertive Trnsesophgel Ehordiogrphy. Anesth Anlg 1999;89: Konstdt SN, Reih DL, Quintn C, Levy M. The sending ort: How muh does trnsesophgel ehordiogrphy see? Anesth Anlg 1994;78: Nierih AP, vn Zne B, Buhre WF, Coddens J, Spnjerserg AJ, Moons KG. Visuliztion of the distl sending ort with A Mode trnsesophgel ehordiogrphy. J Crdiothor Vs Anesth 2008;22: Nierih A. Clinil outome fter pre inision ssessment of ortitheroslerosis y A View ehordiogrphy in 5,886 eletive rdi surgeryptients. J Crdiothor Vs Anesth 2011;25:S1. 9. Buerius J, Gummert JF, Borger MA, Wlther T, Doll N, Onnsh JF, et l. Stroke fter rdi surgery: A risk ftor nlysis of 16,184 onseutive dult ptients. 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13 30. Vignon P, Gueret P, edrinne JM, Lgrnge P, Sem R, Mithell S, et l. Trnsluminl Plement of endovsulr stent grftsfor the tretment of desending thori orti neurysms. N Engl J Med 1994;331: vn Mrrewijk C, Buth J, Hrris PL, Norgren L, Nevelsteen A, Wytt MG. Signifine of endoleks fter endovsulr repir of dominl orti neurysms: The EUROSTAR experiene. J Vs Surg 2002;35: Veith FJ, Bum RA, Ohki T, Amor M, Adiseshih M, Blnkensteijn JD, et l. Nture nd signifine of endoleks nd endotension: Summry of opinions expressed t n interntionl onferene. J Vs Surg 2002;35: TAKE HOME MESSAGES In this detiled review of TEE evlution of the thori Aort, the uthors desrie sed on ntomy of the thori ort, the eho evlution in six different TEE plnes, nd the importne of the epiorti snning (EUS) of the distl sending ort (AA) nd orti rh espeilly in the se of n theromtous plque whih hnges the surgil pln. The rtile lso desries the six zones in EUS, the orti neurysms nd orti dissetions with entry nd exit sites. Corttion of ort nd trumti orti diseses with EVAR is lso desried. Annls of Crdi Anesthesi Otoer 2016 Vol 19 Speil Issue 1 S55