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"Lumps" and "bumps" that mimic acute aortic and brachiocephalic vessel
injury

Article  in  Radiographics · July 1997

DOI: 10.1148/radiographics.17.4.9225385 · Source: PubMed

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“Lumps” and “Bumps”
That Mimic Acute
Aortic and Brachio-
cephalic Vessel Injury1
Richard G. Fisher, MD
Modesto Sanchez-Torres, MD
CliffJ. Whigham, DO
John W. Thomas, MD

Laceration of the thoracic aorta or brachiocephalic vessels due to blunt

trauma is relatively common. In such cases, prompt and accurate diag-
nosis followed by timely surgery is essential. These injuries typically oc-
cur at the aortic isthmus and can usually be readily identffied at aortog-
raphy, which remains the standard of reference for diagnosis. However,
numerous anatomic variants that manifest as “lumps” or “bumps” on
aortograms can mimic true vascular injury, thereby leading to false-posi-
tive or false-negative diagnosis. These variants include aortic spindle,
classic or atypical ductal diverticula, and infundibula of the brachio-
cephalic arteries and adjacent branches or of the right third intercos-
tal artery. Ductus diverticula typically occur at the isthmus and have
smooth, uninterrupted margins with gently sloping shoulders. In-
fundibula are also smoothly marginated but can occur in a variety of
locations and generally taper into one or more vessels at their apex.
Knowledge of the imaging appearances of these anatomic variants is
necessary for correct interpretation of aortograms of the aorta and bra-
chiocephalic vessels in blunt trauma patients.

Abbreviations: LAO left anterior oblique, MVA = motor vehicle accident

Index terms: Aorta, 941.13, 942.13 Aortography,

#{149} 94.121 Arteries,
#{149} innominate, 942.13

RadioGraphics 1997; 17:825-834

‘From the Department of Radiology, Baylor College of Medicine, One Baylor Plaza, Suite 165-B, Houston, TX 77030. Re-
cipient of a Certificate of Merit award for a scientific exhibit at the 1995 RSNA scientific assembly. Received May 24,
1996; revision requestedjune 27 and receivedjuly 25; acceptedJuly 26. Address reprint requests to R.G.F.

See also the article by Fisher et al (pp 835-849) in this issue.

CRSNA, 1997

825
 a. b.
Figure
teries
hide
graphic
1.

accident
examination
Normal
in a 20-year-old
(MVA).
includes
aorta
man
and

Standard
conventional
brachiocephalic
following
normal
a motor
aorto-
ye-

left
ar-

r
anterior oblique (LAO) (45#{176})(a), conventional
anteroposterior (b), and digital steep right ante-
rior oblique (>70#{176})(c) aortograms.

U INTRODUCTION
Blunt thoracic trauma is directly responsible for
over 100,000 admissions to U.S. hospitals annu-
ally. Over half (approximately 55,000) of these
patients undergo emergency thoracic aortogra-
phy to determine whether they have sustained
laceration of the aorta or brachiocephalic yes-
sels. Such injury is relatively common, being
confirmed in nearly 3,000 of those imaged (1).
Accurate diagnosis is essential for prompt triage
c.
of victims of blunt trauma, followed by timely
surgery for those with laceration of the aorta or
brachiocephalic vessels: If left untreated, 94% In this article, we discuss and illustrate sev-
of these patients would die before being dis- eral typical and atypical anatomic variants that
charged (2). can mimic vascular injury, along with various
Aortography remains the standard of refer- criteria for differentiating them from true in-
ence for diagnosis of these injuries, but ana- jury. These variants have been encountered
tomic variants can complicate or confuse the during our 26 years of angiographic experience
diagnosis, thereby leading to false-positive or at a major metropolitan trauma center.
false-negative imaging interpretations. These
variants include aortic spindle as well as ductus U AORTOGRAPHIC TECHNIQUE
diverticula and infundibula that can occur in The aortographic techniques used-including
various vessels and can manifest as “lumps” or catheter and guide-wire combinations; types of
“bumps” of uncertain cause. contrast agents, volumes, and rates; and imag-
ing combinations-are identical to those we de-
scribe elsewhere in this issue (3). The projec-
tions we use to perform a standard aorto-

826 U Scientific Exhibit Volume 17 Number 4

Figure 2. Aortic spindle in a 20-year-old man fol- Figure 3. Classic ductus diverticulum in a 38-year-
lowing a moped accident. Conventional LAO aorto- old man following a motor vehicle-pedestrian acci-
gram (photographic subtraction) shows narrowing dent. Conventional LAO aortogram (photographic
of the isthmus and fusiform dilatation just below the subtraction) reveals a bump with smooth, uninter-
isthmus. rupted margins and gently sloping shoulders just be-
low the isthmus. This is the classic appearance of a
ductus diverticulum.
graphic examination are shown in Figure 1 . The
multiple projections and the mixed conven-
tional and digital technique that we use have . Classic Ductus Diverticulum
evolved over time and have enabled us to The ductus diverticulum is a focal bulge along
achieve consistent imaging results; however, the anteromedial aspect of the aortic isthmus. It
we will soon be converting to fully digitized im- has been identified at thoracic aortography in
aging suites. 33% of infant patients but in only 9% of adult
patients (5). It is critically important to identify
U ANATOMIC VARIANTS this normal variant and distinguish it from a
posttraumatic false aneurysm, which also oc-
. Aortic Spindle curs most commonly at the aortic isthmus (88%
The aorta in the newborn is narrowed between of cases) (6). The classic ductus diverticulum
the left subclavian artery and the ductus arte- has smooth, uninterrupted margins and gently
riosis. This isthmus disappears after 2 months sloping symmetric shoulders (Fig 3); in con-
of age due to cessation of flow through the duc- trast, false aneurysms have a variety of shapes
tus arteriosis and increased flow through the and sizes with sharp margins and often contain
narrowed region. Although this configuration is linear defects (3).
usually no longer visible in the adult, the region
is still referred to as the isthmus. If a circumfer-
ential bulge below the isthmus persists, it is
called the aortic spindle because of its shape
and is considered a normal variant (4). This ana-
tomic bulge is typically smooth in outline (Fig
2).

July-August 1997 Fisher et a! U RadioGraphics U 827

 _rff,

4. 5a. 5b.
Figures 4, 5. (4) Atypical ductus diverticulum in a 30-year-old man following a 30-foot (6-rn) fall. Digital right
lateral aortogram shows a bump with asymmetric shoulders just below the isthmus. The more cephalic shoul-
der has a steep slope, whereas the more caudal shoulder displays a more classic gentle slope. These findings,
in addition to the presence of smooth, uninterrupted margins, characterize the atypical ductus diverticulum.
(5) Ductus diverticulum with delayed washout of contrast material in a 35-year-old woman who was stabbed
in the left side of the upper chest. (a) Digital LAO aortogram shows an asymmetric bump near the isthmus.
(b) Late-phase digital LAO aortogram demonstrates “hang-up” of contrast material in the bump. Delayed wash-
out of contrast material does not help differentiate a ductus bump from a false aneurysm.

. Atypical Ductus Diverticulum It is noteworthy that the steep superior

Compared with the classic ductus diverticulum, slope of an atypical ductus diverticulum may
the atypical ductus diverticulum has a some- create turbulence, resulting in delayed washout
what shorter and steeper slope superiorly and a of contrast material (Fig 5). Therefore, hang-up
more classic gentle slope inferiorly. However, of contrast material in a ductus bump does not
both shoulders have smooth, uninterrupted necessarily help differentiate an atypical ductus
margins, an important feature that distinguishes diverticulum from a posttraumatic false aneu-
this variant from true injury (Fig 4). Atypical rysm as previously suggested (7). Characteris-
ductus diverticula have been seen in patients tics that may be helpful in making the correct
both with and without a history of blunt diagnosis include smooth, uninterrupted mar-
trauma. gins and no evidence of sharp edges (Fig 6).

. Infundibula of the Brachiocephalic

Arteries
Infundibula of the left subclavian, left common
carotid, or brachiocephalic artery (Figs 7-9a)
may be confused with posttraumatic false

828 U Scientific Exhibit Volume 17 Number 4

a. b.
Figure 6. Atypical ductus diverticulum in a 19-year-old man following an MVA. (a) LAO aortogram
(photographic subtraction) shows a small, olive-shaped protrusion just below the isthmus. (b) Con-
ventional right lateral aortogram from a repeat examination shows a similar bulge. The smooth, unin-
terrupted margins and the absence of sharp edges assist in the diagnosis of an anatomic variant.

7. 8.
Figures 7, 8. (7) Infundibulum of the left subclavian artery in a 3 1-year-old man who suffered a nip-
tured spleen in a 30-foot (6-m) fall. Conventional anteroposterior aortogram shows a large bulge with
smooth, orderly margins at the origin of the left subclavian artery, indicating an anatomic variant.
(8) Infundibulum of the left common carotid artery in a 50-year-old man following an MVA. Conven-
tional LAO aortogram shows a subtle bulge with smooth, orderly margins at the origin of the left com-
mon carotid artery (solid arrows), findings indicative of an anatomic variant. The classic conical shape
of an infundibulum of the right third intercostal artery is also seen (open arrow).

July-August 1997 Fisher et al U RadloGraphics U 829

 a. b.
Figure 9. Brachiocephalic artery infundibulum versus false aneurysm (both surgically proved).
(a) Conventional LAO aortogram of a 22-year-old man following an MVA shows a large, somewhat
asymmetric bulge (arrows) at the orifice of the brachiocephalic artery. The smooth, orderly outlines of
the bulge help differentiate it from an injury. (b) Conventional LAO aortogram of a 28-year-old man
following an MVA shows an irregular, sharply marginated bulge (arrows) overlying the base of the bra-
chiocephalic artery. These findings are typical of a false aneurysm and help distinguish it from the ana-
tonic variant shown in a.

aneurysms, leading to unnecessary surgery. . Infundibula of the Brachiocephalic

Infundibula typically occur at the origin of Arterial Branches
these vessels from the aortic arch and have Infundibula can occur at the origins of the low-
smooth anatomic margins. This latter character- est thyroid artery (Fig 10) (8) or the thyrocervi-
istic helps differentiate these variants from false cal and costocervical trunks with (Fig 1 1) or
aneurysms, which are usually irregular and have without (Fig 1 2) incorporation of the internal
sharp nonanatomic margins (Fig 9b). In our ex- mammary artery. In each case, a smooth, unin-
perience, such variants occur most often in the terrupted margin is seen at the base of the in-
left subclavian artery and rarely in the left com- fundibulum as it arises from the branch vessel.
mon carotid artery. Alternatively, a laceration or false aneurysm of
the right subclavian artery (Fig 1 3) is distin-
guishable from an infundibulum by its irregular
outline and sharp margins.

830 U Scientific Exhibit Volume 17 Number 4

10. 11.

12a. 12b.
Figures 10-12. (10) Infundibulum of the lowest thyroid artery in a 35-year-old man whose car fell
from an overpass. Conventional LAO aortogram (photographic subtraction) reveals a small, tentlike
protrusion arising from the medial base of the brachiocephalic artery (arrow). There is a tiny vessel
arising from the apex of the protrusion. This variant is an infundibulum of the lowest thyroid artery,
which in turn supplies the isthmus of the thyroid gland. Again, the smooth, uninterrupted outline of
the infundibulum and the presence of a vessel arising from the apex indicate an anatomic variant.
(11) Infundibulum arising from the left subclavian artery in a 50-year-old woman with no history of
trauma. Aortogram shows a smoothly marginated outpouching from the midportion of the left subcla-
vian artery (arrow) that gives rise to the thyrocervical and costocervical trunks as well as the internal
mammary artery. Fibromuscular hyperplasia involving the internal carotid arteries and a hypoplastic
aberrant left vertebral artery are also incidentally noted. (12) Infundibulum of the right subclavian ar-
tery in a 40-year-old man following an MVA. (a) Conventional LAO aortogram shows a smooth bulge
overlying the origin of the right subclavian artery (arrow). (b) LAO aortogram (photographic subtrac-
tion) shows branch vessels arising from the smooth bulge (arrows). This infundibulum supplies the
thyrocervical and costocervical trunks. Again, the smooth, uninterrupted outline and the clear demon-
stration of branch vessel origins indicate an anatomic variant.

July-August 1997 Fisher et al U RadioGraphics U 831

 a. b.
Figure 14. Normal right third intercostal artery and adjacent branches in a 42-year-old man with a
gunshot wound to the left side of the chest. (a) LAO arteriogram (photographic subtraction) demon-
strates normal right third through sixth intercostal arteries (solid arrows). Branches of a normal left
third intercostal artery are also seen (open arrow). (b) Anteroposterior aortogram (photographic sub-
traction) shows the normal right third intercostal artery (solid arrow) supplying branches to the right
third and second rib spaces (open arrow). This vessel is frequently seen on thoracic aortograms and is
generally more prominent than its left counterpart (not clearly seen on this image).

;:-‘ ‘ #{149}
#{231};WS . ,

-. .-
#{149}(_-

.-., kT ‘.

a. b.
Figure 13. Laceration and false aneurysm of the
right subclavian artery (surgically proved) in a 16-
year-old girl injured in an MVA. The patient was
intoxicated with alcohol and hit a telephone pole
at 100 mph. (a) Conventional LAO aortogram
shows an irregular bulge overlying the proximal
right subclavian artery (arrow). (b) Conventional
anteroposterior aortogram (photographic subtrac-
tion) demonstrates a sharply marginated bulge in-
feriorly (arrow). (c) Digital selective brachio-
cephalic arteriogram also depicts the bulge with
sharp margins and an irregular, angular outline (ar-
row), confirming the presence of vascular injury.

C.

832 U Scientific Exhibit Volume 17 Number 4

15. i6a.
Figures 15, 16. (15) Atypicalinfundibulum of
the right third intercostal artery in a 29-year-old
man with multiple left rib fractures sustained in an
MVA. Conventional LAO aortogram shows an oval
bulge (arrow) arising from the descending thoracic
aorta and giving rise to the right third intercostal ar-
tery and a right bronchial artery. This variant is nei-
ther classic nor tentlike, but the smooth, uninter-
rupted margins leading to vessels at its apex never-
theless help distinguish this infundibulum from a
false aneurysm. (16) Atypical infundibulum of the
intercostal arteries in a 43-year-old man following a
rollover MVA. (a) Conventional anteroposterior
aortogram reveals an oval-conical bulge below the
isthmus (arrow). (b) Digital LAO aortogram shows
“twin peaks” arising from the bulge and leading to
the right third and fourth intercostal arteries (ar-
row). This atypical infundibulum supplies the right
third and fourth intercostal arteries. The smooth,
uninterrupted margins leading to vessels help estab-
16b. lish the diagnosis of an infundibulum.

. Infundibulum of the Right Third The classic infundibulum arising at the origin
Intercostal Artery of the right third intercostal artery usually maul-
The right third intercostal artery-also known fests as a conical, symmetric bulge with smooth,
as the right intercostal-bronchial trunk or the uninterrupted margins leading to a vessel at its
superior intercostal, uppermost intercostal, or apex (Fig 8). This characteristic appearance
highest thoracic intercostal artery-and adja- helps distinguish classic infundibula from small
cent branches are frequently seen on thoracic false aneurysms. Variation does occur, and an in-
aortograms supplying the third and second rib fundibulum may appear more rounded than
spaces (Fig 14) (9). It is usually more prominent conical (Fig 1 5) or may represent the common
than its left counterpart. Anatomic variants (ie, origin oftwo intercostal vessels (Fig 16). Further-
infundibula of the right third and other inter- more, infundibula may be subtle and multiple
costal arteries) can be confused with subtle in- (Fig 17) or quite large and variable in size (Fig
juries at angiography and may interfere with 18).
computed tomographic evaluation of acute aor-
tic injuries (10).

July-August 1997 Fisher et al U RadioGraphics U 833

 Figure 18. Multiple atypical intercostal infun-
Figure 17. Multiple intercostal infundibula in a 35- dibula (surgically proved) in a 27-year-old man with
year-old woman thrown from a car in an MVA. Con- a gunshot wound to the left side of the chest. An-
ventional LAO aortogram shows three tiny bulges teroposterior aortogram (photographic subtraction)
(arrows) protruding from the descending aorta and shows three large oval bumps protruding from the
leading to multiple vessels. Note the smooth ana- descending thoracic aorta and leading to several in-
tomic margins incorporating the origins of vessels. tercostal arteries. There is a common large infun-
The bulges represent multiple infundibula feeding dibulum supplying the right and left third intercostal
the third, fourth, and fifth right intercostal arteries arteries. There is also a common infundibulum lead-
and an associated bronchial artery. ing to the right fourth and fifth intercostal arteries.
(Courtesy of Alan Cohen, MD, University of Texas
Medical School, Houston.)
. SUMMARY
Aortography remains the standard of reference
thoracic aorta and brachiocephalic vessels in
in the diagnosis of aortic or brachiocephalic
blunt thoracic trauma. RadioGraphics 1997; 17:
vessel injuries as well as in distinguishing these 835-849.
injuries from anatomic variants. Anatomic vari- 4. Abrams HL, J#{246}nsson G. Technique, indications,
ants that may mimic aortic or brachiocephalic and hazards of thoracic aortography and the nor-
vessel injury include aortic spindle, classic and mal thoracic aorta. In: Baum S, ed. Abram’s an-
atypical ductus diverticula, and infundibula of giography. 4th ed. Boston, Mass: Little, Brown,
the brachiocephalic arteries and adjacent 1997; 391-414.
branches or of the right third intercostal artery. 5. Goodman PC, Jeffrey RB, Minagi H, Federle MP,
Thomas AN. Angiographic evaluation of the duc-
Typically, ductus diverticula occur at the aortic
tus diverticulum. Cardiovasc Intervent Radiol
isthmus and have smooth outlines and gently
1982; 5:1-4.
sloping shoulders. Infundibula are also smoothly 6. Fisher RG, Hadlock F, Ben-Menachem Y. Lacera-
marginated but can occur in a variety of loca- tion of the thoracic aorta and brachiocephalic ar-
tions and usually taper into one or more vessels teries by blunt trauma: report of 54 cases and re-
at their apex. view of the literature. Radiol Clin North Am
1981; 19:91-110.
Acknowledgment: We thank Lori Burlin for her as- 7. Morse SS, Glickman MG, Greenwood LH, et al.
Traumatic aortic rupture: false-positive aorto-
sistance in the preparation of the manuscript.
graphic diagnosis due to atypical ductus diver-
ticulum. AJR 1988; 150:793-796.
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834 U Scientific Exhibit Volume 17 Number 4

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