Diseases of the aorta Marina Trilesskaya M.D. - PowerPoint Presentation

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Diseases of the aorta

Marina Trilesskaya M.D.

Cardiology

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MKSAP Q

66 year old woman is evaluated in the Emergency Department for abrupt onset of severe chest and back pain that persisted for 2 hours. On exam, she is afebrile, BP 180/110 in both arms, pulse 98, oxygen saturation 96% on 2L of oxygen. Heart is regular, no murmurs, S4 is present. Chest is clear. Pulses are symmetric and equal in all extremities. Labs are notable for normal D-dimer, troponin;

creatinine

is 1.4. ECG shows sinus rhythm, LVH with repolarization abnormalities. Chest CT with contrast shows intramural hematoma distal to the left

subclavian

artery.

Which of the following is the most appropriate management?

A. Emergent cardiac catheterization

B. Emergent cardiothoracic surgery

C. Endovascular stent grafting

D. Intravenous b-blocker, followed by IV sodium

nitroprusside

E. Intravenous heparin

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Overview

Aortic Dissection

Atypical Aortic Dissection

Intramural Hematoma

Penetrating Atherosclerotic UlcerAortic AneurysmIndications for screening and repairZebras…

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Aortic Dissection

Deterioration of medial collagen and elastin

A tear in the intimal layer allows blood to enter the intima-media space

Blood then propagates down this new space creating a “true” and a “false” lumen

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Factors Predisposing to Dissection

Hypertension

Marfan

and

Ehler-DanlosAortic aneurysmCoarctation and bicuspid aortic valvePregnancyCrack cocaineTrauma, high intensity weight lifting

Perforation through an intimal atheromatous plaque

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Intimal flap and tear in a patient with acute type A aortic dissection

Meredith E L , Masani N D Eur J Echocardiogr 2009;10:i31-i39

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Predicting death in Patients with Acute Type A Aortic Dissection

547

pts

; IRAD, Jan 96-Dec 99

In hospital mortality 32.5%Age > 70 yearsAbrupt onset of chest painHypotension, Shock, TamponadeKidney failure

Pulse deficitECG abnormalities

Circulation 2002

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Clinical Presentation

Pain 85-96%

Sudden 85%

Severe 90%

Tearing/Ripping 50%Syncope

Pain, obstruction, barroreceptorsNeurologicalCVA 5%

Paraparesis

or paraplegia

CHF 7%

MI rare (RCA > LCA)

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Physical Findings

Pulse Deficits ( 50% prox ; 15% distal)

Aortic Regurgitation – 16-67% of cases

Neurological Manifestations -6-19%

CVA – 3-6%Altered consciousness or comaSpinal artery perfusion – paraplegia, paraparesis

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Imaging Modality of Choice

GOALS

Confirm the diagnosis

Classify the dissection and determine extent

Detect pericardial involvementDetect and grade AI

CHOICESTTE/TEECTMRIAortography

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Procedure Used for the Diagnosis of Aortic Dissection

Am J Cardiology 2002

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Sensitivity of the Four Imaging Modalities

Image Modality

Overall

Type A

Type B

TEE

88%

90%

80%

CT

93%

93%

93%

MRI

100%

100%100%Aortography87%87%89%

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Aortic dissection: Complications

Rupture

Tamponade

Aortic Regurgitation

Coronary Artery InvolvementOther Branch Vessel Involvement

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Aortic Dissection: Mechanism of AR

1. Dilatation of aortic root

2. Pressure from dissecting hematoma may depress one leaflet

3. Torn annular support of the leaflets

4. Intimal flap prolapse

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Aortic Dissection – Pulse Loss

Due to direct compression

Blockade due to flap of intima

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Management

Type A – surgical emergency (mortality 1%/

hr

)

ICU monitoringAggressive BP controlIV bblocker for goal HR <60; SBP 100-120NitroprussideLong term -- should remain on bblockers; serial imaging at 3,6,12

mo

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Atypical Aortic Dissection

Intramural Hematoma

Penetrating Atherosclerotic Ulcer

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Intramural Hematoma: Diagnosis

Contained hemorrhage within the medial layer of the aortic wall

Crescentic area along the aortic wall

Prevalence 10-15% in CT/MRI/TEE

Normal size lumenFalse negative aortograms

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Intramural Hematoma on CT

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Intramural hematoma

.

Meredith E L , Masani N D Eur J Echocardiogr 2009;10:i31-i39

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Intramural Hematoma of the Aorta

Predictors of Progression to Dissection and Rupture

Location in the ascending aorta

Initial hematoma thickness

> 11mmModerately ectatic aortic diameter with progression

Circulation 2002

Circulation 2003

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Penetrating Atherosclerotic Ulcer

Almost exclusively in the descending

Ao

Usually remains localized

Elderly HTN, evidence for other atherosclerotic CV diseaseChest and back pain without associated AR or neurological deficits

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Penetrating Atherosclerotic Ulcer

Natural history is unclear

No defined strategy

Surgical repair for

PseudoaneurysmTransmural ruptureContinued painDistal embolizationAneurysmal dilatation

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Aortic aneurysm

Definition

:

pathological dilatation of the normal aortic lumen involving one or several segments

Fusiform

(common)

,

saccular

Pseudoaneurysm:

well-defined collection of blood and connective tissue outside the vessel wall

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Thoracic aortic aneurysm (TAA)

Descending aorta > ascending aorta

Cystic media degeneration:

weakening aortic wall (elastic fiber degeneration)

Marfan

syndrome, etc..

Vasculitis

Bicuspid aortic valve

Syphilis: ascending aorta

Infectious

aortitis

/

mycotic

aneurysm

Atherosclerosis

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Thoracic aortic aneurysm (TAA)

40% asymptomatic

Symptoms due to mass effect - superior vena cava syndrome, tracheal deviation

Usually slow growth (0.1 -1 cm/year); increasing risk of rupture in rapidly growing/large TAA

> 6 cm TAA – 15 % yearly risk of rupture/dissection/death

CT, TEE > TTE

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Management

Asymptomatic

Aggressive BP control;

bblockers

Serial imaging CTA/MRI, at 6 month, and then yearly if no rapid growthRepair

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INDICATIONS FOR REPAIR

● Symptoms

● TAA of 5 - 6 cm for an ascending and 6 to 7 cm for a descending

● Replacement 

before aortic size index for the ascending of Ao is 2.75 cm/m2 ● Rapid growth (≥10 mm per year) in aneurysms less than 5 cm● Evidence of dissection● An ascending TAA >4.5 cm at the time of aortic valve surgery

Bicuspid aortic valve w/ TAA > 5 cm and/or rate of growth > 0.5 cm/year● Marfan

patients w/ TAA > 5 cm and any degree of AI

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Abdominal aortic aneurysm

Prevalence:

1% (AAA > 4 cm) in men 55-64 years old

Smoking accounts for > 75% of these

6:1 M:F

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Risk Factors

: white, male, age, smoking, atherosclerosis, hypertension

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Screening

USPTF (2005):

Men 65-75, smoking history – one time US

Routine screening not recommended in women

ACC/AHA (2005):As above andMen >60 with family history of AAA (individualized screening for women w/ family hx)

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Annual risk of rupture

Zero for AAA <4.0 cm in

0.5 to 5 % for AAA 4.0 - 4.9 cm

3 - 15 % for AAA 5.0 - 5.9 cm

10 - 20 % for AAA 6.0 to 6.9 cm20 - 40 % for AAA 7.0 to 7.9 cm

30 - 50 % for AAA ≥8.0 cm

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Management

Aimed at managing CV risk factors

Smoking cessation

ASA/statin (CAD equivalent)

No Rx proven to prevent expansionElective repair indicated if: Asymptomatic AAA ≥5.5 cmRapidly expanding AAAAAA associated with peripheral arterial aneurysm (eg, iliac, popliteal) or peripheral artery disease (

eg, iliac occlusive disease)

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Coarctation

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Middle aortic syndrome (MAS)

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Renal –

vascu

lar

disease in

MAS

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Take home points

Aortic dissection is rare, but has high mortality (increasing with every hour!)

Prompt recognition, aggressive BP/HR control and emergent surgical intervention, if Type A

Screen male smokers 65-75 for AAA w/ US

Serial imaging for known TAA/AAAManage CV risk factors (smoking cessation, antiplatelet Rx; statin)

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Questions?