Date post: | 26-Feb-2018 |
Category: |
Documents |
Upload: | dian-sukarya |
View: | 232 times |
Download: | 0 times |
of 98
7/25/2019 Aorta Dissection.pptx
1/98
Diseases of theAorta and
Trauma of the Heart & the Aorta
Nurnajmia Curie Proklamatina
Ruswandiani
Resource Person : dr. Suko Adiarto PhD S!"P#$%
DEPARTMENT OF CARDIOLOGY & VASCULAR MEDICINEFACULTY OF MEDICINE, UNIVERSITAS INDONESIA
November 2015
7/25/2019 Aorta Dissection.pptx
2/98
utline
Anatom' and Ph'siolo(' of the Aorta
Aortic Aneur'sm
Aortic DissectionTrauma of the Aorta
Trauma of the Heart
7/25/2019 Aorta Dissection.pptx
3/98
Anatom' andPh'siolo('
of the Aorta
7/25/2019 Aorta Dissection.pptx
4/98
Anatom' of the Aorta
Anatomicall' di)ided into:Thoracic aorta: ascendin( arch descendin(
se(ments
A*dominal aorta: su!rarenal infrarenal se(ments
Normal aortic diameters usuall' +,- mmta!er (raduall' downstream
ariation in/uenced *' a(e (ender *od'
si0e *lood !ressure 12!ansion rate 3 -.4 mm #men% -.5 mm#women% for each decade of life
7/25/2019 Aorta Dissection.pptx
5/98
6-7, 1SC 8uidelines on the dia(nosis and treatment of aortic diseases.
7/25/2019 Aorta Dissection.pptx
6/98
6-7, 1SC 8uidelines on the dia(nosis and treatment of aortic diseases.
7/25/2019 Aorta Dissection.pptx
7/98
9icrosco!ic Structure of
the Aorta Aortic wall include three la'ers:
Tunica intima: lined *' endothelial cells demarcated from media *'internal elastic lamina
Tunica media: concentric la'ers of elastic *ers alternatin( with
)ascular smooth muscle cells ;lamellar unit
7/25/2019 Aorta Dissection.pptx
8/98
Ph'siolo(' of the Aorta
Transmits !ulsatile arterial *lood !ressureto all !oints in arterial tree
Bunction de!ends on its !ro!erties aselastic conduit role of second !um!throu(h its elasticit' #Eindkessel function%
Pressure>res!onsi)e rece!tor in ascendin(aorta and aortic arch #control of SR andHR% increased aortic !ressure results indecreased SR and HR )ice )ersa
7/25/2019 Aorta Dissection.pptx
9/98
Pressure>Diameter Cur)e of
the Aorta Aortic wall !ressure>diameter relationshi! is nonlinear
Transition from distensi*le to sti *eha)ior occurs at!ressure FG- mmH(
Cur)e *ecome less stee! with increasin( a(e #aortastien diameter increases% due to: ncreased colla(en>to>elastin ratio #decreased elastin
increased colla(en%
Chan(es in wall #!ro(ressi)e disordered medial elastic
*ers and lamellae dis!la'in( thinnin( and fra(mentation% ncreased wall thickness #colla(en and other 1C9
macromolecules de!osition and elastic *ers calcication%
Arteriosclerotic chan(es #wall stienin(%
7/25/2019 Aorta Dissection.pptx
10/98
1)aluation of the Aorta
Can normall' *e !al!ated inmida*dominal re(ion de!endin( on *od'ha*itus ma' *e detected *' dee!
!al!ation adjacent to s!ine Plain radio(ra!h' is insensiti)e in
e)aluatin( thoracic and a*dominal aorta
9ore dia(nostic detail can *e o*tainedwith ultrasound #includin(echocardio(ra!h'% CT 9R aorto(ra!h'
7/25/2019 Aorta Dissection.pptx
11/98
Aortic Aneur'sms
7/25/2019 Aorta Dissection.pptx
12/98
)er)iew of Aortic Aneur'sms
Patholo(ic aortic se(ment dilation that tend to e2!and andru!ture
ncreased diameter I=-J than e2!ected for same aorticse(ment in unaected indi)iduals of same a(e and se2
Descri*ed in terms of: Si0e #cross>sectional diameter on ima(in(%
9or!holo(' Busiform K s'mmetric entire circumference
Saccular K locali0ed onl' a !ortion of wall circumference a!!ear as focalout!ouchin(%
Pseudoaneur'sm K *leedin( throu(h wall results in contained !eriaortichematoma in continuit' with lumen #trauma or contained ru!ture ofaneur'sm dissection !enetratin( ulcer%
Location #thoracic a*dominal%
Cause #de(enerati)e (enetic disorder etc%
htt!:MMwww.uchos!itals.eduMonline>li*rar'M
7/25/2019 Aorta Dissection.pptx
13/98
A*dominal Aortic
Aneur'sms
7/25/2019 Aorta Dissection.pptx
14/98
)er)iew of AAA
ncreased a*dominal aortadiameter F cm
9ost common form ofaortic aneur'sm
ccurs in >4J men F=-'ears old
G-J infrarenal 7-J!ararenalM)isceral somee2tend to thoraco>
a*dominal se(ment
Risk factors: 9en #=2%
lder a(e #F?- 'ears old%
Ci(arette smokin( #=2%
1m!h'sema H'!ertension
H'!erli!idemia
Bamil' histor' #6-J%
9olecular (enetics:
O! to 6-J of infrarenal AAAha)e famil' histor' of AAAssu((est inherited com!onent
Seuence )ariant onchromosome 4!67 is associatedwith 7J increased risk for AAA
7/25/2019 Aorta Dissection.pptx
15/98
Patho(enesis of AAA
Chronic aortic wall in/ammation increasedlocal e2!ression of !roteinases de(radation ofstructural connecti)e tissue !roteins
Res!onse to forei(n anti(ens and micro*ialinfection autoimmune res!onse !ostulated inAAA de)elo!ment
Aneur'smal dilation and ru!ture result from
mechanical failure of medial elastin andad)entitial colla(en
Natural histor' of AAAs *alance *etweende(radati)e and re!arati)e !rocesses
7/25/2019 Aorta Dissection.pptx
16/98
I!"mm"#or$ Ce%%
E%"#' Co%%"(e
MMP V")*%"r SMC
nltrateaortic wall
Releasematri2>de(radin(en0'meslead to
medialde(eneration
Proin/amma>tor'c'tokines:TNB>Q L>7 L>? B>
9edialelastindestructionandmarkeddecrease inelastinconcentrati
on
Dama(e tolamellae*'elastol'tic!roteinases leads toaneur'smal dilation
ncreasedcolla(encontent#walltensilestren(t
h%
1n0'mesinitiatin(interstitialcolla(enclea)a(era!idaneur'sme2!ansion and
ru!ture
9ost !rominentelastin> & colla(en>de(radin( en0'mesin AAA de(rade*road ran(e ofmatri2 !roteins
99P>6 5 4 76
e2hi*it acti)it'a(ainst elastin
99P>7 G 7initiate intact*rillar colla(ende(radation
99P>4 e2!ression ismarkedl' ele)atedin aneur'sm tissue!otential use ofdo2'c'cline andother 99Pinhi*itors tosu!!ress!ro(ression
Normall' !roduceelastin and colla(endurin( aorticde)elo!ment
Predominate withinelastic media mediate re!air of
connecti)e tissuewithin AAAs
De!letion of medialS9Cs due toa!o!tosis initiated*' medial ischemiasi(nalin( moleculesor cellular immuneres!onses
asa )asoruma*sencesu!!l' tomedia de!ends ondiusion from lumenma' *ejeo!ardi0ed *'
intimal thickenin(and atherosclerotic
7/25/2019 Aorta Dissection.pptx
17/98
Clinical Beatures
nsidious o)er 'ears rarel' s'm!tomatic ina*sence of distal throm*oem*olism ra!ide2!ansion ru!ture
9ostl' small lar(e ones ha)e hi(h risk ofru!ture
9ostl' detected *' screenin(Mincidental ndin(
Ph'sical e2amination is insensiti)e a*dominal
!al!ation ma' re)eal !ulsatilee!i(astricM!erium*ilical mass
AAA !resent in u! to G=J femoral arter'aneur'sm ?-J !o!liteal arter' aneur'sm
7/25/2019 Aorta Dissection.pptx
18/98
Screenin( Aneur'sm screenin( &re!air a*o)e (i)en si0ethreshold=-J reductionin ru!ture and death
Oltrasound Hi(h accurac' detection
sensiti)it'> s!ecicit'almost 7--J ine2!ensi)enonin)asi)e a)oid radiationand contrast a(ent serial
measurement
Less accurate diameterthan CT #not recommendedfor lar(er AAA F,.= cm%
6-7, 1SC 8uidelines on the dia(nosis and treatment of aortic diseases.
7/25/2019 Aorta Dissection.pptx
19/98
ther Dia(nostic ma(in(
CT 12tremel' accurate for detection and diameter measurement es!.
with contrast enhancement thin slice techniues D reconstruction
12tent of disease AAA relationshi! to renalM)isceralMiliac arteriesmural throm*us !atterns calcication coe2ist occlusi)e
atherosclerosis which mi(ht in/uence re!air
9R Hi(h accurac' in detectin( and measurin( diameter a)oids radiation
e2!osure and iodine>*ased contrast
Aorto(ra!h' nitial ste! in 1AR also used in su*seuent inter)entions followin(
AAA stent>(raft re!air such as em*oli0ation of lum*ar or iliac arter'
*ranches 1nlar(ed a*dominal aortic se(ment marked *' calcication lumen
ma' or ma' not a!!ear enlar(ed *ecause of mural throm*us!resence
7/25/2019 Aorta Dissection.pptx
20/98
Natural Histor'
8radual e2!ansion o)er 'earsand e)entual ru!ture
A)era(e e2!ansion rate of >=.= cm ran(es -.6>-. cmM'ear
Aneur'sm si0e wall thicknessintraluminal throm*usthickness and !eak wallstress contri*ute to ru!ture
7>'ear risk for ru!ture: ?.->5.- cm: 7->6-JU 5.->G.- cm:
6->,-JU FG.- cm: ->=-J =>'ear risk for ru!ture:
.->,.- cm: =J ,.->=.= cm: 7->6-J =.=>?.- cm: ->,-J F5.-cm : FG-J
6-7, 1SC 8uidelines on the dia(nosis and treatment of aortic diseases.
7/25/2019 Aorta Dissection.pptx
21/98
Ru!tured AAA
S'm!tomatic AAA related too)ert ru!ture or ra!id e2!ansionand im!endin( ru!ture
Ru!ture into !eritoneal ca)it' acute hemorrha(e se)ere
a*dominal !ain h'!otension
Ru!ture into retro!eritoneum tem!oraril' contained !eriaortic
hematoma se)ere a*dominal or*ack !ain radiate to /ank or (rointender !ulsatile a*dominal or /ankmass h'!otension s'nco!e
->=-J die *eforehos!itali0ation ->,-J die athos!ital *efore treatment SRmortalit' rate ,->=-J ma' *elower with 1AR6-7, 1SC 8uidelines on the dia(nosis and treatment of aortic diseases.
7/25/2019 Aorta Dissection.pptx
22/98
Sur)eillanceM9edical
Thera!' Small AAAs can *e o*ser)edsafel' with ima(in(sur)eillance and little risk forru!ture
Societ' of ascular Sur(er'(uidelines:
6.? >6.4 cm ima(in(M= 'ears
.->., cm ima(in(M 'ears
.=>,., cm ima(in(M76 months
,.=>=., cm ima(in(M? months
Oncertaint' for ,.=>=., cmrecommendations must *eindi)iduali0ed:
Voun( health' es!. women with=>=., cm ma' *enet from earl're!air
9edical thera!' o*jecti)es:
!re)ent C e)ents
limit AAA (rowth
!re!are !atient o!timall' toreduce !erio!erati)e risk
once inter)ention is indicated Risk factor mana(ement:
smokin( cessation#mandator'%
diet & e2ercise #reasona*le% 9edical thera!':
reduce wall shear stress orin/ammation statin AC1>
12!erimental thera!':
WW do2'c'cline ARW as!irin
7/25/2019 Aorta Dissection.pptx
23/98
Sur(ical Thera!'
1lecti)e re!air ofas'm!tomatic !atient #at least=.->=.= cm% de!ends on lifee2!ectanc' risk for ru!turerisk associated with re!air
S'm!tomatic aneur'sms andra!id (rowth #F7 cmM'ear%reuire sur(ical consultation
9or*idit' and mortalit'in/uenced *' CAD C$DCPD D9
Selection of SR or 1AR de!ends on indi)idualanatom' a(e risk associatedwith anesthesia and sur(er'
Wra)erman AC. Diseases of the aorta. n: Wraunwalds Heart Disease. 7- th1dition. 6-7=.
7/25/2019 Aorta Dissection.pptx
24/98
Techniues and
utcomes of SR nfrarenal trans!eritonealMleftretro!eritoneal a!!roach
Prosthetic (raft is sutured
to !ro2imal aorta sutured to distal aorta#tu*e (raft%Mcommon iliacarteries #*ifurcation (raft%after lower e2tremit'/ow restorationaneur'sm sac is sewnto(ether to !re)ent (raftand 8 tract contact
9ortalit' rate ,>GJcom!lication rates 7->-Jcardiac !ulmonar' renalcom!lications and colonic
ischemiaLate com!lications 7=>-Jrelated to incision !ara>anastomotic aneur'sm (raftinfection (raft>entericerosionsMstula (raft lim*
occlusions with lowere2tremit' ischemia
Bollow>u! with =>'earinter)als CT after SR
7/25/2019 Aorta Dissection.pptx
25/98
1AR
Bluorosco!icall' (uidedendo(raft insertionthrou(h femoral arteriesto re>line aorta
Less in)asi)e reuiresadeuate nonaneur'smal!ro2imal and distalattachment sites
1arl' lower mortalit' and
com!lication rate #F='ears similar to sur(icalre!air es!. a(e F5-'ears% hi(her num*er ofre!eated inter)entions
Com!lications: endoleaks endotension
endo(raft mi(ration lim* throm*osisim!lant>related com!lications (raft infection
Contrast>1nhanced CTA at 7 monthM?monthMannuall' after de)ice im!lantation
Color du!le2 ultrasono(ra!h' to detectendoleaks and AAA enlar(ement for thosewith sta*le ima(in( ndin(s
7/25/2019 Aorta Dissection.pptx
26/98
Wra)erman AC. Diseases of the aorta. n:Wraunwalds Heart Disease. 7-th1dition. 6-7=.
6-7, 1SC 8uidelines on the dia(nosis and treatment of aortic diseases.
7/25/2019 Aorta Dissection.pptx
27/98
Wra)erman AC. Diseases of the aorta. n: Wraunwalds Heart Disease. 7- th1dition. 6-7=.
7/25/2019 Aorta Dissection.pptx
28/98
6-7, 1SC 8uidelines on the dia(nosis and treatment of aortic diseases.
7/25/2019 Aorta Dissection.pptx
29/98
Thoracic Aortic
Aneur'sms
7/25/2019 Aorta Dissection.pptx
30/98
)er)iew of TAA
ncidence =>7- !er 7----- !erson>'ears
Cause natural histor' treatment )ar'de!endin( on TAA location
Aortic rootMascendin( aorta ?-Jdescendin( aorta =J aortic arch +7-J
Thoracoa*dominal descendin(
thoracic e2tend distall' to in)ol)ea*dominal aorta
7/25/2019 Aorta Dissection.pptx
31/98
Cause and Patho(enesis
8eneticall' tri((ered de(enerati)e oratherosclerotic mechanical in/ammator' andinfectious diseases
8enetic disorder tend to in)ol)e root& ascendin(aorta
Risk factor: smokin( HT a(e CPD CAD famhistor'
C9D #9BS other (eneticall' tri((ered TAA a(in(
HT%: elastic *ers de(eneration & fra(mentation lossof S9Cs increase colla(en de!osition re!lacementwith interstitial ;c'sts< of mucoid>a!!earin(*aso!hilic>stainin( 1C9!ro(ressi)e weakenin( ofaortic wall result in dilation and aneur'sm
7/25/2019 Aorta Dissection.pptx
32/98
Wra)erman AC. Diseases of the aorta. n: Wraunwalds Heart Disease. 7- th1dition. 6-7=.
7/25/2019 Aorta Dissection.pptx
33/98
Wra)erman AC. Diseases of the aorta. n: Wraunwalds Heart Disease. 7- th1dition. 6-7=.
XA*normalities in aortic media )ascular S9Cs or contractile !roteins o)eracti)ation of si(nalin(!athwa's and downstream mediators
7/25/2019 Aorta Dissection.pptx
34/98
Clinical 9anifestations
9ost are as'm!tomatic disco)ered incidentall' on ima(in( stud'
S'm!toms usuall' related to : Local mass eect !ro(ressi)e AR HB from root dilation s'stemic
em*oli0ation from mural throm*us or atheroem*olism
SCMinnominate )ein o*struction tracheaM*ronchusMeso!ha(us
com!ression Direct mass eect with com!ression of intrathoracic structuresMerosion into
adjacent *ones ma' cause !ersistent chestM*ack !ain
9ost serious com!lications ru!ture and dissection Ru!ture sudden se)ere chestM*ack !ain
Ru!ture into: Pleural ca)it' #usuall' left% or mediastinum is associated with h'!otension
1so!ha(us leads to hematemesis from aortoeso!ha(eal stula #common in infected
TAA% Wronchus or trachea results in hemo!t'sis
Acute aortic e2!ansion contained ru!ture and !seudoaneur'sm can causese)ere chest or *ack !ain
7/25/2019 Aorta Dissection.pptx
35/98
Chest Y Ra'
Eidened mediastinum!rominent aortic kno*dis!laced trachea
Smaller aneur'sms es!.saccular ma' not *e )isi*le
Aneur'sms of sinuses ofalsal)a and aortic root often;hidden< *ehind sternummediastinal structures and)erte*rae
Aortic tortuosit' and unfoldin(in older adults ma' mimic ormask TAAs
CYR cannot e2cludedia(nosis of TAAWra)erman AC. Diseases of the aorta. n: Wraunwalds Heart Disease. 7- th1dition. 6-7=.
7/25/2019 Aorta Dissection.pptx
36/98
TransThoracic1chocardio(ra!h'
12cellent for ima(in(aortic root can *eused to )isuali0e TAAsin)ol)in( sinuses ofalsal)a !ro2imalascendin( aortaaortic arch !ro2imaldescendin( aorta
Aortic root si0e isde!endent on a(ehei(ht or *od'surface area (ender
Wra)erman AC. Diseases of the aorta. n:Wraunwalds Heart Disease. 7-th1dition. 6-7=.
7/25/2019 Aorta Dissection.pptx
37/98
ther 9odalities
Contrast>enhanced CTand 9RA are !referredo)er aorto(r!ah' todene *oth aortic and*ranch )esselanatom'
CT and 9R measuree2ternal diameter of
aorta -.6 >-., cmlar(er than internaldiameter inechocardio(ra!h'
erman AC. Diseases of the aorta. n: Wraunwalds Heart Disease. 7-
th
1dition. 6-7=.
7/25/2019 Aorta Dissection.pptx
38/98
Natural Histor'
Relati)el' indolent (rowth rate -.7>-.6 cmM 'ear and markedindi)idual )aria*ilit'
ther risk factors for increased (rowth and ru!ture: older a(efemale WSA CPD h'!ertension ci(arette smokin( ra!idaneur'sm (rowth !ain aortic dissection !ositi)e famil' histor'
F")#or I!*e)'(N"#*r"% +'#or$
De)r'#'o
Cause 9BS: ra!id (rowth rate #-.= K 7 mmM'ear% RR for aneur'smdissectionMru!ture .5 female 6.4BTAAs: (rowth rate u! to 6.7 mmM'ear #com*ined ascendin(and descendin(%LDS: (rowth rate u! to F7- mmM'ear death at mean a(e of6? 'earsWA: WA ascendin( aortic aneur'sms ha)e hi(her (rowthrate #-.74 cmM'ear% than tricus!id A #-.7 cmM 'ear%
Location Descendin( aorta ha)e (reater (rowth rate # mmM'ear% than
ascendin( aorta #7 mmM'ear%Diameter Si0e 9ost im!ortant risk factor for aneur'sm ru!ture dissection
and deathLar(er aneur'sm (row faster9ean ru!ture or dissection rate 6J !er 'ear for aneur'sms+= cm J !er 'ear =.->=.4 cm 5J !er 'ear F?.- cm
Coe2istin( condition Dissected TAAs (row more ra!idl' #-.7, cmM'ear% thanwithout dissection #-.-4 cmM'ear%
Aortic Si0e nde2 AS +6.5= cmMm6com!lication rate ,J AS 6.5=>,.6= cmMm6
e)ent rate GJ AS F,.6= cmMm6 e)ent rate 6->6=J
7/25/2019 Aorta Dissection.pptx
39/98
Sur)eillanceM9edicalThera!'
9edical treatment: H'!ertension treatment
#ARWMAC1>%
Cholesterol lowerin(#atherosclerotic TAAK statin%
Weta *lockers #9BS%
99P inhi*itor #do2'c'cline%
Lifest'le modication: Awareness of condition and
risk for dissection and ru!ture
Smokin( cessation A)oidance of strenuous
!h'sical acti)it' #isometrice2ercise%
Wra)erman AC. Diseases of the aorta. n: Wraunwalds Heart Disease. 7- th1dition. 6-7=.
7/25/2019 Aorta Dissection.pptx
40/98
6-7, 1SC 8uidelines on the dia(nosis and treatment of aortic diseases.
7/25/2019 Aorta Dissection.pptx
41/98
Sur(ical Treatment #7%
Ascendin( TAA: resection and (raftin( of
ascendin( aorta 3concomitant AR
Aortic Arch: !ro2imal hemiarch resection
arch )essels left intact withdescendin( aorta as roof andremainin( arch is re!laced
e2tended arch resection
remo)e entire arch tissue anduse *ranched (rafts to re!lacearch and (reat )essels
reim!lant island of arch tissueincludin( (reat )essel ori(ins
a)erman AC. Diseases of the aorta. n: Wraunwalds Heart Disease. 7- th1dition. 6-7=.
7/25/2019 Aorta Dissection.pptx
42/98
Sur(ical Treatment
#6% Descendin( TAA:
resection and (raftin( ofaneur'smal se(ment with a!ol'ester (raft
Thoracoa*dominal
aneur'sm: de!ends on Crawford
classication
T1AR: less in)asi)e
aortic anatom' must ha)eadeuate !ro2imal & distal
landin( 0ones of at least 6->6=mm in len(th and diametersthat accommodate endo(raftand adeuate )ascular access
Wra)erman AC. Diseases of the aorta. n: Wraunwalds Heart Disease. 7- th1dition.6-7=.
htt!:MMclinical(ate.comM)ascular>sur(er'M
7/25/2019 Aorta Dissection.pptx
43/98
Acute AorticS'ndrome #AAS%
Classic AorticDissection
Aortic ntramural
Hematoma
#9H%
Penetratin(
AtheroscleroticOlcer
# PAO%
7/25/2019 Aorta Dissection.pptx
44/98
Aortic Dissection
7/25/2019 Aorta Dissection.pptx
45/98
1!idemiolo('
OS 6>.= cases !er 7--.--- !erson>'ears
ncidence is hi(her in men than n women andincreases with a(e
The !ro(nosis is !oorer in women as a resultof at'!ical !resentation and dela'eddia(nosis.
The most common risk factor associated with
AD is h'!ertension #?=K5=J% mostl' !oorl'controlled.
RAD re(istr' the mean a(e was ? 'earsU?=J were men
7/25/2019 Aorta Dissection.pptx
46/98
Patho!h'siolo('
7/25/2019 Aorta Dissection.pptx
47/98
The !ressure of the !ulsatile *lood within the aortic wallafter dissection leads to e2tension of the dissection.
Osuall' !ro!a(ate in an ante(rade direction *ecause ofthe !ressure wa)e from the aortic *lood *ut
occasionall' e2tend in a retro(rade direction.The dissection /a! ma' *e locali0ed or ma's!iral the
entire len(th of the aorta
Arterial !ressure and shear forces further tears in theintimal /a! !roduce e2it sites or additional entr'
sites for /ow of *lood into the false lumen Distention of the false lumen with *lood the intimal
/a! to com!ress the true lumen and narrow its cali*er mal!erfusion s'ndromes.
7/25/2019 Aorta Dissection.pptx
48/98
7/25/2019 Aorta Dissection.pptx
49/98
7/25/2019 Aorta Dissection.pptx
50/98
Classication
De Wake'
: ri(inates in the ascendin( aorta ande2tends at least to the aortic arch andoften to the descendin( aorta # and*e'ond%
: ri(inates in the ascendin( aorta andconned to this se(ment
: ri(inates in the descendin( aortausuall' just distal to the left su*cla)ianarter' and e2tends distall' a : sto!s a*o)e the dia!hra(m * : e2tends *elow the dia!hra(m
Stanford
A : Dissections in)ol)in( the ascendin(aota # with or without e2tension into thedescendi( a!rta%
W : Dissections not in)ol)in( theascendin( aorta
7/25/2019 Aorta Dissection.pptx
51/98
7/25/2019 Aorta Dissection.pptx
52/98
7/25/2019 Aorta Dissection.pptx
53/98
Classication
D*r"#'o
Acute : + 6 weeks
Chronic : F 6 weeks
Su*acute : 6> ? weeks
Chronic : F ? weeks
Pre-'%e)#'o
?=J ascendin( aorta
-J descendin( aorta
+ 7-J aortic arch
3 7J a*dominal aorta
7/25/2019 Aorta Dissection.pptx
54/98
7/25/2019 Aorta Dissection.pptx
55/98
Clinical
9anifestations
7/25/2019 Aorta Dissection.pptx
56/98
Pain
Pain ma' *e shar! ri!!in( tearin( knife>like
T'!icall' dierent from other causes of chst !ain
nset : a*rutness
Site : chest #G-J%>F anterior # T'!e A% *ack #,-J%a*dominal #6=J%T'!e W
9a' radiate from the chest to the *ack or )ice )ersa
Pain in the neck throat jaw or head !redictsin)ol)ement of the ascendin( aorta # and often the(reat )essels%
Pain in the *ack a*domen or lower e2tremities descendin( aorta
7/25/2019 Aorta Dissection.pptx
57/98
Aortic Re(ur(itation
,7>5- J T'!e A ncom!lete coa!tation of the aortic lea/ets
*ecause of concurent dilation of the aortic root
and anuulus or *ecause of acute aortic dilatationfrom an e2!andin( false lumen leadin( to central
aortic re(ur(itation
Aortic lea/et !rola!se caused *' the dissection
/a! !ro!a(atin( into the aortic leadlets orcommissures or *' distortion of !ro!e lea/et
ali(nment *' an as'mmetric dissection /a!
leadin( to eccentric aortic re(ur(itation
B8OR1 =5>7, Aortic re(ur(itation com!licatin( acute t'!e A aorticdissection.
The dissection /a! distorts the normal aortic lea/et ali(nmentthere*' leadin( tomalcoa!tation of the aortic )al)e and su*seuent aorticre(ur(itation. n thise2am!le the dissection /a! e2tends into the ostium of the ri(htcoronar' arter'
(arrow).
7/25/2019 Aorta Dissection.pptx
58/98
7/25/2019 Aorta Dissection.pptx
59/98
Dia(nostic Test
7/25/2019 Aorta Dissection.pptx
60/98
E%e)#ro)"r-'o(r"m .'om"r/er
D> dimer
D dimer > 1600 mg/ dl within the first 6 hours after
initial evaluation
Sensitivity 94%, se!ifity 40"100%#
7/25/2019 Aorta Dissection.pptx
61/98
Wra)erman. Wraunwald Heart Disease 7-th ed. 1lse)ier:6-7=
7/25/2019 Aorta Dissection.pptx
62/98
Chest Radio(ra!h
Non S!esic
n man' cases com!letel' normal
G-> 4- J A*normal aortic contour or widenin( of the aorticsilhouette
6-J!leural eusions
Calcication of the aortic kno* occurdetectse!aration of the intimal calcication from theouter aortic soft tissue *order *' more than -.=to 7.- cmthe ;calcium si(nG-Js!ecit' 4>4?J
7/25/2019 Aorta Dissection.pptx
64/98
Contrast CT
9ost common used for ecaluate Aortic Dissection and *est !erfomredwith electrocardio(ra!hicall' (ated multidetector scanner which ma'eliminate aortic !ulsation motion artifacts.
Presence of two distinct lumina with a )isi*le intimal /a!
Detection of two lumina *' their di((erin( rates of o!acitaion with
contrast material. Balse lumen com!letet' throm*osed low attenuation
Sensiti)it' and s!esicit' 4G>7--J
S!iral #helical% contrast enhanced CT allows D reconstrutcione)aluation dissection & *ranch )esselendo)ascular re!air
contrast
denntit' the !resence of throm*us # !artial or com!lete in the falselumen and detect hemo!ericardium !eriaortic hematoma aortic ru!tureand *ranch in)ol)ement and *lood su!!l' from the true and false lumina.
Limitations : motion artifact # cardiac mo)ement% contrast a(ent# ne!hro!ath'%
7/25/2019 Aorta Dissection.pptx
65/98
FIGURE 510 Contrast>enhanced CT scan of anaortic dissection demonstratin( a fenestration in theintimal /a! (arrow) with contrast material /owin( fromthe small densel' o!acied true lumen into the lesso!acied and lar(er false lumen of the aorta.
FIGURE 512 Contrast>enhanced CT scandemonstratin( acute t'!e A aortic dissection withenlar(ement of the ascendin( aorta and intimal/a!s (arrows) in the ascendin( and descendin(aorta. Woth the true lumen #TL% and the false lumenare o!acied with contrast material in thise2am!le.
7/25/2019 Aorta Dissection.pptx
66/98
9 ti R
7/25/2019 Aorta Dissection.pptx
67/98
9a(netic Resonancema(in(
Accurac' similar to orhi(her than CT
Does not reuire contract or radiation
C : !atients with certainim!lanta*le de)ices# !acemaker de*rilator%and other metallicim!lants.
9ore time needed than CT
Bor lon( term follow u! ofaortic dissection
7/25/2019 Aorta Dissection.pptx
68/98
Aorta(ra!h'
direct an(io(ra!hic
)isuali0ation of the intimal /a! #a ne(ati)efreuentl' mo*ile linear ima(e% or the
reco(nition of two se!arate lumensU indirect si(ns includin( aortic lumen contour
irre(ularities ri(idit' or com!ression *ranch)essel a*normalities thickenin( of the aorticwalls and aortic re(ur(itation
o %o(er *e- or #3e -'"(o' o AD,e4)e# -*r'( )oro"r$ "('o(r"3$ ore-ov")*%"r '#erve#'o
7/25/2019 Aorta Dissection.pptx
69/98
7/25/2019 Aorta Dissection.pptx
70/98
9ANA8191NT
7/25/2019 Aorta Dissection.pptx
71/98
Risk Assesment
Hi(h>risk condition
9BS or related connecti)e tissue disease famil' histor' of aorticdisease known aortic )al)e disease Zsuch as WA[ recent aorticmani!ulation or known TAA%
Hi(h>risk !ain features
chest *ack or a*dominal !ain descri*ed as a*ru!t in onsetse)ere in intensit' and of ri!!in(Mtearin(Mshar! or sta**in(ualit'U
Hi(h>risk e2amination features
!erfusion decit #!ulse decit *lood !ressure dierential focalneurolo(ic decit% murmur of aortic re(ur(itation or h'!otension.
Wra)erman. Wraunwald Heart Disease 7-th ed. 1lse)ier:6-7=
7/25/2019 Aorta Dissection.pptx
72/98
7/25/2019 Aorta Dissection.pptx
73/98
Wra)erman. Wraunwald Heart Disease 7-th ed. 1ls
7/25/2019 Aorta Dissection.pptx
74/98
Wra)erman. Wraunwald Heart Disease 7-th ed. 1lse
7/25/2019 Aorta Dissection.pptx
75/98
.P Re-*)#'o
WP a!!ro2imatel' 7-->76- mmH( or to thelowest le)el a!!ro!riate for adeuate
!erfusion
Weta *lockers(oal HR +\ ?-2M min
Short actin( W *locker esmolol initial *olus=-- mMk( and continous infusion =->6--
mikroMk(Mmin
f contraindicated
CCW Non DHP )era!amilor diltiem.
7/25/2019 Aorta Dissection.pptx
76/98
9ana(ement
C"r-'") T"mo"-e
G>7J in t'!e A AD
Ha)e h'!otension s'nco!e or alteredmental status
Pericardiocentesis for acutehemo!ericardiumrecurrent *leedin( &
acute hemod'namic colla!se es!eciall' if alar(er )olume /uid is remo)e and increaseWPmore *leedin( in !ericardial s!ace
I-')"#'o or S*r(')"%, E-ov")*%"r,"- Me-')"% T3er"$ or A)*#e Aor#')D'e)#'o
Sur(icalThera!'
Acute t'!e A aortic dissection Retro(rade dissection into the ascendin( aorta
1ndo)ascularandMor Sur(ical
Thera!'
Acute t'!e W aortic dissection com!licated *'isceral ischemiaLim* ischemiaRu!ture or im!endin( ru!tureAneur'smal dilationRefractor' !ain
9edicalThera!'
Oncom!licated t'!e W aortic dissection Oncom!licated isolated arch dissection
ntra 9ural
7/25/2019 Aorta Dissection.pptx
77/98
ntra 9uralHaematoma #9H%
Haematomade)elo!s
in the media of theaortic wall in thea*sence of an BL andintimal tear
7->6=J AAS CT and 9R
dia(nosis
7/25/2019 Aorta Dissection.pptx
78/98
Penetratin( Aortic Olcer
7/25/2019 Aorta Dissection.pptx
79/98
Penetratin( Aortic Olcer#PAO% Olceration of an aortic atherosclerotic !laue!enetratin( throu(h the internal elastic lamina into themedia
An atherosclerotic lesion !enetrates throu(h the
internal elastic lamina into the media often associatedwith a )aria*le de(ree of 9H formation
PAOs ma' lead to !seudoaneur'sm formation aorticru!ture or late aneur'sm
Aortic ulcers ma' *e sin(le or multi!le and ran(e from
= to 6= mm in diameter and , to - mm in de!th. PAOs are more common in #3e #3or")') "-"b-om'"% "or#" than in the arch or ascendin( aorta.
7/25/2019 Aorta Dissection.pptx
80/98
9ana(ement
ndi)iduali0edmana(ement
Pre)ent aortic ru!tureand !ro(ression to acuteAD
Recurrent and refractor'!ain as well as si(ns ofcontained ru!ture such
as ra!idl' (rowin( aorticulcer !eriaortichaematoma or !leuraleusion
7/25/2019 Aorta Dissection.pptx
81/98
Traumatic Ru!ture
of The Aorta
7/25/2019 Aorta Dissection.pptx
82/98
Denition
Traumatic aortic ru!ture #TAR% is a lesiondue to *lunt trauma in)ol)in( the aorticwall from the intima to the ad)entitia
TAR can result from car and motorc'clecollisions falls from a hei(ht or *lastinjuries air!lane and train crashes andskiin( and euestrian accidents
7/25/2019 Aorta Dissection.pptx
83/98
A traumatic lesion ma'*e classied as :
#7%intimal haemorrha(e
#6%intimal haemorrha(e
with laceration#%medial laceration
#,%com!lete laceration ofthe aorta
#=%false aneur'smformation
#?%!eri>aortichaemorrha(e
7/25/2019 Aorta Dissection.pptx
84/98
The si(ns of aortic ru!ture are nots!ecic and the !re> sence of coe2istin(head facial ortho!aedic and )isceral
lesions dominates the !h'siciansattention
D's!noea and chest !ain are !rominents'm!toms locali0ed in the *ack in 6-K
5?J of cases. Loss of consciousness andh'!otension are also freuent as(enerall' re!orted in !ol'traumati0ed!atients while (enerali0ed h'!ertension
is re!orted in a*out 75J
7/25/2019 Aorta Dissection.pptx
85/98
Dia(nostic
The most im!ortant dia(nostic ima(in(modalities are chest Y>ra' T11 contrast>enhanced CT 9R and contrast
an(io(ra!h'
7/25/2019 Aorta Dissection.pptx
86/98
9ana(ement
TA associated aortic ru!turesin 6,hours
mmediate treatment # within 6, hours%
Sur(ical thera!' :
> Clam! and sew
> W'!ass
1ndo)ascular stent thera!'
7/25/2019 Aorta Dissection.pptx
87/98
Trauma of the
Heart
7/25/2019 Aorta Dissection.pptx
88/98
)er)iew
Thoracic trauma is: 6=J of )ehicularaccidents deaths 7->5-J due to *luntcardiac ru!ture
1arl' trans!ort times !rehos!ital CPRand successful endotracheal intu*ationare !ositi)e factors for sur)i)al when!atient suers !ulseless cardiac injur' in
the eld
7/25/2019 Aorta Dissection.pptx
89/98
Tsai P et al. Traumatic heart disease. n: Wraunwalds Heart Disease. 7-th1dition. 6-7=.
Penetratin( Cardiac njur'
7/25/2019 Aorta Dissection.pptx
90/98
Penetratin( Cardiac njur'#7%
8reatest risk: R L #Anterior location%
Clinical s!ectrum: cardiac arrest with no )ital si(ns toas'm!tomatic with normal )ital si(ns
Cardiac sta* wounds: tam!onade FF
8unshot wounds: hemorrha(e FF
1)aluation: AWC BAST #!ericardial /uid in unsta*le!atienttransfer to o!eratin( room to address injur'%
ndications for emer(enc' de!artment thoracotom': Sal)a(ea*le !ostinjur' cardiac arrest #witnessed arrest with
hi(h likelihood of intrathoracic injur' es!. !enetratin( cardiacwounds%
Se)ere !ostinjur' h'!otension due to tam!onade airem*olism thoracic hemorrha(e
ital si(ns re(ained after resuscitati)e thoracotom'transfer to o!eratin( room for deniti)e re!air
Penetratin( Cardiac
7/25/2019 Aorta Dissection.pptx
91/98
Penetratin( Cardiacnjur' #6%
Deniti)e treatment:sur(ical e2!osure throu(hanterior thoracotom' ormedian sternotom'
8oals of treatment: reliefof tam!onade and controlof hemorrha(e
Concomitant correction ofacidosis and h'!othermiaand reesta*lishment ofeecti)e coronar'!erfusion *' a!!ro!riateresuscitation
Tsai P et al. Traumatic heart disease. n: Wraunwalds Heart Disease. 7-th1dition. 6-7=.
7/25/2019 Aorta Dissection.pptx
92/98
Tsai P et al. Traumatic heart disease. n: Wraunwalds Heart Disease. 7-th1dition. 6-7=.
7/25/2019 Aorta Dissection.pptx
93/98
Wlunt Cardiac njur' #7%
Ran(in( from minor *ruises of m'ocardium tocardiac ru!ture
Caused *' direct ener(' transfer to heart orheart com!ression *etween sternum and
)erte*ral column 9anifested as se!tal ru!ture free wall ru!ture
coronar' arter' throm*osis cardiac failured'srh'thmias ru!ture of chordae tendineae or
!a!illar' muscles Clinicall' se)ere *lunt cardiac trauma is
manifested as tam!onade or hemorrha(e into!leural ca)it' de!ends on !ericardium status
7/25/2019 Aorta Dissection.pptx
94/98
Wlunt Cardiac njur' #6%
Routine AWCs
BAST e2amination
76>lead 1C8
T11
se!tal defects )al)ular insu]cienc'Treatment:
Normotensi)e normal initial 1C8 sus!ected *luntcardiac injur': o*ser)ation units
A*normal 1C8: admitted for monitorin( and treated
accordin(l' nitiall' seen in cardio(enic shock: e)aluated and an'
structural injur' conrmed *est re!aired *' acardiothoracic sur(eon
7/25/2019 Aorta Dissection.pptx
95/98
Tsai P et al. Traumatic heart disease. n: Wraunwalds Heart Disease. 7-th1dition. 6-7=.
9iscellaneous Cardiac
7/25/2019 Aorta Dissection.pptx
96/98
9iscellaneous Cardiacnjur' atro(enic Cardiac njur'
12ternalMo!en cardiac massa(e central )enous line insertion cardiaccatheteri0ation !rocedures endo)ascularMcardiac inter)entions !ercutaneous!ericardiocentesis o!en !ericardial window
ntracardiac Borei(n Wodies Can cause acute su!!urati)e !ericarditis chronic constricti)e !ericarditis
forei(n *od' reaction hemo!ericardium
9eta*olic Cardiac njur'MWurns Cardiac d'sfunction in res!onse to injur' associated with *urns electrical
injur' se!sis SRS multis'stem trauma
1lectrical njur' mmediate cardiac arrest acute m'ocardial necrosis 3 )entricular failure
m'ocardial ischemia d'srh'thmias conduction a*normalities acuteh'!ertension^!eri!heral )asos!asm as'm!tomatic nons!ecic a*normalities
Pericardial njur'Traumatic !ericardial ru!ture is rare occurs mostl' in left !leuro!ericardial
surface motor )ehicular accidents as main cause
Late Seuelae of Cardiac
7/25/2019 Aorta Dissection.pptx
97/98
Late Seuelae of Cardiacnjur' nclude )al)ular a*normalities and
intracardiac stulas
Can *e identied intrao!erati)el' *'
(ross !al!ation of a thrill or with T11 ncidence is as hi(h as =?J follow>u!
echocardio(ra!h' , weeks after injur'
7/25/2019 Aorta Dissection.pptx
98/98
Thank Vou