AORTIC AORTIC DISSECTIONDISSECTION
SYED RAZASYED RAZA
CASE 1CASE 1
University Teaching HospitalUniversity Teaching Hospital 53/f admitted to Heart Emergency 53/f admitted to Heart Emergency
CentreCentre Chest pain/discomfort – 1 hourChest pain/discomfort – 1 hour right leg numbnessright leg numbness PMH- Hypertension – not on PMH- Hypertension – not on
medicationmedication Smoker – 5 cigs/daySmoker – 5 cigs/day BP 170/80 mmHgBP 170/80 mmHg Power RLL 4/5 , Grade 2 AR murmur . Power RLL 4/5 , Grade 2 AR murmur .
Case 1 contd:Case 1 contd:
ECG- Ischemic changes Inferior ECG- Ischemic changes Inferior leads.leads.
CXR – NormalCXR – Normal Troponin – NegativeTroponin – Negative Routine blood tests - normalRoutine blood tests - normal
Case 1 contd:Case 1 contd:
MRAMRA – – Aortic aneurysm (6.5 Aortic aneurysm (6.5 cms).Aortic Dissection from aortic cms).Aortic Dissection from aortic root, extending to ascending Aorta root, extending to ascending Aorta and arch involving the left common and arch involving the left common carotid artery.carotid artery.
Small area of infarct Left MCA Small area of infarct Left MCA territoryterritory..
Urgent Surgery – Urgent Surgery – Patient did not Patient did not survivesurvive
Case 2Case 2
University Teaching HospitalUniversity Teaching Hospital
26/f , Univ. student26/f , Univ. student Chest pain after returning from holiday in USAChest pain after returning from holiday in USA 2 pm 2 pm Seen in ER , ECG and D-dimer - NormalSeen in ER , ECG and D-dimer - Normal diagnosed- musculoskeletal chest pain, diagnosed- musculoskeletal chest pain,
discharged on simple analgesicsdischarged on simple analgesics 8 pm 8 pm Patient returned to ER in 6 hrs Patient returned to ER in 6 hrs Seen by Med. Registrar on call – ‘ heard Seen by Med. Registrar on call – ‘ heard
pericardial rub’ – admitted , NSAIDSpericardial rub’ – admitted , NSAIDS
Case 2 contd:Case 2 contd:
• 8 am 8 am Referred to CardiologyReferred to Cardiology• Auscultation – not rub but AR murmurAuscultation – not rub but AR murmur• 9 am 9 am TTE – Dissection flap , Moderate TTE – Dissection flap , Moderate
ARAR• Urgent referral to surgeon (wanted CT Urgent referral to surgeon (wanted CT
Angio while OR was being prepared)Angio while OR was being prepared)• CT scan CT scan – – Extensive dissection from Extensive dissection from
Aortic root till abdominal aorta Aortic root till abdominal aorta involving renal arteriesinvolving renal arteries
Case 2 contd:Case 2 contd:
10.30 am 10.30 am – Rushed to OR– Rushed to OR Post operative course in ICU – Post operative course in ICU –
Sepsis ,severe renal failure , Sepsis ,severe renal failure , Mechanical ventilator and maximum Mechanical ventilator and maximum
ionotropic supportionotropic support Died after 5 daysDied after 5 days Post Mortem genetic analysis : Post Mortem genetic analysis :
Heterozygous PC 1307Y of the FBN1 Heterozygous PC 1307Y of the FBN1 gene. gene.
CASE 3CASE 3
• District General HospitalDistrict General Hospital• 79 yrs old Chinese lady , did not 79 yrs old Chinese lady , did not
speak Englishspeak English• Seen in ER with chest pain , anterior Seen in ER with chest pain , anterior
, on and off for more than 2 weeks, on and off for more than 2 weeks• PMH- HPN,DM, End stage COPD PMH- HPN,DM, End stage COPD • BP- 124/72 mmHgBP- 124/72 mmHg• CVS- NADCVS- NAD
ECG-non specific T wave changes. ECG-non specific T wave changes. Trop I – normal Hb 10.1Trop I – normal Hb 10.1
Discharged as Musculo skeletal Discharged as Musculo skeletal chest pain. Anaemia for Inv.chest pain. Anaemia for Inv.
CASE 3 contd:CASE 3 contd:
• Returned to ER following day – Returned to ER following day – continuing chest pain. Admitted as continuing chest pain. Admitted as Atypical chest pain. CXR-unfolded Atypical chest pain. CXR-unfolded aortaaorta
• Repeat Trop I-normal , D-dimer –Repeat Trop I-normal , D-dimer –elevated(>500 ng/dl)elevated(>500 ng/dl)
• CTPA – Requested .CTPA – Requested .• Anticoagulant commenced.Anticoagulant commenced.• ECG - <1 mm ST elevation in Inferior ECG - <1 mm ST elevation in Inferior
leads. Referred to Cardiologyleads. Referred to Cardiology
Case 3 contd:Case 3 contd:
• History from grand sonHistory from grand son
Admitted in hospital in China for 1 Admitted in hospital in China for 1 day just before coming to the UK.day just before coming to the UK.
EX- BP right arm 170/96 left arm EX- BP right arm 170/96 left arm 122/ 70122/ 70
CXR- Widened mediastinumCXR- Widened mediastinum
CASE 3 contd:CASE 3 contd:
CTPACTPA – –Dissection Asc. Aorta involving RCA , Dissection Asc. Aorta involving RCA , Arch of aorta involving left sub clavian Arch of aorta involving left sub clavian artery extending just beyond the diaphragm. artery extending just beyond the diaphragm. Small to moderate pericardial effusion.Small to moderate pericardial effusion.
Discussed with surgeon- High risk for Discussed with surgeon- High risk for surgery.surgery.
Patient and family not keen for intervention.Patient and family not keen for intervention.
Medical management – aggressive BP Medical management – aggressive BP controlcontrol
Anticoagulant stoppedAnticoagulant stopped
OBJECTIVES OBJECTIVES 1.Recognition of Aortic Dissection1.Recognition of Aortic Dissection 2.Prevalance2.Prevalance 3.Clinical features3.Clinical features 4.Investigation and Management4.Investigation and Management
Acute Aortic Dissection is a medical Acute Aortic Dissection is a medical emergencyemergency
High mortality rateHigh mortality rate Mortality rate rises at 1% per hour if Mortality rate rises at 1% per hour if
left untreated.left untreated. Atypical presentations are very Atypical presentations are very
uncommonuncommon Painless AAD have been reportedPainless AAD have been reported
Most important factorMost important factor
leading to a correct diagnosis isleading to a correct diagnosis is
a high clinical suspicion!a high clinical suspicion!
How Big Is The Problem?How Big Is The Problem? Incidence and prevalence uncertain.Incidence and prevalence uncertain.
5-30 cases per 1 million population per year.5-30 cases per 1 million population per year.
Available information: 2000 cases/year in U.S.Available information: 2000 cases/year in U.S.
Males 3 times more frequent than femalesMales 3 times more frequent than females
Descending dissections: 60-70 years oldDescending dissections: 60-70 years old
Ascending dissections: 50-59 years oldAscending dissections: 50-59 years old
(<40 years: Marfan, pregnancy, AV disease/Coarctation of Ao)(<40 years: Marfan, pregnancy, AV disease/Coarctation of Ao)
CLASSIFICATIONCLASSIFICATION
DDEEBAKEYBAKEYType IType IAscending aorta extending beyond Ascending aorta extending beyond archarch
Type IIType IIAscending aorta onlyAscending aorta only
Type III aType III aDescending aorta distal to left Descending aorta distal to left subclavian (above diaphragm)subclavian (above diaphragm)
Type III bType III bDescending aorta distal to LSA Descending aorta distal to LSA extending below diaphragmextending below diaphragm
SSTANFORDTANFORD A – Ascending aortaA – Ascending aorta
B – Not involving B – Not involving Ascending AortaAscending Aorta
CLINICAL FEATURES CLINICAL FEATURES
Sudden Onset Severe Pain (90%)Sudden Onset Severe Pain (90%)
• More severe at onsetMore severe at onset• Never experienced beforeNever experienced before• RestlessRestless
Anterior Pain: Proximal DissectionAnterior Pain: Proximal DissectionPosterior Pain: Distal DissectionPosterior Pain: Distal Dissection
PHYSICAL EXAMINATIONPHYSICAL EXAMINATION• May or may not look acutely ill.May or may not look acutely ill.
• HypertensionHypertension (moderate to severe) (moderate to severe)
• HypotensionHypotension (20%): acute complications (20%): acute complications
• Aortic insufficiencyAortic insufficiency: (50-60% ascending dissections): (50-60% ascending dissections)
• Pulse deficitsPulse deficits: (if left subclavian artery involved): (if left subclavian artery involved)
• OtherOther• Look for signs of Connective Tissue Disease (Look for signs of Connective Tissue Disease (Marfans Marfans
Syndrome)Syndrome)
NATURAL HISTORYNATURAL HISTORY Autopsy Series: Autopsy Series: >50%>50% of people with untreated aortic of people with untreated aortic
dissections are dissections are dead within 48 hoursdead within 48 hours..
1934 Shennan: >300 cases reviewed.1934 Shennan: >300 cases reviewed.40% acute ascending dissections died suddenly.40% acute ascending dissections died suddenly.None lived > 5 weeksNone lived > 5 weeks
Anagnostopoulos et al. Am J Card 1972Anagnostopoulos et al. Am J Card 1972973 pts with untreated proximal and distal dissections973 pts with untreated proximal and distal dissections50% died with 48 hours50% died with 48 hours84% died within 1 month84% died within 1 month
DIAGNOSTIC EVALUATIONDIAGNOSTIC EVALUATION
Chest radiographChest radiograph
Tran thoracic echocardiogramTran thoracic echocardiogram
Tran esophageal echocardiogram*Tran esophageal echocardiogram*
Computed tomography*Computed tomography*
Magnetic resonance imaging*Magnetic resonance imaging*
AortographyAortography
**Choice based on rapid availability and quality of performanceChoice based on rapid availability and quality of performance
CHEST X-RAYCHEST X-RAY
1. widened mediastinum, (sen: 44-80%)1. widened mediastinum, (sen: 44-80%)
2. Calcium sign -Displaced intimal calcification (>10mm) 2. Calcium sign -Displaced intimal calcification (>10mm)
from outer aortic wall– useful in older patientsfrom outer aortic wall– useful in older patients
3.pleural effusion (involvement of descending aorta)3.pleural effusion (involvement of descending aorta)
4.Normal in 18%4.Normal in 18%
A Normal CXR Should Not Deter Further EvaluatioA Normal CXR Should Not Deter Further Evaluation.n.
TTETTE
Indicated as an initial test if patient Indicated as an initial test if patient is very unwell and other modalities is very unwell and other modalities of imaging not readily availableof imaging not readily available
Can be performed bedsideCan be performed bedside Can detect intimal flap and ARCan detect intimal flap and AR LimitationLimitation: No information beyond : No information beyond
aortic root and early part of aortic root and early part of proximal aortaproximal aorta
TRANSTHORACIC TRANSTHORACIC ECHOECHO
TRANSESOPHAGEAL ECHOTRANSESOPHAGEAL ECHO
• Procedure of first choice for dissection, if readily availableProcedure of first choice for dissection, if readily available
• Portability of equipment facilities in emergency to ER or ICUPortability of equipment facilities in emergency to ER or ICU
• High sensitivity (98%) and specificity(97%)High sensitivity (98%) and specificity(97%)
Limitations : Unable to visualize distal part of asc. AortaLimitations : Unable to visualize distal part of asc. Aorta
(beginning of aortic arch) and desc. Aorta below stomach (beginning of aortic arch) and desc. Aorta below stomach
CT SCAN WITH CONTRASTCT SCAN WITH CONTRAST
• Sensitivity 98-100% Specificity 98-100%Sensitivity 98-100% Specificity 98-100%
• LimitationsLimitations::
Use of contrastUse of contrast
• Inability to identify site of tearInability to identify site of tear No evaluation of aortic regurgitationNo evaluation of aortic regurgitation Limited information on branch vesselsLimited information on branch vessels
• Useful for follow-up of dissectionsUseful for follow-up of dissections
MRAMRA
• Good alternative to TEE or CT, if readily availableGood alternative to TEE or CT, if readily available
• High sensitivity (98%) and specificity (98%)High sensitivity (98%) and specificity (98%)• Provides three dimensional reconstructionProvides three dimensional reconstruction
• Can detect site of intimal tear and involvement of branch Can detect site of intimal tear and involvement of branch vesselsvessels
• Non-invasive; neither x-rays nor contrast neededNon-invasive; neither x-rays nor contrast needed
• LimitationLimitation: claustrophobic, more costly, not readily available: claustrophobic, more costly, not readily available
AORTOGRAPHYAORTOGRAPHY
Considered Gold standard in olden daysConsidered Gold standard in olden days Sensitivity (88%) Specificity (94%)Sensitivity (88%) Specificity (94%) Identify intimal flap, true and false lumen Identify intimal flap, true and false lumen
Aortic insufficiency, branch vessel involvementAortic insufficiency, branch vessel involvement
LimitationsLimitations InvasiveInvasive Use of contrastUse of contrast Time delay in preparationTime delay in preparation
TREATMENTTREATMENT
Surgical Management – Stanford Surgical Management – Stanford Type AType A
Medical Management – Stanford Medical Management – Stanford Type BType B
Medical TreatmentMedical Treatment
ICU admission ICU admission
Close observation of BP, urine output, neurology statusClose observation of BP, urine output, neurology status
Prompt blood pressure control is criticalPrompt blood pressure control is critical Can reduce propagation of dissectionCan reduce propagation of dissection Decrease BP and LV contractility Decrease BP and LV contractility
Sodium nitroprusside + Beta blockerSodium nitroprusside + Beta blocker and and – blocker (Labetalol)– blocker (Labetalol) Calcium channel blocker (rate limiting)Calcium channel blocker (rate limiting)
SURGERYSURGERY
INDICATIONS FOR INDICATIONS FOR SURGERYSURGERY
Stanford type A (DeBakey type I and II) Stanford type A (DeBakey type I and II) ascending aortic dissection ascending aortic dissection
Complicated Stanford type B (DeBakey type Complicated Stanford type B (DeBakey type IIIIII) aortic dissections with clinical or radiological ) aortic dissections with clinical or radiological evidence of the following conditions: evidence of the following conditions: Propagation (increasing aortic diameter) Propagation (increasing aortic diameter) Increasing size of hematoma Increasing size of hematoma Compromise of major branches of the aorta Compromise of major branches of the aorta Impending rupture Impending rupture
PROGNOSISPROGNOSIS
Without treatment Without treatment about 50% will die about 50% will die within 48 hourswithin 48 hours
Without treatmentWithout treatment, about 75% will die , about 75% will die within the first 2 weeks. within the first 2 weeks.
With treatmentWith treatment, about 70% who have Type , about 70% who have Type A dissection and about 90% who have Type A dissection and about 90% who have Type B dissection survive to leave the hospital. B dissection survive to leave the hospital.
About 60% of people who survive the first 2 About 60% of people who survive the first 2 weeks are still alive 5 years after treatment, weeks are still alive 5 years after treatment, and 40% live at least 10 years. and 40% live at least 10 years.
TAKE HOME MESSAGETAKE HOME MESSAGE
Medical emergencyMedical emergency Many misdiagnosed or undiagnosedMany misdiagnosed or undiagnosed High clinical suspicion. Should consider High clinical suspicion. Should consider
as a differential diagnosis with all chest as a differential diagnosis with all chest pain.pain.
Thrombolytic ,Anticoagulants and anti Thrombolytic ,Anticoagulants and anti platelet therapy may be catastrophic.platelet therapy may be catastrophic.
Early diagnosis + prompt action = Early diagnosis + prompt action = SURVIVALSURVIVAL
THANK YOU FOR
YOUR ATTENTION