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Diseases of the aorta
Heart Disease
Braunwald
CV R4 李威廷醫師
Supervisor: 李貽恆醫師
Aorta
• Intima, media, adventitia
• ascending, arch, descending
• Aortic isthmus: arch-descending junction
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
Abdominal aortic aneurysm
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Age (M>55 y/o; F>70 y/o)
Atherosclerosis
Infrarenal arota: no vasa vasorum at media
Gene (Marfan, Ehlers-Danlos syndrome)
Prevalence: >3%
Aneurysm rupture: 80% into left retroperitonium
cavity
Abdominal aortic aneurysm
• Pain: most common, at hypogastrium or back, not
affected by movement
• Asymptom
• Rupture triad: abdominal or back pain; palpable/
pulsatile abdominal mass; hypotension (<1/3 cases)
• Bruit (+/-)
• Abdomianl echo, CT, MRA, aortography
Abdominal aortic aneurysm
• Surgical indication: rupture; size >4—5 cm;
expanding rapidly (>0.5 cm/year)
• Coronary angiography
• Medication control: Hyperlipidemia,
hypertension, cigarette smoking
• CT follow up every 3—6 months
Thoracic aortic aneurysm
• Descending aorta > ascending aorta
• Cystic media degeneration: weakening aortic
wall (elastic fiber degeneration)
• Marfan syndrome: autosomal dominant
• Ahterosclerosis
• Syphilis: ascending aorta
• Infectious aortitis / mycotic aneurysm
Thoracic aortic aneurysm
• 40% asymptom, pain
• A-V shunt, superior vena cava syndrome
(mass effect), tracheal deviation, hematemesis
• CT, TEE > TTE
• Surgery: >5cm (mean expansion rate= 0.43 cm/year)
• Op risk: 5%
Thoracic aortic aneurysm
• Annuloaortic ectasia: elastic fiber degeneration
+ aortic regurgitation
• Aortic valve replacement
Aortic dissection
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Tear in aortic intima
Antegrade, retrograde
false lumen, intimal flap, true lumen
Acute (2/3), chronic (1/3)
Ascending (65%), arch (20%), descending
thoracic (10%), abdominal (5%)
• Mortality: 1% per hour
Aortic dissection
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Peak: 60—70 y/o
Hypertension, bicuspid aortic valve
Marfan syndrome (cystic media degeneration)
3rd trimester pergnancy
Blunt trauma
IABP
Prior cardiac surgery
Aortic dissection
• Severe tearing pain (sudden onset), CHF,
syncope, CVA, ischemic peripheral
neuropathy, paraplegia, cardiac arrest,
sudden death
• Anterior pain only: 90% ascending
• Interscapular pain only: 90% descending
Aortic dissection
• Hypertension (descending), hypotension (ascending)
• Pseudohypotension (involving brachiocephalic
vessel)
• Pulse deficit (transient), AR, neurological finding
(proximal, conscious level or spinal cord ischemia)
• AMI (RCA > LCA)
• Pleural effusion (left side), cardiac tamponade
• Horner syndrome
Aortic dissection
• Calcium sign: 1.0cm (suggestive, not
diagnostic)
• Normal CXR cannot exclude dissection
• EKG: LVH (1/3); absence of ST and T
change; AMI (involving coronary a.)
• Initial diagnosis rate: 62%
Aortic dissection
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Mortality: 25% (<24h), 50% (1w), 75% (1m), 90% (1y)
BP favor RA
BP on LA if higher BP in LA than RA
SBP: 100—120mmHg,
mean BP: 60—75mmHg
Pain control, beta-blocker, nitroprusside, ACEI
Hypotension: prefer levophed
Pericardiocentesis for cardiac tamponade
Atypical aortic dissection
Intramural hematoma:
• rupture of vasa vasorum,
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aortic dissection without intimal flap,
10% type B dissection,
failed diagnosis in aortography,
high risk for aneurysm formation,
medication (distal) or surgery (proximal)
Atypical aortic dissection
Penetrating atherosclerotic ulcer:
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old, hypertension
no false lumen,
Aortography is standard
no definite treatment
Aortic atheromatous disease
Aortic atherothrombotic emboli
• Age, hypertension, DM, hyperlipidemia, vascular
disease
• Most common in descending thoracic aorta
• Coumadin is for high risk patients to prevent
embolic event
• Post-operative stroke
Cholesterol embolization syndrome
• Cholesterol crystal from ulcerated atheromatous
plaques
• “blue-toe” or “purple-toe” syndrome
• Elevated ESR & eosinophil
• Reduced complement level
• No specific therapy
Acute aortic oolusion
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Infrarenal aorta at bifurcation
Saddle embolus
Af / RHD, MI, DCM, aneurysm
Bilateral leg pain, weakness, numbness, paresthesia,
Cold, cyanosis, absent pulse, diminished or absent deep
tendon reflexes
• Aortogram
• Heparin, transcatheter, operation
• life-long anticoagulant
Primary tumor of aorta
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< 50 Cases
Equal in thoracic and abdomen aorta
Back pain
Aortography, biopsy
Prevent embolization
Peripheral artery diseases
Heart Disease
Braunwald Zipes Libby
sixth edition, 2001
CV R4 李威廷醫師
Supervisor: 李貽恆醫師
Jul 1st , 2004
Peripheral artery diseases
< 60 y/o population: <3%
> 75 y/o population: >20%
Peripheral artery diseases—risk factors
Peripheral artery diseases
Peripheral artery diseases
Intermittent claudication:
• pain, ache, fatigue, or discomfort in the affected leg
during exercise, particularly walking (oxygen demand)
• resolved with rest within few minutes
• Buttock, hip, thigh
• Gastrocnemius muscle is most common
• Walking Impairment Questionnaire
• Arterial embolism, vasculitis / arteritis, secondary
compression, lumbar sacroradiculopathy (neurogenic
pseudoclaudication, standing)
Peripheral artery diseases
Rest pain
• Inadequate blood flow
• Skin fissure, ulceration, or necorsis
• DM neuropathy or ischemic neuropathy
Peripheral artery diseases
Physical examination:
• Absent pulse distal to the stenotic site
• Bruit of the stenotic site
• Muscle atrophy, hair loss, cool skin, poor
healing, pressure sore,
Peripheral artery diseases
Peripheral artery diseases
Ankle/brachial index (ABI):
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SBP ratio (normal: >=1)
ABI <0.9 : 95% sensitive for PAD
ABI 05—0.8 with claudication: critical limb ischemia
ABI <0.5 or ankle BP <55mmHG: poor ulcer healing
MR angiography: 95% sensitivity and specificity
Contrast angiography
Peripheral artery diseases—treatment
Risk factor modification
Control DM, HTN, smoking cessation
Antiplatelet therapy: ticlopidine, plavix
Exercise: improve maximal walking distance than
PTA
Angioplasty / stents and surgery
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Trental: RBC flexibility and anti-inflammatory
Pletal: unknown
Beta-blocker: controversial
Thromboangitis obliterans
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Young smokers
Medium and smalll vessels of the arms
Cause unknown? Type I and III collagen
Pain, digit ulceration, Raynaud phenomenon
Abnormal allen test (2/3)
Tx: Cessation smoking, prostacyclin analogue,
Acute limb ischemia
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Arterial embolism (Af)
thrombosis with plaque ruprure
dissection,
trauma