Download diseases_of_aorta

Jakub Honěk
Kardiologická klinika
2.LF UK a FN Motol
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Anatomy and physiology
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Abdominal aortic aneurysm (AAA)
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Aneurysm of thoracic aorta
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Aortic dissection
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Ascending aorta
◦ Aortic root
◦ ST junction
◦ Tubular part
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Aortic arch
◦ Aortic isthmus
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Descending aorta
Abdominal aorta
◦ Suprarenal segment
◦ Infrarenal segment
◦ Bifurcation
Zieman SJ. Arterioscler Thromb Vasc Biol 2005;25:932-943.
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Localized distension
of aortic diameter >50%
(>3.0cm in women, >3.4 cm in men)
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90 % subrenal
Progresses over time
5x more frequent in men
Prevalence ↑ with age
Multifactorial etiology
Risk factors simillar to atherosclerosis,
pathophysiology is different - aortic wall
remodelling
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Mostly asymptomatic!
Rarely patient palpates pulsatile mass, or
feels pulsations
Mostly first smyptoms occur due to
complications
◦ Peripheral thromboembolism
◦ AAA rupture (first sign in 40%!)
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Emergent, life threatening situation
Mortality 80–90 % when optimally treated
90% retroperitoneal rupture
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Clinical triad
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◦ PAIN (amdominal/lumbar, radiation to groins)
◦ PULSATILE MASS
◦ HYPOTENSION (circulatory shock)
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Duplex ultrasound
◦ Fast, cheap, screening of pts.
in risk, follow-up
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CTA/MRA
◦ Optimal resolution, anatomy
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DSA
◦ Invasive treatment, luminography
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Screening
◦ Effective in risk groups (pts. With family history, CAD,
PAD, male smokers >65 yrs…)
◦ Prevention of fatal complications,
elective operation/inetervention
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Lifestyle changes, follow-up, blood pressure
control (beta-blockers)
Preventive operation/intervention
Indication based on AAA diameter:
> 55 mm
> 10 mm increase/year
Modified by BSA, sex, comorbidities
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Surgery
◦ Resection of aneurysmal sac, implantation of
vascular prosthesis
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Endovascular treatment
◦ Implantation of stentgraft
◦ Femoral approch
◦ Simila longterm results to surgery
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Conservative
◦ Follow-up, risk of rupture
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Emergent surgery/endovascular tretament
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Patient stabilization, fast imaging
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Up to 50% pts. die before reaching hospital
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30-40% die die before reaching op. Theatre
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40-50% of the operated die
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Overall mortality 80-90%
Less frequent than AAA (10/100 000)
 Same definition
 60% ascending, 5-10% arch, 30-35%
descendning
 Anuloaortic
ectasia
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Multiple etiologies – genetic, degenerative,
infectious, inflammatory
Bicuspid aortopathy
Cystic medial degeneration
Mostly assymptomatic
Symptoms of complications: Ao regurgitation,
embolization, compression sy., dissection,
rupture
Iamging: TTE, TEE, CTA, MRA, DSA
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BP control
Follow-up
Elective
surgery
Bonow et al. Braunwalds heart disease.
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Incidence: 3/100 000 per year
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High mortality
◦ Untreated: 25%/24h, 50%/week
◦ Optimal treatment: 20%/30 days
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Intimal tear – entry
Intimal flap, false lumen
Reentry
Arterial hypertension
Genetically triggered thoracic aortic disease
Marfan syndrome
Bicuspid aortic valve (bicuspid aortopathy)
Ehlers-Danlos syndrome
Congenital diseases
Coarctation of aorta
Tetralogy of Fallot
Atherosclerosis of aorta
Iatrogenic or blunt trauma
Catheterisation or stenting
Surgery (CABG, valve replacement, operation of aorta)
Intraaortic balloon contrapulsation
Trauma (road traffic accidents)
Gravidity
Cocaine abuse
Inflammatory and infectious diseases
Takayasu arteritis, giant cell arteritis, syphilis
Stanford
De Bakey
Entry: 65% root, 20% isthmus, 15% other
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Pain
◦ severe, sudden, sharp – stabbing, tearing („stabbed
in the chestwhit a knife“)
◦ Retrosternal (+radiation to neck, jaw), between
scapulae, abdominal, back
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Acute heart failure, MI, syncope, stroke,
paraplegia…
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Urgent situation – fast diagnosis
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Rare disease vs. Common diseases
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Physical exam, ECG, lab (D dimers)
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Ideal imaging test – fast, available, good
resolution – CTA
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Trasthoracic echo - bediside
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Urgent situation, high mortality in first hours
Multidisciplinary approach
Initial management:
BP control (beta blockers)
Pain control
Hemodynamic stabilization
In type A – plan urgent surgery
In type B – conservative/ surgery/endovascular