acute aortc syndromes

8/6/2019 Acute Aortc Syndromes

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Acute aortic syndromes

Padmanabhan TNC

Cardiologist, KIMS23 april 2011


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Acute aortic syndromes

Life threatening disorders that occur in thesetting of preexisting disease of aorta or occurwithout warning

Acute dissection (class1) IMH (5-25%) (class2)

PAU (5-15%) (class4)

Intimal tear without hematoma (class 3) Rupture of aortic aneurysm

Aortic trauma (class5)


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Aortic dissection

Uncommon , often

catastrophic

Acute mortality 1%

every hour


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Classification of AAD

Acuity: acute 8 wks

Pathophysiology : Class 1: classic: with intimal flap bet true & false lumens

Class2: Intramural hematoma without intimal flap(IMH) Class 3: Intimal tear without hematoma

Class 4 : Atherosclerotic plaque rupture with penetrating

ulcer(PAU)

Class 5: Iatrogenic or traumatic aortic dissection


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Clinical manifestations

Symptoms:

Pain (96%) in acute: sudden onset, severe max atinception

Nature: tearing, ripping, sharp, stabbing Migration: along path of dissection(17%)

Location: anterior vs interscapular

rarely pleuritic

Rarely : CHF(7%) , syncope (13%) ( tamponade orstroke), CVA(6%) , paraplegia, ischemic peripheralneuropathy or cardiac arrest or sudden death


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AD: uncommon CLINICAL FEATURES

A.

Syncope 10%

Ominous external rupture

(hemopericardium)

B.

StrokeCarotid artery

C.Paraparesis, Paraplegia

Spinal artery

D.

Horner Syndrome


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Physical findings

Very variable

Reflect location of dissection

HTN 70% (distal) 36% ( proximal)

Hypotension ( 25% vs 4%) (tamponade, acute AR or rupture)Pseudohypotension

Pulse deficit ( 30% vs 15% prox vs distal ) transient , Murmur of AR (1/2 to 2/3 of prox): murmur unimpressive, waxing &

waning, no peripheral signs of AR

(incomplete closure, leaflet detachment with prolapse, intimal tearextending into leaflet)

Neurological manifestations (6-19% of all)-Proximal ; CVA ,alteredconsciousness or even coma or paraparesis ( spinal ischemia) MI 1-2% Rt > Lt (mortality 71% with TLT)

Visceral ischemia: renal 5-8%, mesenteric 3-5%, iliacs 12%


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Other phy findings

Pleural effusion(small-reactive) large(hemothorax)

Hoarseness, upper airway obstruction,hemoptysis, dysphagia, hematemesis, SVCsyndrome, pulsating neck masses, Hornerssyndrome or unexplained fever

Continuous murmur with CHF One series initial diagnosis was different in

38% cases


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CLINICAL FEATURES contd.

Most important factor

leading to a correct diagnosis is

a high clinical suspicion!


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: Widening of aortic silhoutte 81-90% Widening of superiormediastinum

Calcium sign > 1.0cm Normal 12%


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ECG

Nonspecific

LVH 1/3rd

To r/o ACS & Dx MI due to dissection


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Lab investigations

D Dimer specificity 99% sensitivity 34%


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Diagnostic techniques

Aortography :

Direct signs (2 lumina, Intimal flap)

Indirect signs ( deformed aortic lumen,thickening of aortic wall, branch vessel

abnormalities or AR)

S

ensitivity 88% (77%) specificity 94% Invasive, contrast, time consuming


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Computed tomography

Sensitivity & specificity 96-100%

Noninvasive, contrast needed, fast,3 D R


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Contrast CT : dilated desc. Tho Aorta, intimal

flap, equal opacity of true & false lumens


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Echocardiography

TTE:

Intimal flap: more than 2 views, motion independentfrom aortic wall

Sensitivity 59-85%, specificity 63-96%

Echo window

TEE: better anatomical detail

Poor visualization of distal asc.aorta & prox.arch.sensitivity 98-99% (intimal flap 73%) specificity 94-

97%) AR & PE (100%)

C. angio? Dissection, CAD (25%).Routine CART ?


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Type A dissection: TTE, CTA


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MRI

Noninvasive, no contrast or ionising radiation

Sensitivity & specificity of 98%

Time consuming Not suitable for unstable pts

Poor visualization of branch vessels without

gadolinium


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MRA : dissectionof Abdl aorta with

remote h/o

sudden

deceleration injury


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Comparative diagnostic utility of imaging in AAD


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Mechanismsof death:Aortic

Dissection


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Acute management of AAD

Betablockers Indication Dose

Esmolol 500mcg/kg bolus,

50mcg/kg/min infusion

Labetelol 20 mg bolus, 2mg/min

Propranolol 1-10mg over 10min, 6hrly

NonDHP CCB When BB are

contraindicated

Enalaprelat 0.625-1.25mg 6hrly

SNP 0.3mcg/kg/min max

10mcg/kg/min

NTG 5-200mcg/min

Fenoldopam iv In renal failure


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Definitive therapy

Proximal : surgery Distal : medical (except vital organ or limb ischemia, uncontrolled pain or

rapid expansion)

Chronic : MM

Surgery: resection of damaged aorta, excision of intimal flap & obliteration

of false lumen

Interposition of prosthetic sleeve graft

AR: decompression of false lumen, resuspension of commissures & PHVreplacement

Complications: immediate: bleeding, infection renal or pulmonaryinsufficiency & spinal cord ischemia

Late: progressive AR, localised aneurysm formation & recurrentdissection

30 day survival 74% (proximal ) 69% (distal)

Newer surgical techniques: use of tissue glue


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Endovascular techniques

Distal

INSTEAD trial

Definitive medical Rx: antiHTN Long term FU: 5 yr 75-82%

Late compli: AR, recurrent dissection,

aneurysm or rupture


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Malperfusion of distal aorta by occlusive type B dissection: stent graft inprox.desc. Aorta restores flow


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Acute type B aortic dissection in a 44-year-old man; note thecommunications between the true and false lumen at the

thoracic and abdominal level


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IRAD:30 day mortality in AAD


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Atypical aortic dissection


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CTA of PAU: A sagittal B transverse


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MRA of PAU (desc. Aorta) surface

shaded rendering


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Evolutions of acute IMH of the descending aorta (left) togrowing local dissection and formation of an aneurysm on

spiral contrast-enhanced CAT scans within 4 months;

reconstruction of the dissected aorta and exclusion ofaneurysm after interventional stent-graft placement


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Pain

Hemodynamic instability

Shock


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Aortic rupture

Atherosclerotic Aneurysm

PAU, IMH

Dissection ( Type A& B, Acute & chronic)

Postoperative at anastomotic site

Posttraumatic (blunt trauma, gunshot & stabwound)

Iatrogenic Aortobronchial & aortoenteric fistulae


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Thank you for attention

acute aortc syndromes

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