aneurysms & aortic dissection

8/9/2019 Aneurysms & Aortic Dissection

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Schwartz’s Chapter 22Betsy White DO, PGY1

Thoracic Aneuryss !Aortic Dissection


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Anatoy o" AortaPro#ia$ AortaAscen%in&'aortic (a$(e

to ori&in o" innoinate a) Trans(erse'area "ro

which the *rachiocepha$ic

*ranches arise

Dista$ AortaDescen%in& Thoracic'

%ista$ to ori&in o" +su*c$a(ian to%isphra&atic hiatusA*%oina$'hiatus to

i$iacs


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Thoracic Aortic AneuryssPeranent, $oca$ize% %i$atation o" aorta %iaeter at

$east -. &reater than nora$/nci%ence )0 per 1--,--- personsay *e sin&$e or u$tip$e se&ent, thoracoa*%oina$

or mega-aortaT rue "usi"or or saccu$ar3 or 4a$se

pseu%oaneuryss, $ea5s in wa$$ cause pouches o"scar tissue on e#terior3

Consistent$y increase in size6 ost re7uire sur&ica$inter(ention6 a$$ re7uire a&&ressi(e 8T9 ana&eent

Aortic %iaeter stron& pre%ictor o" rupture, %issection,orta$ity :;c annua$ rate o" cop$ications. %issection, 1-)?. %eath3


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@tio$o&y ! Patho&enesis@$astin content hi&hest ascen%in& aorta6 %ecreases

%ista$$y) u$tip$e "actors can $ea% to aneurysstur*u$ent *$oo% ow, increase %iaeterwa$$ tension+ap$ace’s +aw3, poststenotic aortic %i$atation Aostenosis, coarctation3, atherosc$erosis)

9onspeciEc e%ia$ De&enerationAortic DissectionGenetic Disor%ers


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C$inica$ ani"estations@#pansion ! ipin&eent on a%acent structures

cause chronic pain) C s# anterior chest %isco"ort,iic5in& an&ina especia$$y in ascen%in& aortiaaneursys)

Copression o" SC, PAerosion causin& heoptysis3,airwaycausin& cou&h, wheezin&, stri%or, pneuonitis3,

sternu6 8oarseness an%or + (oca$ cor% para$ysis %uerecurrent $aryn&ea$ ner(e6 *ac5scapu$a pain, sa$$*owe$ o*struction, G/ *$ee%in&, au%ice)

Aortic (a$(e re&ur&itation %ue to %isp$ace% aortic (a$(ecoissures ! annu$ar %i$atation

Dista$ e*o$izationFupture'su%%en, se(ere pain in anterior chest,

*ac5$e"t chest, $e"t an5 a*%oen causin& car%iactapona%e, se(ere heorrha&ic shoc5, an%orrespiratory "ai$ure)


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@(a$uationP$ain 4i$ Fa%io$o&yH$trasoun%'ore use"u$ in"rarena$ aneuryss@chocar%io&raphy'TT@T@@ pro(i%e (isua$ization o"

ascen%in& aorta, inc$u%in& root6 T@@ a$$ows(isua$ization %escen%in& aorta not i%ea$ "ortrans(erse aorta3

CT'C use%6 pro(i%es (isua$ization o"thoracica*%oina$ aorta an% in"o o" aneurys’s$ocation, e#tent, anoa$ies, re$ationship to *ranches,an% %iaeter) W contrast pro(i%es in"o on $uen,aortic %issection, E*rosis, heatoas)

FA'(isua$ization o" entire aorta6 *ranchin& (esse$stenosisCar%iac Cath'use to *e I&o$% stan%ar%J especia$$y

ascen%in& %isease6 %eterines "unction o" hearta$thou&h increase ris5s o" proce%ure itse$"


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TreatentAsyptoatic patients e%ucation, thorou&h 8!P,

sur(ei$$ance CT scans, a&&ressi(e BP contro$ unti$syptoatic&rowin& aneurys then sur&ica$treatent)

Coon$y ha(e u$tip$e aneurys in which sta&e%

operations occur treatin& ost $i"e threatenin& Erst)/n%ications "or sur&eryAscen%in& %iaeter :) c,Descen%in& %iaeter : ;)c, orFate o" %i$atation is :1cyr)

Kar"an’s, +oeys


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Open (s @n%o(ascu$ar FepairDescen%in& Thoracic Aneursys'@n%o(ascu$ar

repair consi%eration i"8eo%ynaica$$y sta*$e

Pro#ia$ nec5 :2- "ro + su*c$a(ian artery

Dista$ nec5 :2- "ro $e"t ce$iac arterya#iu nec5 %iaeter L=> an% iniu 2=

A*sence o" $ar&e, o*i$e aortic atheroa

Consi%er in patient with se(ere pu$onary%isease, a%(ance% a&e, or u$tip$e co


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Operationspectru (aries

4ro sip$e &ra"trep$aceent o"tu*u$ar portion o"scen%in& aorta to&ra"t rep$aceent

o" the entirepro#ia$ aorta,inc$u%in& aorticroot !

reattachent o"coronary arteries !*rachiocepha$ic*ranches)


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Pro#ia$ Thoracic AorticAneuryss Aortic Valve Disease & Root AneurysmsPer"ore% throu&h i%sterna$ incision an% re7uire CPB)i$% to o%erate (a$(e re&ur& with annu$ar %i$atation

is a%%resse% *y pi$catin& annu$us with attresssutures p$ace *e$ow each coisuure) a$(e isrep$ace% w stente% *io$o&ic or echanica$ prosthesisin ore se(ere re&ur& pts)

Aortic root is rep$ace% ech*io$o&ic &ra"t'*oth (a$(ean% aortic con%uit)

Foss proce%ure pu$onary artery root is e#cise% an%p$ace% in aortic position3 not use% in patient w CT

%iseasea$(e


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Ascen%in& aorta repair

Tu*u$ar portion o" ascen%in&aorta rep$ace% *y &ra"t, an% thenati(e aortic root ! arch intact)

o%iEe% Benta$$ proce%ure'aortic (a$(ean% entire ascen%in& aorta rep$ace% *yechanica$ &ra"t) Coronary arteries with

*uttons reattache%


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Pro#ia$ Thoracic AorticAneuryssCoronary arteries must be reattached to graftBenta$$ an% De Bono


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Pro#ia$ Thoracic AorticAneuryss

Aortic Arch AneurysmsSaccu$ar aneuryss that arise "ro the $esser

cur(ature ! ta5e up L-. o" aortic circu"erenceare treate% *y patch &ra"t aortop$asty)4usi"or aneuryss a sin&$e *e(e$e% rep$aceent

o" $ower cur(ature is per"ore%)@#tensi(e arch aneuryss re7uire tota$

rep$aceent %ista$ anastoosis to pro#ia$%escen%in& thoracic aorta, separate reattachento" *rachiocepha$ic *ranches3)@#tree cases in(o$(in& entire arch, e#ten%in&

into %escen%in& aorta re7uires the Borst’se$ephant trun5 techni7ue o" sta&e% tota$ archrep$aceent)


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Borst’s e$ephant trun5


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@AF ! 8y*ri% Fepairs@AF'$iite% "or pro#ia$ aortic

repairs %ue to anatoy an%uninterrupte% cere*ra$ per"usion

8y*ri% Arch repairs'in(o$(e

"or o" I%e*ranchin&J o"*rachiocepha$ic (esse$s,"o$$owe% *y en%o(acu$ar

e#c$usion o" arch)Fis5 o" e*o$izationstro5e %ue to

wire ! %e(ice anipu$ation withinarch) 9o $ar&e sca$e stu%iescop$ete% at tie o" *oo5pu*$ishe%3) Hse% "or hi&h ris5sur&ica$ can%i%ates)


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Dista$ Thoracic AorticAneuryssDTAA'in(o$(es the portion o" aorta "ro +

su*c$a(ian to %iaphra&6 open repairre7uires $e"t thoracotoy) Dou*$e $uen@TT "or se$ecti(e (enti$ation

Thoracoa*%oina$'entire aorta "ro +su*c$a(ian to *i"urcation Craw"or%c$assiEcation36 open repair re7uirese#ten%e% thoracotoy across costa$ ar&in

! into a*%oen) Transperitonea$ e#posure*y e%ia$ (iscera$ rotation ! %i(ision o"%iaphra&)


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Craw"or% C$assiEcation

@#tent /


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DTAA Cop$icationsFis5C$apin& o" %ista$ DTA causes ischeia o" the

spina$ cor% ! a*%oina$ (iscera $ess coonhepatic, pancreatic, *owe$3) Se(era$ strate&iesto pre(ent an%or ipro(e these e(ents

All repairs--Systeic heparinization 1&5&3, i$%hypotheria =2


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@AF o" DTAAPriari$y use% to treat %e&enerati(e DTAA6 now it’s the

$ess in(asi(e options in pts w aortic %issection,trauatic, ycotic, rupture% aneuryss, e$%er$y pts wu$tip$e coor*i%ities, or pre(ious aortic proce%ures)

ascu$ar access o*taine% "eora$ or i$iac e#pose%36

heparinization, en%o&ra"t a%(ance% into aorta wuoroscopic 7ui%ance, %e(ice %ep$oye%, pro#%ista$en%s e#pan%e% *y *a$$oon catheter, aorto&ra ta5enro $ea5s, protaine &i(en)

Coon$y co(er + su*c$a(ian %urin& pro#ia$ I$an%in&

zoneJ now can construct caroti%


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DTAA Fepairs Con’tElephant Trunk CompletionHse% when aneurys e#ten%s "ro %ista$

arch to DTA6 en%o&ra"t is i%ea$ copare% toopen approach)

Can *e %ep$oye% at tie o" trun5construction or separatesta&e% proce%ure6Fa%ioacti(e ar5ers p$ace% at %ista$ en%Erst proce%ure3 a$$ows "or retro&ra%e

%ep$oyent with i%entiEcation (iauoroscopy)


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@AF o" TAAAFeains e#perienta$ accor%in& to *oo536

cop$e# proce%ures re7uirin& at $east 1 o"(iscera$ (esse$s to *e incorporate%)Stent &ra"ts'"enestrate%, rein"orce%

"enestrate%, *ranches, o%u$ar co*inations6soe custo


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Postoperati(e Consi%erationsOpen proce%ures/nitia$ 2


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@n%o$ea5s Type /


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Aortic DissectionPro&ressi(e separation o" aortic wa$$ a"ter tear "ors

in intia an% inner e%ia6 creatin& at $east twochanne$s) C catastrophic e(ent in(o$(in& aorta)True lumen'ori&ina$ $uen $ine% *y intia" #alse

lumen'new$y "ore% channe$ within $ayers o"

e%ia) Dissectin& e*rane separates the two6ay ha(e counications re-entry sites3 Hsua$$ypro&resses %ista$$y *ut ay procee% pro#ia$ proximal extension ore retrograde dissection3Se(ere conse7uences'"a$se $uen thin"ra&i$e

there"ore, prone to e#pansion or rupture in stressstates, ay copress true $uen malperfusionsyndrome3, or ay cause acute (a$(u$arre&ur&itation when aortic root in(o$(e%)


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DeBa5ey ! Stan"or%C$assiEcationDescri*e se&ents o" aorta in(o$(e% in %issection rather than site o"

initia$ intia$ tear


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@tio$o&y, Patho&enesis,ani"estationAcute sta&e within Erst 1 %ays o" initia$ tear6 chronic

a"ter 1 %ays) ariants inc$u%e intramural hematoma$ /8 no intia$ tear, ;


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@(a$uationO*(ious$y no $a* ar5ers *ut D. cases, @MGcar%iac ar5erswi$$ *e nora$ in ost %issections)CF shows wi%ene% e%iastinu *ut 1;. o"

pts w %issection with ha(e nora$ CF3Constrast CT showin& %ou*$e $uen aorta

Sensiti(ity 0?., speciEcity ?>.3FA pro(i%es e#ce$$ent ia&in& consi%erin&

I&o$% stan%ar%J Sensiti(itySpeciEcity 0?.3 T@@ can %eterine presence o" %issection,

aneurys or /8 in ascen%in& aorta)Sensiti(ity 0?.SpeciEcity 0.3


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Treatent /n(asi(e /CH onitorin&, a&&ressi(e BP onitorin&contro$

usua$$y with / B


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@AF@n%o(ascu$ar therapy is routine$y use% in patients

with %escen%in& aortic %issection cop$icate% *y(iscera$ a$per"usion)Endoascular fenestration' a *a$$oon is use% to create a

tear in the %issection ap, which a$$ows *$oo% to ow in*oth the true an% "a$se $uens when a (iscera$ *ranch is*ein& supp$ie% *y an un%erper"use% true or "a$se $uen3 P$aceent o" a stent &ra"t in the true $uen o" the aorta

can reso$(e a U%ynaicU a$per"usion) Soeties sa$$stent ust *e p$ace% %irect$y in the $uen o" a (iscera$ orrena$ artery *ecause the %issection has propa&ate% intothe *ranch)

Acute %issection'&oa$ to stent &ra"t to e(entua$$ycausin& thro*osis o" "a$se $uen) PAH'we$$ suite%"or @AF, co(erin& "oca$ u$ceration)


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Open Fepair Acute Dissection

Priary &oa$ o" sur&ery to pre(ent "ata$rupture an% restore *ranch (esse$per"usion) C site o" rupture %escen%in& ispro#ia$ thir%Qthere"ore upper ha$"

repaire%3Gra"t rep$aceent o" entire aorta is not

attepte% un$ess a $ar&e coe#istin&aneurys


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Dissection (s) Aneurys

Sii$ar *ut separate entities)Dissection occurs in patients without

aneuryss) Pro&ressi(e %i$atation o" thewea5ene% outer aortic wa$$ resu$ts in an

aneurys)De&enerati(e aneuryss, the on&oin&

%eterioration o" the aortic wa$$ can $ea% to asuperipose% %issection dissectinganeurysm%


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aneurysms & aortic dissection

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