aorta dissection.pptx

7/25/2019 Aorta Dissection.pptx

1/98

Diseases of theAorta and

Trauma of the Heart & the Aorta

Nurnajmia Curie Proklamatina

Ruswandiani

Resource Person : dr. Suko Adiarto PhD S!"P#$%

DEPARTMENT OF CARDIOLOGY & VASCULAR MEDICINEFACULTY OF MEDICINE, UNIVERSITAS INDONESIA

November 2015


2/98

utline

Anatom' and Ph'siolo(' of the Aorta

Aortic Aneur'sm

Aortic DissectionTrauma of the Aorta

Trauma of the Heart


3/98

Anatom' andPh'siolo('

of the Aorta


4/98

Anatom' of the Aorta

Anatomicall' di)ided into:Thoracic aorta: ascendin( arch descendin(

se(ments

A*dominal aorta: su!rarenal infrarenal se(ments

Normal aortic diameters usuall' +,- mmta!er (raduall' downstream

ariation in/uenced *' a(e (ender *od'

si0e *lood !ressure 12!ansion rate 3 -.4 mm #men% -.5 mm#women% for each decade of life


5/98

6-7, 1SC 8uidelines on the dia(nosis and treatment of aortic diseases.


6/98



7/98

9icrosco!ic Structure of

the Aorta Aortic wall include three la'ers:

Tunica intima: lined *' endothelial cells demarcated from media *'internal elastic lamina

Tunica media: concentric la'ers of elastic *ers alternatin( with

)ascular smooth muscle cells ;lamellar unit


8/98

Ph'siolo(' of the Aorta

Transmits !ulsatile arterial *lood !ressureto all !oints in arterial tree

Bunction de!ends on its !ro!erties aselastic conduit role of second !um!throu(h its elasticit' #Eindkessel function%

Pressure>res!onsi)e rece!tor in ascendin(aorta and aortic arch #control of SR andHR% increased aortic !ressure results indecreased SR and HR )ice )ersa


9/98

Pressure>Diameter Cur)e of

the Aorta Aortic wall !ressure>diameter relationshi! is nonlinear

Transition from distensi*le to sti *eha)ior occurs at!ressure FG- mmH(

Cur)e *ecome less stee! with increasin( a(e #aortastien diameter increases% due to: ncreased colla(en>to>elastin ratio #decreased elastin

increased colla(en%

Chan(es in wall #!ro(ressi)e disordered medial elastic

*ers and lamellae dis!la'in( thinnin( and fra(mentation% ncreased wall thickness #colla(en and other 1C9

macromolecules de!osition and elastic *ers calcication%

Arteriosclerotic chan(es #wall stienin(%


10/98

1)aluation of the Aorta

Can normall' *e !al!ated inmida*dominal re(ion de!endin( on *od'ha*itus ma' *e detected *' dee!

!al!ation adjacent to s!ine Plain radio(ra!h' is insensiti)e in

e)aluatin( thoracic and a*dominal aorta

9ore dia(nostic detail can *e o*tainedwith ultrasound #includin(echocardio(ra!h'% CT 9R aorto(ra!h'


11/98

Aortic Aneur'sms


12/98

)er)iew of Aortic Aneur'sms

Patholo(ic aortic se(ment dilation that tend to e2!and andru!ture

ncreased diameter I=-J than e2!ected for same aorticse(ment in unaected indi)iduals of same a(e and se2

Descri*ed in terms of: Si0e #cross>sectional diameter on ima(in(%

9or!holo(' Busiform K s'mmetric entire circumference

Saccular K locali0ed onl' a !ortion of wall circumference a!!ear as focalout!ouchin(%

Pseudoaneur'sm K *leedin( throu(h wall results in contained !eriaortichematoma in continuit' with lumen #trauma or contained ru!ture ofaneur'sm dissection !enetratin( ulcer%

Location #thoracic a*dominal%

Cause #de(enerati)e (enetic disorder etc%

htt!:MMwww.uchos!itals.eduMonline>li*rar'M


13/98

A*dominal Aortic

Aneur'sms


14/98

)er)iew of AAA

ncreased a*dominal aortadiameter F cm

9ost common form ofaortic aneur'sm

ccurs in >4J men F=-'ears old

G-J infrarenal 7-J!ararenalM)isceral somee2tend to thoraco>

a*dominal se(ment

Risk factors: 9en #=2%

lder a(e #F?- 'ears old%

Ci(arette smokin( #=2%

1m!h'sema H'!ertension

H'!erli!idemia

Bamil' histor' #6-J%

9olecular (enetics:

O! to 6-J of infrarenal AAAha)e famil' histor' of AAAssu((est inherited com!onent

Seuence )ariant onchromosome 4!67 is associatedwith 7J increased risk for AAA


15/98

Patho(enesis of AAA

Chronic aortic wall in/ammation increasedlocal e2!ression of !roteinases de(radation ofstructural connecti)e tissue !roteins

Res!onse to forei(n anti(ens and micro*ialinfection autoimmune res!onse !ostulated inAAA de)elo!ment

Aneur'smal dilation and ru!ture result from

mechanical failure of medial elastin andad)entitial colla(en

Natural histor' of AAAs *alance *etweende(radati)e and re!arati)e !rocesses


16/98

I!"mm"#or$ Ce%%

E%"#' Co%%"(e

MMP V")*%"r SMC

nltrateaortic wall

Releasematri2>de(radin(en0'meslead to

medialde(eneration

Proin/amma>tor'c'tokines:TNB>Q L>7 L>? B>

9edialelastindestructionandmarkeddecrease inelastinconcentrati

on

Dama(e tolamellae*'elastol'tic!roteinases leads toaneur'smal dilation

ncreasedcolla(encontent#walltensilestren(t

h%

1n0'mesinitiatin(interstitialcolla(enclea)a(era!idaneur'sme2!ansion and

ru!ture

9ost !rominentelastin> & colla(en>de(radin( en0'mesin AAA de(rade*road ran(e ofmatri2 !roteins

99P>6 5 4 76

e2hi*it acti)it'a(ainst elastin

99P>7 G 7initiate intact*rillar colla(ende(radation

99P>4 e2!ression ismarkedl' ele)atedin aneur'sm tissue!otential use ofdo2'c'cline andother 99Pinhi*itors tosu!!ress!ro(ression

Normall' !roduceelastin and colla(endurin( aorticde)elo!ment

Predominate withinelastic media mediate re!air of

connecti)e tissuewithin AAAs

De!letion of medialS9Cs due toa!o!tosis initiated*' medial ischemiasi(nalin( moleculesor cellular immuneres!onses

asa )asoruma*sencesu!!l' tomedia de!ends ondiusion from lumenma' *ejeo!ardi0ed *'

intimal thickenin(and atherosclerotic


17/98

Clinical Beatures

nsidious o)er 'ears rarel' s'm!tomatic ina*sence of distal throm*oem*olism ra!ide2!ansion ru!ture

9ostl' small lar(e ones ha)e hi(h risk ofru!ture

9ostl' detected *' screenin(Mincidental ndin(

Ph'sical e2amination is insensiti)e a*dominal

!al!ation ma' re)eal !ulsatilee!i(astricM!erium*ilical mass

AAA !resent in u! to G=J femoral arter'aneur'sm ?-J !o!liteal arter' aneur'sm


18/98

Screenin( Aneur'sm screenin( &re!air a*o)e (i)en si0ethreshold=-J reductionin ru!ture and death

Oltrasound Hi(h accurac' detection

sensiti)it'> s!ecicit'almost 7--J ine2!ensi)enonin)asi)e a)oid radiationand contrast a(ent serial

measurement

Less accurate diameterthan CT #not recommendedfor lar(er AAA F,.= cm%



19/98

ther Dia(nostic ma(in(

CT 12tremel' accurate for detection and diameter measurement es!.

with contrast enhancement thin slice techniues D reconstruction

12tent of disease AAA relationshi! to renalM)isceralMiliac arteriesmural throm*us !atterns calcication coe2ist occlusi)e

atherosclerosis which mi(ht in/uence re!air

9R Hi(h accurac' in detectin( and measurin( diameter a)oids radiation

e2!osure and iodine>*ased contrast

Aorto(ra!h' nitial ste! in 1AR also used in su*seuent inter)entions followin(

AAA stent>(raft re!air such as em*oli0ation of lum*ar or iliac arter'

*ranches 1nlar(ed a*dominal aortic se(ment marked *' calcication lumen

ma' or ma' not a!!ear enlar(ed *ecause of mural throm*us!resence


20/98

Natural Histor'

8radual e2!ansion o)er 'earsand e)entual ru!ture

A)era(e e2!ansion rate of >=.= cm ran(es -.6>-. cmM'ear

Aneur'sm si0e wall thicknessintraluminal throm*usthickness and !eak wallstress contri*ute to ru!ture

7>'ear risk for ru!ture: ?.->5.- cm: 7->6-JU 5.->G.- cm:

6->,-JU FG.- cm: ->=-J =>'ear risk for ru!ture:

.->,.- cm: =J ,.->=.= cm: 7->6-J =.=>?.- cm: ->,-J F5.-cm : FG-J



21/98

Ru!tured AAA

S'm!tomatic AAA related too)ert ru!ture or ra!id e2!ansionand im!endin( ru!ture

Ru!ture into !eritoneal ca)it' acute hemorrha(e se)ere

a*dominal !ain h'!otension

Ru!ture into retro!eritoneum tem!oraril' contained !eriaortic

hematoma se)ere a*dominal or*ack !ain radiate to /ank or (rointender !ulsatile a*dominal or /ankmass h'!otension s'nco!e

->=-J die *eforehos!itali0ation ->,-J die athos!ital *efore treatment SRmortalit' rate ,->=-J ma' *elower with 1AR6-7, 1SC 8uidelines on the dia(nosis and treatment of aortic diseases.


22/98

Sur)eillanceM9edical

Thera!' Small AAAs can *e o*ser)edsafel' with ima(in(sur)eillance and little risk forru!ture

Societ' of ascular Sur(er'(uidelines:

6.? >6.4 cm ima(in(M= 'ears

.->., cm ima(in(M 'ears

.=>,., cm ima(in(M76 months

,.=>=., cm ima(in(M? months

Oncertaint' for ,.=>=., cmrecommendations must *eindi)iduali0ed:

Voun( health' es!. women with=>=., cm ma' *enet from earl're!air

9edical thera!' o*jecti)es:

!re)ent C e)ents

limit AAA (rowth

!re!are !atient o!timall' toreduce !erio!erati)e risk

once inter)ention is indicated Risk factor mana(ement:

smokin( cessation#mandator'%

diet & e2ercise #reasona*le% 9edical thera!':

reduce wall shear stress orin/ammation statin AC1>

12!erimental thera!':

WW do2'c'cline ARW as!irin


23/98

Sur(ical Thera!'

1lecti)e re!air ofas'm!tomatic !atient #at least=.->=.= cm% de!ends on lifee2!ectanc' risk for ru!turerisk associated with re!air

S'm!tomatic aneur'sms andra!id (rowth #F7 cmM'ear%reuire sur(ical consultation

9or*idit' and mortalit'in/uenced *' CAD C$DCPD D9

Selection of SR or 1AR de!ends on indi)idualanatom' a(e risk associatedwith anesthesia and sur(er'

Wra)erman AC. Diseases of the aorta. n: Wraunwalds Heart Disease. 7- th1dition. 6-7=.


24/98

Techniues and

utcomes of SR nfrarenal trans!eritonealMleftretro!eritoneal a!!roach

Prosthetic (raft is sutured

to !ro2imal aorta sutured to distal aorta#tu*e (raft%Mcommon iliacarteries #*ifurcation (raft%after lower e2tremit'/ow restorationaneur'sm sac is sewnto(ether to !re)ent (raftand 8 tract contact

9ortalit' rate ,>GJcom!lication rates 7->-Jcardiac !ulmonar' renalcom!lications and colonic

ischemiaLate com!lications 7=>-Jrelated to incision !ara>anastomotic aneur'sm (raftinfection (raft>entericerosionsMstula (raft lim*

occlusions with lowere2tremit' ischemia

Bollow>u! with =>'earinter)als CT after SR


25/98

1AR

Bluorosco!icall' (uidedendo(raft insertionthrou(h femoral arteriesto re>line aorta

Less in)asi)e reuiresadeuate nonaneur'smal!ro2imal and distalattachment sites

1arl' lower mortalit' and

com!lication rate #F='ears similar to sur(icalre!air es!. a(e F5-'ears% hi(her num*er ofre!eated inter)entions

Com!lications: endoleaks endotension

endo(raft mi(ration lim* throm*osisim!lant>related com!lications (raft infection

Contrast>1nhanced CTA at 7 monthM?monthMannuall' after de)ice im!lantation

Color du!le2 ultrasono(ra!h' to detectendoleaks and AAA enlar(ement for thosewith sta*le ima(in( ndin(s


26/98

Wra)erman AC. Diseases of the aorta. n:Wraunwalds Heart Disease. 7-th1dition. 6-7=.



27/98



28/98



29/98

Thoracic Aortic

Aneur'sms


30/98

)er)iew of TAA

ncidence =>7- !er 7----- !erson>'ears

Cause natural histor' treatment )ar'de!endin( on TAA location

Aortic rootMascendin( aorta ?-Jdescendin( aorta =J aortic arch +7-J

Thoracoa*dominal descendin(

thoracic e2tend distall' to in)ol)ea*dominal aorta


31/98

Cause and Patho(enesis

8eneticall' tri((ered de(enerati)e oratherosclerotic mechanical in/ammator' andinfectious diseases

8enetic disorder tend to in)ol)e root& ascendin(aorta

Risk factor: smokin( HT a(e CPD CAD famhistor'

C9D #9BS other (eneticall' tri((ered TAA a(in(

HT%: elastic *ers de(eneration & fra(mentation lossof S9Cs increase colla(en de!osition re!lacementwith interstitial ;c'sts< of mucoid>a!!earin(*aso!hilic>stainin( 1C9!ro(ressi)e weakenin( ofaortic wall result in dilation and aneur'sm


32/98



33/98


XA*normalities in aortic media )ascular S9Cs or contractile !roteins o)eracti)ation of si(nalin(!athwa's and downstream mediators


34/98

Clinical 9anifestations

9ost are as'm!tomatic disco)ered incidentall' on ima(in( stud'

S'm!toms usuall' related to : Local mass eect !ro(ressi)e AR HB from root dilation s'stemic

em*oli0ation from mural throm*us or atheroem*olism

SCMinnominate )ein o*struction tracheaM*ronchusMeso!ha(us

com!ression Direct mass eect with com!ression of intrathoracic structuresMerosion into

adjacent *ones ma' cause !ersistent chestM*ack !ain

9ost serious com!lications ru!ture and dissection Ru!ture sudden se)ere chestM*ack !ain

Ru!ture into: Pleural ca)it' #usuall' left% or mediastinum is associated with h'!otension

1so!ha(us leads to hematemesis from aortoeso!ha(eal stula #common in infected

TAA% Wronchus or trachea results in hemo!t'sis

Acute aortic e2!ansion contained ru!ture and !seudoaneur'sm can causese)ere chest or *ack !ain


35/98

Chest Y Ra'

Eidened mediastinum!rominent aortic kno*dis!laced trachea

Smaller aneur'sms es!.saccular ma' not *e )isi*le

Aneur'sms of sinuses ofalsal)a and aortic root often;hidden< *ehind sternummediastinal structures and)erte*rae

Aortic tortuosit' and unfoldin(in older adults ma' mimic ormask TAAs

CYR cannot e2cludedia(nosis of TAAWra)erman AC. Diseases of the aorta. n: Wraunwalds Heart Disease. 7- th1dition. 6-7=.


36/98

TransThoracic1chocardio(ra!h'

12cellent for ima(in(aortic root can *eused to )isuali0e TAAsin)ol)in( sinuses ofalsal)a !ro2imalascendin( aortaaortic arch !ro2imaldescendin( aorta

Aortic root si0e isde!endent on a(ehei(ht or *od'surface area (ender

Wra)erman AC. Diseases of the aorta. n:Wraunwalds Heart Disease. 7-th1dition. 6-7=.


37/98

ther 9odalities

Contrast>enhanced CTand 9RA are !referredo)er aorto(r!ah' todene *oth aortic and*ranch )esselanatom'

CT and 9R measuree2ternal diameter of

aorta -.6 >-., cmlar(er than internaldiameter inechocardio(ra!h'

erman AC. Diseases of the aorta. n: Wraunwalds Heart Disease. 7-

th

1dition. 6-7=.


38/98

Natural Histor'

Relati)el' indolent (rowth rate -.7>-.6 cmM 'ear and markedindi)idual )aria*ilit'

ther risk factors for increased (rowth and ru!ture: older a(efemale WSA CPD h'!ertension ci(arette smokin( ra!idaneur'sm (rowth !ain aortic dissection !ositi)e famil' histor'

F")#or I!*e)'(N"#*r"% +'#or$

De)r'#'o

Cause 9BS: ra!id (rowth rate #-.= K 7 mmM'ear% RR for aneur'smdissectionMru!ture .5 female 6.4BTAAs: (rowth rate u! to 6.7 mmM'ear #com*ined ascendin(and descendin(%LDS: (rowth rate u! to F7- mmM'ear death at mean a(e of6? 'earsWA: WA ascendin( aortic aneur'sms ha)e hi(her (rowthrate #-.74 cmM'ear% than tricus!id A #-.7 cmM 'ear%

Location Descendin( aorta ha)e (reater (rowth rate # mmM'ear% than

ascendin( aorta #7 mmM'ear%Diameter Si0e 9ost im!ortant risk factor for aneur'sm ru!ture dissection

and deathLar(er aneur'sm (row faster9ean ru!ture or dissection rate 6J !er 'ear for aneur'sms+= cm J !er 'ear =.->=.4 cm 5J !er 'ear F?.- cm

Coe2istin( condition Dissected TAAs (row more ra!idl' #-.7, cmM'ear% thanwithout dissection #-.-4 cmM'ear%

Aortic Si0e nde2 AS +6.5= cmMm6com!lication rate ,J AS 6.5=>,.6= cmMm6

e)ent rate GJ AS F,.6= cmMm6 e)ent rate 6->6=J


39/98

Sur)eillanceM9edicalThera!'

9edical treatment: H'!ertension treatment

#ARWMAC1>%

Cholesterol lowerin(#atherosclerotic TAAK statin%

Weta *lockers #9BS%

99P inhi*itor #do2'c'cline%

Lifest'le modication: Awareness of condition and

risk for dissection and ru!ture

Smokin( cessation A)oidance of strenuous

!h'sical acti)it' #isometrice2ercise%



40/98



41/98

Sur(ical Treatment #7%

Ascendin( TAA: resection and (raftin( of

ascendin( aorta 3concomitant AR

Aortic Arch: !ro2imal hemiarch resection

arch )essels left intact withdescendin( aorta as roof andremainin( arch is re!laced

e2tended arch resection

remo)e entire arch tissue anduse *ranched (rafts to re!lacearch and (reat )essels

reim!lant island of arch tissueincludin( (reat )essel ori(ins

a)erman AC. Diseases of the aorta. n: Wraunwalds Heart Disease. 7- th1dition. 6-7=.


42/98

Sur(ical Treatment

#6% Descendin( TAA:

resection and (raftin( ofaneur'smal se(ment with a!ol'ester (raft

Thoracoa*dominal

aneur'sm: de!ends on Crawford

classication

T1AR: less in)asi)e

aortic anatom' must ha)eadeuate !ro2imal & distal

landin( 0ones of at least 6->6=mm in len(th and diametersthat accommodate endo(raftand adeuate )ascular access

Wra)erman AC. Diseases of the aorta. n: Wraunwalds Heart Disease. 7- th1dition.6-7=.

htt!:MMclinical(ate.comM)ascular>sur(er'M


43/98

Acute AorticS'ndrome #AAS%

Classic AorticDissection

Aortic ntramural

Hematoma

#9H%

Penetratin(

AtheroscleroticOlcer

# PAO%


44/98

Aortic Dissection


45/98

1!idemiolo('

OS 6>.= cases !er 7--.--- !erson>'ears

ncidence is hi(her in men than n women andincreases with a(e

The !ro(nosis is !oorer in women as a resultof at'!ical !resentation and dela'eddia(nosis.

The most common risk factor associated with

AD is h'!ertension #?=K5=J% mostl' !oorl'controlled.

RAD re(istr' the mean a(e was ? 'earsU?=J were men


46/98

Patho!h'siolo('


47/98

The !ressure of the !ulsatile *lood within the aortic wallafter dissection leads to e2tension of the dissection.

Osuall' !ro!a(ate in an ante(rade direction *ecause ofthe !ressure wa)e from the aortic *lood *ut

occasionall' e2tend in a retro(rade direction.The dissection /a! ma' *e locali0ed or ma's!iral the

entire len(th of the aorta

Arterial !ressure and shear forces further tears in theintimal /a! !roduce e2it sites or additional entr'

sites for /ow of *lood into the false lumen Distention of the false lumen with *lood the intimal

/a! to com!ress the true lumen and narrow its cali*er mal!erfusion s'ndromes.


48/98


49/98


50/98

Classication

De Wake'

: ri(inates in the ascendin( aorta ande2tends at least to the aortic arch andoften to the descendin( aorta # and*e'ond%

: ri(inates in the ascendin( aorta andconned to this se(ment

: ri(inates in the descendin( aortausuall' just distal to the left su*cla)ianarter' and e2tends distall' a : sto!s a*o)e the dia!hra(m * : e2tends *elow the dia!hra(m

Stanford

A : Dissections in)ol)in( the ascendin(aota # with or without e2tension into thedescendi( a!rta%

W : Dissections not in)ol)in( theascendin( aorta


51/98


52/98


53/98

Classication

D*r"#'o

Acute : + 6 weeks

Chronic : F 6 weeks

Su*acute : 6> ? weeks

Chronic : F ? weeks

Pre-'%e)#'o

?=J ascendin( aorta

-J descendin( aorta

+ 7-J aortic arch

3 7J a*dominal aorta


54/98


55/98

Clinical

9anifestations


56/98

Pain

Pain ma' *e shar! ri!!in( tearin( knife>like

T'!icall' dierent from other causes of chst !ain

nset : a*rutness

Site : chest #G-J%>F anterior # T'!e A% *ack #,-J%a*dominal #6=J%T'!e W

9a' radiate from the chest to the *ack or )ice )ersa

Pain in the neck throat jaw or head !redictsin)ol)ement of the ascendin( aorta # and often the(reat )essels%

Pain in the *ack a*domen or lower e2tremities descendin( aorta


57/98

Aortic Re(ur(itation

,7>5- J T'!e A ncom!lete coa!tation of the aortic lea/ets

*ecause of concurent dilation of the aortic root

and anuulus or *ecause of acute aortic dilatationfrom an e2!andin( false lumen leadin( to central

aortic re(ur(itation

Aortic lea/et !rola!se caused *' the dissection

/a! !ro!a(atin( into the aortic leadlets orcommissures or *' distortion of !ro!e lea/et

ali(nment *' an as'mmetric dissection /a!

leadin( to eccentric aortic re(ur(itation

B8OR1 =5>7, Aortic re(ur(itation com!licatin( acute t'!e A aorticdissection.

The dissection /a! distorts the normal aortic lea/et ali(nmentthere*' leadin( tomalcoa!tation of the aortic )al)e and su*seuent aorticre(ur(itation. n thise2am!le the dissection /a! e2tends into the ostium of the ri(htcoronar' arter'

(arrow).


58/98


59/98

Dia(nostic Test


60/98

E%e)#ro)"r-'o(r"m .'om"r/er

D> dimer

D dimer > 1600 mg/ dl within the first 6 hours after

initial evaluation

Sensitivity 94%, se!ifity 40"100%#


61/98

Wra)erman. Wraunwald Heart Disease 7-th ed. 1lse)ier:6-7=


62/98

Chest Radio(ra!h

Non S!esic

n man' cases com!letel' normal

G-> 4- J A*normal aortic contour or widenin( of the aorticsilhouette

6-J!leural eusions

Calcication of the aortic kno* occurdetectse!aration of the intimal calcication from theouter aortic soft tissue *order *' more than -.=to 7.- cmthe ;calcium si(nG-Js!ecit' 4>4?J


64/98

Contrast CT

9ost common used for ecaluate Aortic Dissection and *est !erfomredwith electrocardio(ra!hicall' (ated multidetector scanner which ma'eliminate aortic !ulsation motion artifacts.

Presence of two distinct lumina with a )isi*le intimal /a!

Detection of two lumina *' their di((erin( rates of o!acitaion with

contrast material. Balse lumen com!letet' throm*osed low attenuation

Sensiti)it' and s!esicit' 4G>7--J

S!iral #helical% contrast enhanced CT allows D reconstrutcione)aluation dissection & *ranch )esselendo)ascular re!air

contrast

denntit' the !resence of throm*us # !artial or com!lete in the falselumen and detect hemo!ericardium !eriaortic hematoma aortic ru!tureand *ranch in)ol)ement and *lood su!!l' from the true and false lumina.

Limitations : motion artifact # cardiac mo)ement% contrast a(ent# ne!hro!ath'%


65/98

FIGURE 510 Contrast>enhanced CT scan of anaortic dissection demonstratin( a fenestration in theintimal /a! (arrow) with contrast material /owin( fromthe small densel' o!acied true lumen into the lesso!acied and lar(er false lumen of the aorta.

FIGURE 512 Contrast>enhanced CT scandemonstratin( acute t'!e A aortic dissection withenlar(ement of the ascendin( aorta and intimal/a!s (arrows) in the ascendin( and descendin(aorta. Woth the true lumen #TL% and the false lumenare o!acied with contrast material in thise2am!le.


66/98

9 ti R


67/98

9a(netic Resonancema(in(

Accurac' similar to orhi(her than CT

Does not reuire contract or radiation

C : !atients with certainim!lanta*le de)ices# !acemaker de*rilator%and other metallicim!lants.

9ore time needed than CT

Bor lon( term follow u! ofaortic dissection


68/98

Aorta(ra!h'

direct an(io(ra!hic

)isuali0ation of the intimal /a! #a ne(ati)efreuentl' mo*ile linear ima(e% or the

reco(nition of two se!arate lumensU indirect si(ns includin( aortic lumen contour

irre(ularities ri(idit' or com!ression *ranch)essel a*normalities thickenin( of the aorticwalls and aortic re(ur(itation

o %o(er *e- or #3e -'"(o' o AD,e4)e# -*r'( )oro"r$ "('o(r"3$ ore-ov")*%"r '#erve#'o


69/98


70/98

9ANA8191NT


71/98

Risk Assesment

Hi(h>risk condition

9BS or related connecti)e tissue disease famil' histor' of aorticdisease known aortic )al)e disease Zsuch as WA[ recent aorticmani!ulation or known TAA%

Hi(h>risk !ain features

chest *ack or a*dominal !ain descri*ed as a*ru!t in onsetse)ere in intensit' and of ri!!in(Mtearin(Mshar! or sta**in(ualit'U

Hi(h>risk e2amination features

!erfusion decit #!ulse decit *lood !ressure dierential focalneurolo(ic decit% murmur of aortic re(ur(itation or h'!otension.

Wra)erman. Wraunwald Heart Disease 7-th ed. 1lse)ier:6-7=


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73/98

Wra)erman. Wraunwald Heart Disease 7-th ed. 1ls


74/98

Wra)erman. Wraunwald Heart Disease 7-th ed. 1lse


75/98

.P Re-*)#'o

WP a!!ro2imatel' 7-->76- mmH( or to thelowest le)el a!!ro!riate for adeuate

!erfusion

Weta *lockers(oal HR +\ ?-2M min

Short actin( W *locker esmolol initial *olus=-- mMk( and continous infusion =->6--

mikroMk(Mmin

f contraindicated

CCW Non DHP )era!amilor diltiem.


76/98

9ana(ement

C"r-'") T"mo"-e

G>7J in t'!e A AD

Ha)e h'!otension s'nco!e or alteredmental status

Pericardiocentesis for acutehemo!ericardiumrecurrent *leedin( &

acute hemod'namic colla!se es!eciall' if alar(er )olume /uid is remo)e and increaseWPmore *leedin( in !ericardial s!ace

I-')"#'o or S*r(')"%, E-ov")*%"r,"- Me-')"% T3er"$ or A)*#e Aor#')D'e)#'o

Sur(icalThera!'

Acute t'!e A aortic dissection Retro(rade dissection into the ascendin( aorta

1ndo)ascularandMor Sur(ical

Thera!'

Acute t'!e W aortic dissection com!licated *'isceral ischemiaLim* ischemiaRu!ture or im!endin( ru!tureAneur'smal dilationRefractor' !ain

9edicalThera!'

Oncom!licated t'!e W aortic dissection Oncom!licated isolated arch dissection

ntra 9ural


77/98

ntra 9uralHaematoma #9H%

Haematomade)elo!s

in the media of theaortic wall in thea*sence of an BL andintimal tear

7->6=J AAS CT and 9R

dia(nosis


78/98

Penetratin( Aortic Olcer


79/98

Penetratin( Aortic Olcer#PAO% Olceration of an aortic atherosclerotic !laue!enetratin( throu(h the internal elastic lamina into themedia

An atherosclerotic lesion !enetrates throu(h the

internal elastic lamina into the media often associatedwith a )aria*le de(ree of 9H formation

PAOs ma' lead to !seudoaneur'sm formation aorticru!ture or late aneur'sm

Aortic ulcers ma' *e sin(le or multi!le and ran(e from

= to 6= mm in diameter and , to - mm in de!th. PAOs are more common in #3e #3or")') "-"b-om'"% "or#" than in the arch or ascendin( aorta.


80/98

9ana(ement

ndi)iduali0edmana(ement

Pre)ent aortic ru!tureand !ro(ression to acuteAD

Recurrent and refractor'!ain as well as si(ns ofcontained ru!ture such

as ra!idl' (rowin( aorticulcer !eriaortichaematoma or !leuraleusion


81/98

Traumatic Ru!ture

of The Aorta


82/98

Denition

Traumatic aortic ru!ture #TAR% is a lesiondue to *lunt trauma in)ol)in( the aorticwall from the intima to the ad)entitia

TAR can result from car and motorc'clecollisions falls from a hei(ht or *lastinjuries air!lane and train crashes andskiin( and euestrian accidents


83/98

A traumatic lesion ma'*e classied as :

#7%intimal haemorrha(e

#6%intimal haemorrha(e

with laceration#%medial laceration

#,%com!lete laceration ofthe aorta

#=%false aneur'smformation

#?%!eri>aortichaemorrha(e


84/98

The si(ns of aortic ru!ture are nots!ecic and the !re> sence of coe2istin(head facial ortho!aedic and )isceral

lesions dominates the !h'siciansattention

D's!noea and chest !ain are !rominents'm!toms locali0ed in the *ack in 6-K

5?J of cases. Loss of consciousness andh'!otension are also freuent as(enerall' re!orted in !ol'traumati0ed!atients while (enerali0ed h'!ertension

is re!orted in a*out 75J


85/98

Dia(nostic

The most im!ortant dia(nostic ima(in(modalities are chest Y>ra' T11 contrast>enhanced CT 9R and contrast

an(io(ra!h'


86/98

9ana(ement

TA associated aortic ru!turesin 6,hours

mmediate treatment # within 6, hours%

Sur(ical thera!' :

> Clam! and sew

> W'!ass

1ndo)ascular stent thera!'


87/98

Trauma of the

Heart


88/98

)er)iew

Thoracic trauma is: 6=J of )ehicularaccidents deaths 7->5-J due to *luntcardiac ru!ture

1arl' trans!ort times !rehos!ital CPRand successful endotracheal intu*ationare !ositi)e factors for sur)i)al when!atient suers !ulseless cardiac injur' in

the eld


89/98

Tsai P et al. Traumatic heart disease. n: Wraunwalds Heart Disease. 7-th1dition. 6-7=.

Penetratin( Cardiac njur'


90/98

Penetratin( Cardiac njur'#7%

8reatest risk: R L #Anterior location%

Clinical s!ectrum: cardiac arrest with no )ital si(ns toas'm!tomatic with normal )ital si(ns

Cardiac sta* wounds: tam!onade FF

8unshot wounds: hemorrha(e FF

1)aluation: AWC BAST #!ericardial /uid in unsta*le!atienttransfer to o!eratin( room to address injur'%

ndications for emer(enc' de!artment thoracotom': Sal)a(ea*le !ostinjur' cardiac arrest #witnessed arrest with

hi(h likelihood of intrathoracic injur' es!. !enetratin( cardiacwounds%

Se)ere !ostinjur' h'!otension due to tam!onade airem*olism thoracic hemorrha(e

ital si(ns re(ained after resuscitati)e thoracotom'transfer to o!eratin( room for deniti)e re!air

Penetratin( Cardiac


91/98

Penetratin( Cardiacnjur' #6%

Deniti)e treatment:sur(ical e2!osure throu(hanterior thoracotom' ormedian sternotom'

8oals of treatment: reliefof tam!onade and controlof hemorrha(e

Concomitant correction ofacidosis and h'!othermiaand reesta*lishment ofeecti)e coronar'!erfusion *' a!!ro!riateresuscitation



92/98



93/98

Wlunt Cardiac njur' #7%

Ran(in( from minor *ruises of m'ocardium tocardiac ru!ture

Caused *' direct ener(' transfer to heart orheart com!ression *etween sternum and

)erte*ral column 9anifested as se!tal ru!ture free wall ru!ture

coronar' arter' throm*osis cardiac failured'srh'thmias ru!ture of chordae tendineae or

!a!illar' muscles Clinicall' se)ere *lunt cardiac trauma is

manifested as tam!onade or hemorrha(e into!leural ca)it' de!ends on !ericardium status


94/98

Wlunt Cardiac njur' #6%

Routine AWCs

BAST e2amination

76>lead 1C8

T11

se!tal defects )al)ular insu]cienc'Treatment:

Normotensi)e normal initial 1C8 sus!ected *luntcardiac injur': o*ser)ation units

A*normal 1C8: admitted for monitorin( and treated

accordin(l' nitiall' seen in cardio(enic shock: e)aluated and an'

structural injur' conrmed *est re!aired *' acardiothoracic sur(eon


95/98


9iscellaneous Cardiac


96/98

9iscellaneous Cardiacnjur' atro(enic Cardiac njur'

12ternalMo!en cardiac massa(e central )enous line insertion cardiaccatheteri0ation !rocedures endo)ascularMcardiac inter)entions !ercutaneous!ericardiocentesis o!en !ericardial window

ntracardiac Borei(n Wodies Can cause acute su!!urati)e !ericarditis chronic constricti)e !ericarditis

forei(n *od' reaction hemo!ericardium

9eta*olic Cardiac njur'MWurns Cardiac d'sfunction in res!onse to injur' associated with *urns electrical

injur' se!sis SRS multis'stem trauma

1lectrical njur' mmediate cardiac arrest acute m'ocardial necrosis 3 )entricular failure

m'ocardial ischemia d'srh'thmias conduction a*normalities acuteh'!ertension^!eri!heral )asos!asm as'm!tomatic nons!ecic a*normalities

Pericardial njur'Traumatic !ericardial ru!ture is rare occurs mostl' in left !leuro!ericardial

surface motor )ehicular accidents as main cause

Late Seuelae of Cardiac


97/98

Late Seuelae of Cardiacnjur' nclude )al)ular a*normalities and

intracardiac stulas

Can *e identied intrao!erati)el' *'

(ross !al!ation of a thrill or with T11 ncidence is as hi(h as =?J follow>u!

echocardio(ra!h' , weeks after injur'


98/98

Thank Vou

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