aortic dissection prof. dr. suat nail ÖmeroĞlu. the most catastrophic disease of the aorta the...
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AORTIC DISSECTIONAORTIC DISSECTION
Prof. Dr. Suat Nail ÖMEROĞLUProf. Dr. Suat Nail ÖMEROĞLU
The most catastrophic disease of the aortaThe most catastrophic disease of the aorta 5-10 patients/ 1 milion per year5-10 patients/ 1 milion per year Incidence is 0.2-0.8 % in autopsy seriesIncidence is 0.2-0.8 % in autopsy series M/F: 2.5-3M/F: 2.5-3 Most frequently seen 5.-6. decade of age.Most frequently seen 5.-6. decade of age.
MortalityMortality
First 24-48 hoursFirst 24-48 hours 20-50%20-50%– Increases 1% every passing hourIncreases 1% every passing hour
First 2 weeksFirst 2 weeks 75%75% First 3 monthsFirst 3 months 90%90%
DefinitionDefinition
Aortic dissection is an aortic wall disease.Aortic dissection is an aortic wall disease. Intimal layer separates from the medial layer Intimal layer separates from the medial layer
and this separation continues in general to the and this separation continues in general to the distal of the Aorta.distal of the Aorta.
PatogenesisPatogenesis
1. 1. Primary intimal tear theoryPrimary intimal tear theory– Proxymal dissections 95-100%Proxymal dissections 95-100%– Distal dissections 90-95%Distal dissections 90-95%
2. Occurence of intramural hematoma 2. Occurence of intramural hematoma theorytheory– Vasovasorum ruptureVasovasorum rupture– Rupture of penetrating atherosclerotic Rupture of penetrating atherosclerotic
ulcersulcers
Intimal tearIntimal tear
60-70% Ascending aorta60-70% Ascending aorta 10-20% Arcus aorta10-20% Arcus aorta 25% Descending aorta25% Descending aorta
Intimal tearIntimal tear
Intimal layer separates Intimal layer separates and it results in 2 and it results in 2 lumens: True lumen lumens: True lumen and False lumen.and False lumen.
EthiologyEthiology
HypertensionHypertension Medial degenerative diseaseMedial degenerative disease Genetic diseasesGenetic diseases Congenital heart and vascular diseasesCongenital heart and vascular diseases AtherosclerosisAtherosclerosis Inflammatory aortic diseasesInflammatory aortic diseases Travmatic injuriesTravmatic injuries Iatrogenic injuriesIatrogenic injuries Drug abuseDrug abuse PregnancyPregnancy
ClassificationsClassifications
Clinical classificationClinical classification Topografical classificationTopografical classification
– De BakeyDe Bakey– StanfordStanford– SvenssonSvensson
Clinical ClassificationClinical Classification
Acute:Acute: 0-14 days0-14 days Subacute:Subacute: 14 days- 2 months14 days- 2 months Chronic:Chronic: After 2 monthsAfter 2 months
Topografical ClassificationTopografical Classification
Stanford Stanford
ClassificatioClassificationn
Topografical ClassificationTopografical Classification
De Bakey De Bakey
RuptureRupture
Rupture is the most frequent cause of death Rupture is the most frequent cause of death and usually occurs at the site of intimal tear.and usually occurs at the site of intimal tear.
Type A dissectionType A dissection IntrapericardialIntrapericardial Dissection of arcus aortaDissection of arcus aorta IntramediastinalIntramediastinal Type B dissectionType B dissection Left pleuraLeft pleura
Organ malperfusionOrgan malperfusion
Serebral ischemiaSerebral ischemia Spinal ischemia Spinal ischemia Renal ischemiaRenal ischemia Visceral ischemiaVisceral ischemia Lower extremity ischemiaLower extremity ischemia Cardiac ischemiaCardiac ischemia
Clinical FindingsClinical Findings
PainPain Serebrovascular accidents (Syncope, stroke)Serebrovascular accidents (Syncope, stroke) CHFCHF Acute aortic valve insufficiencyAcute aortic valve insufficiency HypovolemiaHypovolemia Cardiac tamponadeCardiac tamponade Malperfusion signsMalperfusion signs
Pain in Acute Type A Pain in Acute Type A DissectionDissection
Pain in Acute Type B Pain in Acute Type B DissectionDissection
Clinical FindingsClinical Findings
Typical patient: 60 year old male patient with Typical patient: 60 year old male patient with hypertension, sudden severe painhypertension, sudden severe pain
Differential DiagnosisDifferential Diagnosis
Coronary ischemiaCoronary ischemia MIMI AIAI Aortic aneurysmsAortic aneurysms Mediastinal tumorsMediastinal tumors PerikarditisPerikarditis Pulmonary embolusPulmonary embolus StrokeStroke Visceral or lower extremity ischemiaVisceral or lower extremity ischemia
Physical ExaminationPhysical Examination
PalePale AnxietyAnxiety ShockShock Periferik perfüzyon bozukluğuPeriferik perfüzyon bozukluğu HypertensionHypertension 80 %80 % HypotentionHypotention 20 %20 % Neurologic dysordersNeurologic dysorders 20 %20 % BP DifferenceBP Difference
DiagnosisDiagnosis
ECGECG– Low voltageLow voltage– ST-T wave changesST-T wave changes
Blood testsBlood tests
DiagnosisDiagnosis
Chest x-rayChest x-ray CTCT MRIMRI TTETTE TEETEE AortographyAortography
To whom shall we perform To whom shall we perform angiography?angiography?
No need for patients with Acute type A No need for patients with Acute type A dissectiondissection
It can be performed to patients with Acute It can be performed to patients with Acute type B dissection, because CAD is frequenttype B dissection, because CAD is frequent
It must be performed to patients with It must be performed to patients with chronic dissectionchronic dissection
TreatmentTreatment
Surgical treatmentSurgical treatment Medical treatmentMedical treatment Endovascular treatmentEndovascular treatment Hybrid treatmentHybrid treatment
Treatment-AimTreatment-Aim
Stabilize the dissectionStabilize the dissection Avoid the ruptureAvoid the rupture Avoid organ ischemiaAvoid organ ischemia
Systolic BPSystolic BP 100-110 mmHg100-110 mmHg Mean BPMean BP 60-75 mmHg 60-75 mmHg Urine output and neurologic Urine output and neurologic
status should be monitorizedstatus should be monitorized
Treatment-Emergency UnitTreatment-Emergency Unit
Fluid replacementFluid replacement ECGECG Blood testsBlood tests Chest x-rayChest x-ray OO22
Analgesia (Morphine)Analgesia (Morphine) Invasive arterial monitoringInvasive arterial monitoring B-blockerB-blocker
Surgical TreatmentSurgical Treatment
Acute Type AAcute Type A Emergent surgical Emergent surgical treatmenttreatment
Acute Type BAcute Type B Endovascular or Endovascular or medical treatment (surgery for rupture, medical treatment (surgery for rupture, intractable sympoms or organ ischemia)intractable sympoms or organ ischemia)
Chronic Type AChronic Type A Elective surgical Elective surgical treatmenttreatment
Chronic Type BChronic Type B Surgery for Surgery for aneurysmatic aorta, organ ischemia.aneurysmatic aorta, organ ischemia.
41 year-old female with 8 children41 year-old female with 8 children ECG: Paroxysmal AF ECG: Paroxysmal AF EntubatedEntubated Diagnosis: Acute Diagnosis: Acute Stanford tStanford tyyppee A A AAortorticic
DissectionDissection HypertensionHypertension
Case ReportCase Report
Femoral or axillary arterial Femoral or axillary arterial cannulationcannulation
Venous cannulationVenous cannulation Venting from RUPVVenting from RUPV
Surgical TechniqueSurgical Technique
ResultResult
464 patients, 12 centers464 patients, 12 centers Mortality:Mortality:
Type A Type A Type BType B
SurgerySurgery 28 % 28 % 31 %31 %
MedicalMedical 58 % 58 % 10 %10 %
The results are even worse for the patients The results are even worse for the patients with paraplegia, visceral or renal with paraplegia, visceral or renal ischemia.ischemia.