Aortic Disease Lecture

8/21/2019 Aortic Disease Lecture

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Aortic EmergenciesAortic Emergencies


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ObjectivesObjectives

Abdominal aortic aneurysmsAbdominal aortic aneurysms

Mycotic aneurysmsMycotic aneurysms

Aortic dissectionAortic dissection

Epidemiology and pathophysiologyEpidemiology and pathophysiology

Clinical presentation and diagnosisClinical presentation and diagnosis

ManagementManagement


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Abdominal AorticAbdominal Aortic

Aneurysm (AAA)Aneurysm (AAA) Most common site of arterialMost common site of arterial

aneurysmaneurysm

Most commonly infrarenalMost commonly infrarenal 15-37 cases per 100,000 life years15-37 cases per 100,000 life years

15,000 deaths annually15,000 deaths annually

! " # o$er age 50 ! " # o$er age 50 %re$alence increases &ith age%re$alence increases &ith age

'are in &omen under 55 yrs'are in &omen under 55 yrs


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AAAAAA

AgeAge

(mo)ing(mo)ing

AtherosclerosisAtherosclerosis

*amily +istory*amily +istory

MenMen CC

+ypertension+ypertension


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AAAAAA

.rue $s .rue $s

pseudoaneurysmpseudoaneurysm

ElastinElastin CollagenCollagen

/nammation/nammation

atural historyatural history


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AAAAAA

2sually asymptomatic until2sually asymptomatic until

rupturerupture

%hysical eam%hysical eam

4ac) painabdominal pain &ith4ac) painabdominal pain &ith

syncopesyncope

6reat masuerader6reat masuerader


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AAAAAA

Clinical diagnosisClinical diagnosis

2ltrasound2ltrasound

C.C.

M'/M'AM'/M'A


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Aortic Repair SurgeryAortic Repair Surgery


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AAAAAA

'is) of rupture related to si8e'is) of rupture related to si8e 9arger aneurysms gro& faster9arger aneurysms gro& faster :bser$e:bser$e Electi$e repairElecti$e repair Emergent repairEmergent repair


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Aortic Stent GraftAortic Stent Graft


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Aortic Stent GraftAortic Stent Graft


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Thoracic AorticThoracic Aortic

AneurysmAneurysm ; cases per 100,000 patient years; cases per 100,000 patient years

Most commonly in ;Most commonly in ;thth < 7< 7thth decadesdecades

MalesMales

+ypertension+ypertension

CC

asculitisasculitis

AtherosclerosisAtherosclerosis


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AneurysmAneurysm %ain%ain

C+*C+*

Myocardial ischemiaMyocardial ischemia

Mediastinal erosionMediastinal erosion

eurologic manifestationseurologic manifestations


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AneurysmAneurysm C='C='

C.C.

M'/M'/

AngiographyAngiography


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AneurysmAneurysm AscendingAscending ArchArch escendingescending Cra&ford Classi>cationCra&ford Classi>cation

! .ype /? %roimal descending to proimal .ype /? %roimal descending to proimalabdominalabdominal

! .ype //? %roimal descending to infrarenal .ype //? %roimal descending to infrarenal! .ype ///? istal descending &ith abdominal .ype ///? istal descending &ith abdominal

! .ype /? %rimarily abdominal .ype /? %rimarily abdominal


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AneurysmAneurysm Management based on si8e andManagement based on si8e and

locationlocation

Medical managementMedical management! 4lood pressure control4lood pressure control

! (erial imaging(erial imaging

! (ur$eillance for signs and symptoms(ur$eillance for signs and symptomsof gro&th or lea)agof gro&th or lea)ag

! 4 bloc)ers4 bloc)ers


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AneurysmAneurysm (urgical indications(urgical indications

! (ymptoms(ymptoms

! 5 ! ; cm si8e in ascending aorta5 ! ; cm si8e in ascending aorta

! ; ! 7 cm in descending aorta; ! 7 cm in descending aorta

! gro&th @ 1 cm per yeargro&th @ 1 cm per year

! E$idence of dissectionE$idence of dissection! Arch and Cra&ford // ha$e highestArch and Cra&ford // ha$e highest

morbidity and mortality after repairmorbidity and mortality after repair


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ycotic Aneurysmycotic Aneurysm

%rimary or secondary%rimary or secondary

(eptic emboli(eptic emboli

Contiguous infecti$e focusContiguous infecti$e focus

.rauma .rauma


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Arterial traumaArterial trauma

4acterial endocarditis4acterial endocarditis

9ocal or concurrent infection9ocal or concurrent infection /mmunosuppressed/mmunosuppressed

AgeAge

(taphylococcus, (almonella,(taphylococcus, (almonella, .reponema .reponema

MycobacteriumMycobacterium


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%ainful, pulsatile mass in contet%ainful, pulsatile mass in contet

of fe$erof fe$er

:$erlying inammation in /2:$erlying inammation in /2 ComplicationsComplications


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9eu)ocytosis, anemia9eu)ocytosis, anemia

4lood cultures4lood cultures

/maging/maging

.reatment .reatment

! (urgery(urgery

! Antibiotics for at least " &)sAntibiotics for at least " &)s


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Aortic !issectionAortic !issection

5-30 cases per5-30 cases per

million people permillion people per

yearyear

MaleMale

+ypertension,+ypertension,

atherosclerosisatherosclerosis

%re-eisting aortic%re-eisting aortic

diseasedisease

CC

.rauma .rauma


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(hear stress(hear stress

/ntimal tear/ntimal tear

Cystic medial necrosisCystic medial necrosis

*alse lumen*alse lumen

/ntramural hematoma/ntramural hematoma Aortic ulcersAortic ulcers


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StanfordStanford"lassi#cation"lassi#cation

Type A$Type A$ascendingascendingaortaaorta

Type %$ aortaType %$ aorta

distal to leftdistal to leftsubclaviansubclavian

e4a)eye4a)eyClassi>cationClassi>cation

.ype /? both .ype /? bothascending andascending anddescendingdescending

.ype //? only .ype //? only

ascending aortaascending aorta .ype ///? only .ype ///? only

descending aortadescending aorta


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(tanford(tanfordClassi>cationClassi>cation

.ype A? .ype A?ascending aortaascending aorta .ype 4? aorta .ype 4? aorta

distal to leftdistal to left

subcla$iansubcla$ian

!e%a&ey!e%a&ey"lassi#cation"lassi#cation

Type '$ bothType '$ bothascending andascending anddescendingdescending

Type ''$ onlyType ''$ onlyascending aortaascending aorta

Type '''$ onlyType '''$ onlydescendingdescendingaortaaorta


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%ain is the most common%ain is the most common

presenting complaintpresenting complaint

! Abrupt more speci>c thanAbrupt more speci>c thandescriptiondescription

Cardiac manifestationsCardiac manifestations

eurologic manifestationseurologic manifestations isceral organ in$ol$mentisceral organ in$ol$ment


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igh clinical suspicionigh clinical suspicion

Smooth muscle myosin heavySmooth muscle myosin heavy

chainchain "R"R

C.C.

2ltrasound2ltrasound M'/M'/

AngiogramAngiogram


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9ac)s speci>city9ac)s speci>cityalonealone

MediastinalMediastinal&idening&idening Altered aorticAltered aortic

con>gurationcon>guration

isplacedisplacedcalci>cationscalci>cations

%leural eusion%leural eusion

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+igh clinical suspicion+igh clinical suspicion

C='C='

"T"T


M'/M'/

AngiogramAngiogram


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S"T angioS"T angio


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.&o distinct .&o distinct

lumenslumens

+elical+elical Allo&s $isuali8ationAllo&s $isuali8ation

of lesion and otherof lesion and other

structuresstructures

%atient must lea$e%atient must lea$ethe Ethe E

ContrastContrast

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C='C='

C.C.

*ltrasound*ltrasound

M'/M'/

AngiogramAngiogram


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.EE better than .EE better than

..E ..E

4edside test4edside test :perator:perator

dependentdependent

4lind spots4lind spots


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C='C='

C.C.


R'R'

AngiogramAngiogram


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(ensiti$e and(ensiti$e and

speci>cspeci>c

o contrasto contrast .ime consuming .ime consuming

ot &idelyot &idely

a$ailablea$ailable


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C='C='

C.C.


M'/M'/

AngiogramAngiogram


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(ensiti$e and(ensiti$e and

speci>cspeci>c

/n$asi$e/n$asi$e .ime consuming .ime consuming

Can be doneCan be done

intraoperati$ely ifintraoperati$ely if

neededneeded

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C='C='

C.C.


M'/M'/

AngiogramAngiogram


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Medical managementMedical management

! ecrease stress on &allecrease stress on &all

! 4 bloc)ers4 bloc)ers! asodilatorsasodilators

(urgical inter$ention(urgical inter$ention

! Any dissection in$ol$ing the ascendingAny dissection in$ol$ing the ascending

aortaaorta

! (ymptomatic or complicated descending(ymptomatic or complicated descending

aortic dissectionsaortic dissections


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SummarySummary

Clinical suspicion is )eyClinical suspicion is )ey

iagnosis based on clinicaliagnosis based on clinical

presentation and imagingpresentation and imaging Anatomy and si8e determineAnatomy and si8e determine

managementmanagement

/n$ol$e consultations early as/n$ol$e consultations early asemergent surgery is oftenemergent surgery is often

necessarynecessary


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Spotlight Case January 2004

Crushing Chest Pain:A Missed Opportunity


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Case: Crushing Chest Pain

A 62-year-old female presented with 12 hoursof crushing chest pain. Her blood pressure was140/90, heart rate 110, and respiratory rate 16.

An EKG revealed left ventricular hypertrophywith strain. Review of the chest x-ray in theemergency department (ED) revealed noabnormalities. She was treated for an acute

coronary syndrome (ACS) with heparin, aspirin,morphine, and a nitroglycerin drip. Cardiacenzymes were drawn.


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The patient was admitted to the cardiac careunit. Seven hours after admission, the patientbecame hypotensive, with a systolic blood

pressure in the 80s and a heart rate in the120s. A repeat EKG revealed no significantchanges. Right-sided leads showed no

evidence of right ventricular infarct. The firstset of cardiac enzymes was equivocal, and aCPK-MB was minimally elevated.

Case (cont.): Crushing Chest Pain


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Chest Pain in the Emergency Dept.•Chest pain is a common complaint inthe ED

•Correct and timely diagnosis is criticaland linked to morbidity and mortality inmany diagnoses

–Acute coronary syndrome

–Pulmonary embolism

–Aortic dissection

.


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Diagnosis of Chest Pain in the ED

von Kodolitsch Y, et al. Arch Intern Med. 2000;160:2977-82.


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Case (cont.): Crushing Chest PainThe team re-reviewed the chest x-rayand discovered an abnormality in the

aorta: a 1-cm separation between theintimal calcification and the adventitialoutline of the descending aorta (the

“calcium sign”), consistent with aorticdissection.


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Chest X-ray with Calcium Sign (arrow)


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Aortic Dissection•Mortality rates approach 1% per hour

•Diagnosis is missed in 25%-50% ofpatients

•Survival exceeds 90% with promptdiagnosis and management

Spittell PC, et al. Mayo Clin Proc. 1993;68:642-51. Klompas M. JAMA. 2002;287:2262-72. Nienaber CA, et al. N Engl J Med. 1993;328:1-9.


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Aortic Dissection

•Classic presentation includes acute-onset,severe chest/back pain described as “tearing”or “ripping”

•Atypical presentations are common–15% of patients report NO pain

•Supportive findings include pulse deficit, newaortic regurgitation, tamponade, and focal

neurological deficits•Majority of patients have no specific physicalfindings

Spittell PC, et al. Mayo Clin Proc. 1993;68:642-51.Hagan PG, et al. JAMA. 2000;283:897-903.


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Aortic Dissection: Physical Exam Findings

Klompas M. JAMA. 2002;287:2262-72.


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Aortic Dissection•90% of patients with aortic dissection have anabnormal CXR

•Abnormal aortic contour and widenedmediastinum are the most common findings

•A NORMAL CXR DOES NOT RULE OUTAORTIC DISSECTION!

Spittell PC, et al. Mayo Clin Proc. 1993;68:642-51.Hagan PG, et al. JAMA. 2000;283:897-903.


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Aortic Dissection: CXR Findings

Klompas M. JAMA. 2002;287:2262-72.


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Case (cont.): Crushing Chest Pain A transesophageal echocardiogram revealed anascending aortic dissection. Anticoagulation

therapy was discontinued, beta-blocker therapy wasinitiated, and cardiothoracic surgery was called. The patient was transported to the operating room.Upon arrival in the operating room, the patient

became progressively hypotensive, coded, anddied. Post-mortem autopsy revealed hemorrhageinto the pericardium.


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Transesophageal Echocardiography of

Aortic Dissection

Video

http://webmm.ahrq.gov/spotlightcases.aspx?ic=45http://webmm.ahrq.gov/spotlightcases.aspx?ic=45


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What are risk factors you would


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yask about for cardiac etiologies

for chest pain?• Smoking

• Family history

• Hyperlipidemia• Left ventricular hypertrophy

• Hypertension

• Cocaine• ge

• !ast History

What characteristics of the chest


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pain might make you more

concerned for cardiac chest pain?• Location

• ssociated Symptoms

• "uality• Chronology

• #nset

• $uration

• %ntensity

• &'acerbating• (elieving

• Situation


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ny e'am findings that might


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y g ghelp distinguish cardiac from non

cardiac chest pain?• General Appearance

– may suggestseriousness ofsymptoms.

• Vital signs – marked difference in

blood pressure betweenarms suggests aorticdissection

• Palpate the chest wall – Hyperesthesia may be

due to herpes zoster

• omplete cardiace!amination – pericardial rub

– signs of acute A" or A# – "schemia may result in

$" murmur% #& or #'

• (etermine if breathsounds are symmetricand if wheezes%crackles or e)idence ofconsolidation


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ny tests that might help that

you can do in the &(?• &)*

+ S, elevation of - .mm or new " in / leads

• Sens 012 + bove 3 S, depression or ,4wave inversion

• Sens 562

• False positive rate 7 .52


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ny tests that might help that

you can do in the &(?• ,roponin8 C)8 myoglobin

+ C)49: ;;46


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What is your differential?


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What e'am findings might you

look for?• cute 9%

• Hypotension in one e'tremity

•ortic murmur • Aeurologic deficits8 including paraplegia8 stroke8 ordecreased consciousness

• Syncope8 tamponade8 and sudden death due to

rupture of the aorta into the pericardial space• Shock8 hemothora'8 and e'sanguination

• cute lower e'tremity ischemia


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6= percent of acute aortic dissections can be

identified based upon some combination of the

following three clinical features. %mmediate onset of aortic pain with a tearing

and@or ripping character

/ 9ediastinal and@or aortic widening on chest

radiograph> Bariation in pulse and@or blood pressure between

the right and left armBon kodolitsch 8 SchwartD *8 Aienaber C Clinical prediction of acute aortic

dissection rchives of %nternal 9edicine /


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What tests could you do and

why?• CG(4sensitivity =>2

• C, sensitivity 6028 specificity ;52

• ,&&

• 9(% sensitivity 6;28 specificity ;12

• ortogram sensitivity ;;28 specificity 602


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Chest !ain in the

&mergency $epartment

&sther Chen8 9$ssistant !rofessor

$epartment of &mergency 9edicine

niversity of !ennsylvania


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I,he :ig FiveJFive life4threatening causes of Chest !ain

• cute coronary syndrome

• ortic dissection• !ulmonary &mbolism

• ,ension !neumothora'

• Esophageal Rupture


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,he %mmediate *oals

. :CKs@StabiliDation@(esuscitation

+ %B8 #/8 monitor8 pulse o'imeter

/ &C*

> (@# the I,he :ig FiveJ

ti $i ti


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ortic $issection

• Definition: + %ntimal tear with entry of blood into the media

+ IdissectsJ between the intima and adventitia

• . site ascending aorta at the ligamentumarteriosum

• Stanford Classification: + involves Ascending aorta Mw@ or w@o descendingN

• ;


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ortic $issection


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ortic $issection

• %ncreased risk + *roup -1< yoa with hypertension

+ *roup : younger pts with 9arfanKs8 &hler4$anlos8

pregnancy

• 9ortality + ,ype

• Untreated: 75%

• Surgically treated: 15-20%

+ ,ype :• >/4>=2 with or without surgery

ortic $issection


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ortic $issectionClinical !resentation

• History

+ -6


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• "uestion Which of the following presentationscan be seen with aortic dissection?

Stroke

: !araplegia

C bdominal pain

$ ortic insufficiency

& !ericardial tamponade

F Hoarseness* WheeDing

H $ysphagia

ortic $issection


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• Associated sy#pto#s based on progression of dissection

• Carotid arteries stroke

• Spinal arteries paraplegia

• Abdominal aorta/renal arteries/iliacs: bdominal@flank pain

• Coronary arteries aortic insufficiencyE pericardial

effusion@tamponade

• Laryngeal nerve compression hoarseness

• Tracheal compression: dyspnea@stridor@wheeDing

• Esophageal compression: dysphagia

ortic $issection


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• !hysical &'am

+ Symptoms@signs as above

+ 9ost commonly normal heart and lungs• ortic insufficiency murmur in .=4/


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ortic $issection$iagnosis

• CG(

+ ;12 with some abnormality

• widened mediastinum most common• left pleural effusionE indistinct aortic knobE

displaced8 calcified intima - =mm from outer aortic

wall

• C, vs ,&& vs aortogram

ortic $issection


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CG(

ortic $issection


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C, Scan

ortic $issection


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rteriogram

ti $i ti


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ortic $issection,reatment

• Considering it? + / large bore %BKs8 monitor8 ,QC8 &C*

• :lood pressure + $ecrease the shear force on the intima to minimiDe

progression• Lower arterial blood pressure

• $ecrease LB contractility

• Question: + Why not nipride alone?


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Aortic Disease Lecture

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