Aortic ulcer intramural hematoma aortic dissection
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Transcript of Aortic ulcer intramural hematoma aortic dissection
Aortic ulcer – intramural hematoma- aortic dissection: a continuous spectrum
R Erbel, H Eggebrecht, D Baumgart, J DebatinJ Barkhausen,U Herold, H Jakob
Department of Cardiology Radiology and Thoracic and Cardiovascular Surgery
University Essen, Germany
Classification of acute aortic syndromes
Svensson LG et al.Circulation 99: 1331-6, 20001- Classic dissection
2- Intramural
hematoma
3- Discrete/subtitle
dissection
4- Plaque ulcer,
plaque rupture
5- Iatrogenic/traumatic
dissection
1 2 3
4 5
ESC TF Eur Heart J 22: 1642 81, 2001
History of IMH• 1920 Krukenberg: Bleeding to the outer layer of the media due to rupture of vasa vasorum without tear.• 1952 Gore,• 1958 Hirst and 1982 Wilson: pathologic studies• 1988 Yamada et al: 1st CT and MRI study• 1991 Zotz et al: 1st IMH FU to AD by TEE• 1994 Mohr-Kahaly: 1st TEE clinical study and FU• 2000 v Kodolitsch et al: „Hemorrhagic stroke of the
aortic wall“
Cystic Media Necrosis
Collagen Fiber Rupture
Cystic Media Necrosis
Collagen Fiber Rupture and Intramural Hemorrhage
Desc. Aorta SAX at 35 cm
Intramural Hematoma Typ I
N = 17
X = 64 years
3 – 20cm length
0.7 – 3 cm W Th
35% echolucent zones
Mohr-Kahaly et al JACC 23:658 – 64, 1994
Intramural
Hematoma Type II
with Vessel Wall
Layering and
Shearing N = 10
-Age 70 years
-Aortic ectasia,aneurysm
-Calcium displacement
-3 – 23 cm length
-0.7 – 4 cm W Th
- 70 % echolucent zones
Mohr-Kahaly et al JACC 23:658 – 64, 1994
- Hematoma formation within the aortic wall in the absence of a
detectable intimal tear (wall thickening)
- Due to spontaneous rupture of vasa vasorum
- Potential precursor of overt dissection class 1
- Class 2 aortic dissection
Intramural hematoma (IMH)
Erbel R, EHJ 2001
Vilacosta, Am Heart J 1997
- Displacement of intimal calcifications
- Affects long segment of the aorta
Intramural hematoma, Class 2 AD (IMH)
Differentiation against thrombosed aneurysm
Meta-Analysis1 (143 patients):
- 5-20% of patients with acute aortic syndromes
- 61% men, mean age 68 yrs.
- 53% hypertension
- Rare: traumatic (motor vehicle accident)
- 80% chest pain
- ~ 21% mortality
Intramural hematoma (IMH)
1Maraj et al,, Am J Cardiol 2000
Outcome1:
IMH- Outcome
1Mara et al,, Am J Cardiol 2000
Intramural Hematoma
Aortography
IVUS
Class 2 AD type B
Intravascular Ultrasound
Pericardial tamponade, progression to dissection, rupture
within one week despite
RR control
IMH- Complications
History of PAU Reports
• 1935 Shennan T 4/218 cases AD begin in the
base of AU
• 1941 Will ius /Cragg „some of AD accociated with
ulcerating atheromatous
abscesses“• 1973 Gore/Hirst < 4% cause of AD• 1986 Stanson: Penetrating aortic ulcer
PAU
Vilacosta et al JACC 32:83 – 9,1998
- Elderly, hypertensive patients
- Symptomatic vs. asymptomatic (incidental finding)
- Most common site: mid/distal descending thoracic aorta
- Strong association with concomitant abdominal aneurysm
Penetrating Atherosclerotic Ulcer (PAU)
Atheroma Plaque erosion
Intimal ulcer PAU+IMH Pseudoaneurysm Rupture
Von Kodolitsch, Z Kardiol 1998
- Ulceration of aortic atherosclerotic plaque penetrating
through the internal elastic lamina into the media
- Class 4 aortic dissection
- 2.3 - 7.6% in symptomatic patients with acute aortic
syndromes
Penetrating Atherosclerotic Ulcer (PAU)
CTIVUSErbel R, EHJ 2001
Plaque Rupture class 4 AD
Ao
Fibrous cap
Ulcer core
1 cm
Erbel R Heart 2001
IVUS
MRI Imaging
PAU- Complications
- Intramural hematoma :• 10 – 100% 1,2
•due to erosion of vasa vasorum• upredictor of adverse outcome
IMH
IMH
(Ganaha et a. Circulation 2002)1. Vilacosta et al JACC 1998
2. Kazerooni et al Radiology 1992
Ruptured Plaque with Floating Fibrous Cap
Tear
Fibrous Cap
Ulcer
PAU- Complications
- Pseudoaneurysm : 0- 50%1,2
Growth rate: 0,31 cm/ year
1Yucel, Radiology 19902Harris, J Vasc Surg 1994
- Embolism: rare
PAU- Complications
- 0- 44%1,2 rupture
1Stanson, Ann Vasc Surg 19862Harris, J Vasc Surg 19943Coady, J Vasc Surg 1998
- 40% for PAU vs. 3.6% for classic type B dissection3
- Risk factors : symptomatic patient, aortic diameter,
*
type-A PAU
Impending Perforation of Plaque Rupture of descending Aorta
Pleuraeffusion
Plaque-rupture
Aortic sclerosisclass 4 AD
IMH with /without PAU
• Age/year 71 67• Male/% 44 61• Ao asc/% 9 26• Ao desc/% 91 74• WTH mm 16 _ 5 13 _ 4• Stable 25% 91%• Ao rupture 16% 4%• Ao dissection 12% 4%
Pt group IMH with PAU without PAU
Ganaha et al Circulation 106:342 – 8, 2002
Indicators of Disease Progression
• Age/years 71 72 • Male/% 58 23• Pain persistence/% 75 7• Pl effusion /% 75 0• PAU diameter/mm 21 12 • PAU depth /mm 14 7• PAU number 1.2 1.5• Ao diameter/mm 48 46• WTh /mm 17 14• IMH segments 3.3 3.9
Clinical Signs Progression Stable Course
Ganaha et al Circulation 106:342 – 8, 2002
Media Necrosis Erdheim Gsell Aortic Disease
Entry Tear
IMH Aortic dissection
class 2 AD
Aortic rupture
Healing
No continuity: PAU, IMH, dissection
Arteriosclerosis Progression
Stary IV – V Atherom, Fibroatherom
Plaque Rupture
Ulcer Hematoma Mural Thrombosis
VIa VIb VIc
Yes: PAU/ IMH/ Aortic Dissection
can be a continuity in atherosclerosis
Aortic Diseases
Aortic rupture
Aortic Disease-congenital-degenerative-arteriosclerotic-inf lammatory-traumatc,toxic
Healing
TraumaClass 5
Plaque rupture Class4
Discrete/subtit leDissection Class 3
IntramuralHaematomaHaemorrhage Class 2
Aort ic dissection Class 1Communicating/non communicating AD
ESC Task Force EHJ 2001
IMH with PAUMRI:
Contained rupture of the descending thoracic aorta due to penetrating (PAU)
atherosclerotic ulcer (class IV type B) with IMH pleural effusion
IMH
Arteriosclerosis and Aneurysm Formation
Preexisting atherosclerosis not required
-absence in animals
-Proteolytic activity different (MMPs)
-Disparity in characteristics of pts
Reed et al Circulation 85:205-11,1992
Characteristics of PAU Patients
No Sex Age Co morbidity Ao D Location FU
1 F 68 EH 4.4 IIIa IMH,R
2 M 65 EH,CABG 2.9 IIIa free
3 M 66 EH, 2-VD 1.9 IIIb free
4 F 75 EH, CABG 3.0 IIIa IMH,Pseu
5 M 71 EH, 1-VD 3.0 IIIa free
6 M 69 EH,AF 2.9 IIIa free
7 M 78 EH, 3-VD 2.8 IIIa IMH,R
8 M 72 CABG, PVD 3.9 Arch Pseudoan
9 M 72 EH 2.0 II IMH,>1PAU
PAU – Graft Stenting
• Stent diameter/mm 34 _ 7 24 – 46• Stent length /mm 90 _17 60 – 130• Fluoroscopy time /min 12 _ 6 5 - 21• Contrast material /ml 244 _ 115 50 - 450• Neurological deficit none• Late FU 1/9 ex for renal stenosis• Mortality 0
x _ s range
PAU References
• Stanson 86 16 81% 44% 44%• Yucel 90 7 100% 14% 43%• Kazeroni 92 16 81% 56% 19%• Harris 94 18 22% - 6%• Coady 98 15 80% 20% 27%• Vilacosta 98 12 100% 17% 42%• Hayoshi 00 12 - - 33%• Quint 01 38 58% 16% -
x 134 66% 21% 20%
Author year N Sympt Rupture Surgery
PAU References
• Stanson 86 16 - - - 44%• Yucel 90 7 - - 0% 0%• Kazeroni 92 16 6% 11% - 31%• Harris 94 18 - 0% 50% -• Coady 98 15 20% 27% - -• Vilacosta 98 12 17% 0% - 0%• Hayoshi 00 12 17% 0% 0% 0%• Quint 01 38 0% 0% 16% 16%
Author Year N Mortality Delayed Progress S/stent
Rupture to Aneury in FU
Prognosis of PAU Total Type A Type BAortic dissection 16 % 57 % 12 %Rupture 12 % 57 % 5 %Stable without surgery 54 % 0 % 75 %Mortality surgery 13 % 0 % 13 % med Th 26 % 100 % 11 % total mortality 19 % 57% 14 %
v. Kodolitsch et al Z Kardiol 87:917 – 27,1998
Clinical Features of PAU
• Age > 65 years sex: M 60%• 15 % Type A, Type B 85 %• RF: EH 85 %, Smoking 72 %, HLP 35 %• 85 % Single PAU, 4 % two, > 2 PAUs 11 % • 73 % IMH• 16 % AD, 4 % typical class 1AD• 27 % Pseudoaneurysm• 19 % Fusiforme Aneurysm• 12% Rupture v. Kodolitsch et al Z Kardiol 87:917 – 27,1998
93 References, nearly all case reports
FOLLOW UP IMH
Ascending aorta:n= 3 1surgery 1ruptur 1 dissectionDescending aorta:n=24 4 dissection 3 surgery 3 healing 6 death
Assessment of the true and false lumen Ao desc 23 cm
1.19 cm
Visualisation of Intimal Tearusing 3D-Echocardiography
Non communicating dissection type B 38 cm
Aortic dissection classification
Morphology of False Lumen
WL
FL
WL
FL
WL
FL
Pitfalse
Artefacts
Explanation: Reverberationof the aortic wall, chest wallNot integrated in the anatomy of the aorta
Intramural Hematoma class 2 AD
Transesophageal Echocardiography
Erbel R, Heart 2001
Intramural Hematoma
No Intimal flap! circular or half mond-thickening of Aortic wall >7mmCalcification of intima
Mohr - Kahaly et al JACC 1993
class 2 AD Dissection
Drohende Perforation bei Plaqueruptur in der descendierenden Aorta
thoracalis
Pleuraerguß
Plaque-rupture
Aortensklerose
Klasse 4 AD
Case 2
Angio-Spiral CT mit KM
Aortendissektion Klasse 2
Diagnostik von Aortenerkrankungen
Magnetresonanztomographie
Aortendissektion Aneurysma
Klasse 1
Aortographie
TL
FL
Aortendissektion Klasse 1
Svensson LG et al. Circulation 1999
Begrenzte Aortendissektion Klasse 3
Intravaskulärer Ultraschall (IVUS)
Plaqueruptur(Klasse 4)
Plaquerupturder Aorta Abdominalis(Klasse 4)
IntramuralesHämatom(Klasse 2)
Eggebrecht H, et al., Heart 2001
Angio-Spiral CT
Case 2
• Physical examination: percussion sound dullness over left lower chest and 2/6 systolic murmur heard best over the 2nd intercostal space at the right parasternal line
• ECG: Sokolov-index elevated, slight ST-depression
V3-V5
• X-ray: Elongation of the ascending aorta and
shadowing over left lower area
• CK 90 U/l; Troponine I 0,1 ng/ml; CRP: 8,4 mg/dl
Case 3
• 69 year-old female patient
• History : Arterial hypertension >10 y
IDDM
Atrial fibrillation
• Severe thoracic back pain
Case 3
• EKG: atrial fibrillation, ST depression II,III
• CK 33 U/l, Troponine I 0.0 ng/ml
Case 3TEE:
Case 3Intravascular ultrasound (IVUS, Manual Pullback)
2D Longitudinal reconstruction
Intramural hematoma of the descending aorta (class 2 dissection)
Case 3
Antihypertensive treatment: Beta-blockerACE-inhibitorDiureticsCa-antagonist
RR controlled around 110/80 mmHg
After 10 days (just before discharge) :
recurrent severe back pain at rest
Case 3
Progression to overt dissection
Case 3
Progression to overt dissection
Case 3
Additional pleural effusion as a sign of impending rupture
FLTL
Case 3Therapy: Endovascular stent-graft placement
PAU- Therapeutic approach
- Ascending aorta - Descending aorta
Surgery
Type-A PAU Type-B PAU
symptomatic asymptomatic
Medical Tx
Risk factors:• Aortic diameter• Recurrent pain• IMH• (Pseudoaneurysm)
No risk factors
Stent-Graft (?)
Diagnostic Aims• Confirmation of diagnosis
• Classification, extent
• Differentiation TL/FL
• Tear localisation (entry , reentry)
• Side brnch involvement
• Aortic regurgitation (Grading, etiology, valve
morphology)
• Signs of emergency: periaortic -, mediastinal hematoma,
pleural, pericardial effusionOP / Stent - Graft-Stent / medical therapyOP / Stent - Graft-Stent / medical therapy
II IIII
IMH- Therapeutic approach
- Ascending aorta - Descending aorta
Surgery
Type-A IMH Type-B IMH
No risk factors
Medical Tx
Risk factors:• Recurrent pain• Progression to dissection• Pleural effusion
Stent-Graft (?)
Definition of IMH• Wall thickening < 7 (5) mm• Segmental/crescentic wall thickening• Thrombus – like appearance• Wall layering,layer shifting• Absence of tear(s) and flow • Echolucent zones (+/-),high signal intensity• Central calcium displacement
Mohr-Kahaly et al JACC 23:658 – 64, 1994
Mohr-Kahly JACC 37:1611- 13, 2001
TYPE I INTRAMURAL HEMATOMA• smooth luminal surface• circular thickening of the wall• aortic diameter normal (3.5 cm)
•irregular luminal surface
• extensive arteriosclerotic plaques
• ectatic aorta (4,5 cm)
TYPE II INTRAMURAL HEMATOMA
Mohr-Kahaly et al JACC 23:658 – 64, 1994