BCC4: Plunkett on Thoracic Aortic Dissection
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Brian Plunkett Advanced Trainee in Cardiothoracic Surgery Dept Cardiothoracic Surgery, RNSH Aortic Dissection Bedside Critical Care, Cairns, 2013
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Budding cardiothoracic intensivists will enjoy this talk by Brian Plunkett on thoracic aortic dissection given at Bedside Critical Care Conference 4. For the audio access and similar talks, head over to intensivecarenetwork.com
Transcript of BCC4: Plunkett on Thoracic Aortic Dissection
Brian PlunkettAdvanced Trainee in Cardiothoracic Surgery
Dept Cardiothoracic Surgery, RNSH
Aortic Dissection
Bedside Critical Care, Cairns, 2013
Pathogenesis
Entry tears: Asc Ao 60%, Arch 10%, Descending 30%
Intimal tear, propagates in medial layer antegrade (90%)
Pathogenesis: Risk Factors
A: age, atherosclerosis, aneurysm B: bicuspid aortic valve (fibrillin def.)
blood pressure (hypertension)
C: connective tissue disorder Marfan’s, Ehlers-Danlos, Lewy Deitz
D: degenerative cystic medial degeneration
E: trauma, iatrogenic, surgery, pregnancy
2-3 / 100,000 age 60-70 M:F >2:1
Pathogenesis
Pathogenesis
Pathogenesis
Pathogenesis: Acute Aortic Syndrome
Penetrating atherosclerotic ulcer & acute intramural haematoma
Classification
Presentation Pain – ‘ripping’, ‘tearing’
- may radiate to back Symptoms of organ malperfusion
- MI, stroke, mesenteric ischaemia Dyspnoea
-AR, tamponade, haemothorax Hypo or hypertension, BP differential AR murmur Absent distal pulses
Diagnosis
60% 95%
98%99%
Management - MedicalMedical & drug history, clinical exam: document neurology and pulses
Normalise the blood pressure (care with AR)Defer intubation until theatre if possible
Opioids, invasive monitoringPray they haven’t given aspirin, clopidogrel, clexane
Type A Essentially all patients considered (age, met’s) Resect primary tear, stabilize aortic wall End organ protection, correct malperfusion Prevent life threatening rupture, tamponade, AR,
coronary dissection
Type B Reserved for ‘complicated’ cases
Rupture or impending rupture (pain, eff.) Threatened or evident malperfusion Sometimes controversial
Surgery
Surgery
Surgery
Approaches to the Ascending Aorta
Cerebral perfusion strategies
Approaches to the Aortic Root
Bentall’s
David & Yacoub
De-branching and replacing ascending aorta
De-branching and stenting the arch
Stenting Type B dissections
10% 30 day medical mortality, 25% with surgery, paraplegia 15%+
Key points
Goals
• early diagnosis, initiate therapy before confirmation
• atypical NSTEMI – think AoD before anticoagulation
• early path to definitive therapy
• the right operation for the right patient
Pitfalls
• misdiagnosis: MI, stroke, ischaemic limb embolism
• delayed care
• failure to control, or adequately control HR & BP
- includes postoperatively!
