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Transcript of Large vessel disease
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بسم الله الرحمن الرحيم
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Large Vessel Disease
By
Ahmed Shafie AmmarMD, FACC
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Aorta
Anatomy
Ascending, arch, descending thoracic, abdominal aorta
Aortic isthmus: arch-descending junction
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Histology
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Aortic Aneurysm
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Epidemiology
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Aneurysm rupture: 80% into left retroperitonium cavity
Most common site of AAA is infrarenal, because no vasa vasora in the media of this region
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Types of aneurysm
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AAAClinical presentation
• Pain: most common, at hypogastrium or back, not affected by movement
• Asymptomatic• Bruit (+/-)• Rupture triad:
♠ abdominal or back pain;
♠ palpable/ pulsatile abdominal mass;
♠ hypotension (<1/3 cases)
AAA
Beyond Grey Hair and Back Pain
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Diagnosis & Screening
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Essential Elements of Aortic Imaging Reports
1. The location at which the aorta is abnormal.
2. The maximum diameter of any dilatation, measured from the external wall of the aorta, perpendicular to the axis of flow, and the length of the aorta that is abnormal.
3. For patients with presumed or documented genetic syndromes at risk for aortic root disease measurements of aortic valve, sinuses of Valsalva, sinotubular junction, and ascending aorta.
4. The presence of internal filling defects consistent with thrombus or atheroma.
5. The presence of intramural hematoma (IMH), penetrating atherosclerotic ulcer (PAU), and calcification.
6. Extension of aortic abnormality into branch vessels, including dissection and aneurysm, and secondary evidence of end-organ injury (eg, renal or bowel hypoperfusion).
7. Evidence of aortic rupture, including periaortic and mediastinal hematoma, pericardial and pleural fluid, and contrast extravasation from the aortic lumen.
8. When a prior examination is available, direct image to image comparison to determine if there has been any increase in diameter.
Note: This is Table 5 in the full-text version of the TAD Guideline
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AAAManagement
• Medications :
Control of hyperlipidemia, hypertension (β- blockers), cigarette smoking
• CT follow up every 3—6 months
• Surgical indication: >rupture;
>size >5.5 cm;
>expanding rapidly (>0.5 cm/year)
• Coronary angio (before surgery)
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AAA Repair
• Two types of repair performed
OPEN ENDOVASCULAR
First performed 1951•Now involves placement of Dacron or PTFE graft•2-4% operative death rate, •5-10% complication rate
First performed 1991• Less invasive, done through femoral vessels• Only certain types of AAA can be repaired
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Bifurcated Endograft Placement
Katzen, et al
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Thoracic Aortic Aneurysms
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Etiology
• Cystic medial degeneration
• Genetic
• Atherosclerosis
• Uncommon causes
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Genetic Syndromes Associated With Thoracic Aortic Aneurysm and Dissection
Genetic Syndrome
Genetic
Common Clinical Features Defect Diagnostic Test Comments on Aortic Disease
Marfan syndrome
Skeletal features (see text);
Ectopia Lentis; Dural ectasia
FBN1 mutations*
Ghent diagnostic
criteria
DNA for
sequencing
Surgical repair when the aorta reaches 5.0 cm unless there is a family history of AoD at <5.0 cm, a rapidly expanding aneurysm or presence or significant aortic valve regurgitation
Loeys-Dietz syndrome
Bifid uvula or cleft palate;
Arterial tortuosity; Hypertelorism;
Skeletal features similar to MFS;
Craniosynostosis; Aneurysms
and dissections of other arteries
TGFBR2 or TGFBR1 mutations
DNA for
sequencing
Surgical repair recommended at an aortic diameter of ≥4.2 cm by TEE (internal diameter) or 4.4 to ≥4.6 cm by CT and/or MR (external diameter)
Ehlers-Danlos syndrome (vascular form)
Thin, translucent skin;
Gastrointestinal rupture; Rupture of
the gravid uterus; Rupture of
medium-sized to large arteries
COL3A1 mutations
DNA for
sequencing
Dermal fibroblasts
for analysis of
type 3 collagen
Surgical repair is complicated by
friable tissues
Noninvasive imaging recommended
Turner syndrome
Short stature; Primary amenorrhea;
Bicuspid aortic valve; Aortic
coarctation; Webbed neck, low-set
ears, low hairline, broad chest
45,X karyotype Blood (cells) for
karyotype analysis
AoD risk is increased in patients with bicuspid aortic valve, aortic coarctation, hypertension, or pregnancy
* The defective gene at a second locus for MFS is TGFBR2 but the clinical phenotype as MFS is debated. AoD = aortic dissection; COL3A1, type III collagen; FBN1, fibrillin 1; MFS, Marfan syndrome; TGFBR1, transforming growth factor-beta receptor type 1; and TGFBR2, transforming growth factor beta receptor type 2.
Note: Table 7 in full-text version of TAD Guidelines
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Aortic Dissection
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Epidemiology• 2-3X more in male• Majority between 50-70 years of age• Relatively rare before 40 y/o except in
association with : Marfan’s syndrome, Ehlers-Danlos syndrome, congenital heart disease, familial incidence, pregnancy, coarctation of aorta, Turner’s syndrome and trauma
• History of systemic hypertension occur in more than 2/3 of patients
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Risk Factors for Development of Thoracic Aortic Dissection
Conditions Associated With Increased Aortic Wall Stress
• Hypertension, particularly if uncontrolled• Pheochromocytoma• Cocaine or other stimulant use• Weight lifting or other Valsalva maneuver• Trauma• Deceleration or torsional injury (eg, motor vehicle crash,
fall)• Coarctation of the aorta
Note: Information on this slide is adapted from Table 9 in full-text version of TAD Guidelines
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Risk Factors for Development of Thoracic Aortic Dissection (continued)
Conditions Associated With Aortic Media Abnormalities Genetic
• Marfan syndrome• Ehlers-Danlos syndrome, vascular form• Bicuspid aortic valve (including prior aortic valve replacement)• Turner syndrome• Loeys-Dietz syndrome• Familial thoracic aortic aneurysm and dissection syndrome
Note: Information on this slide is adapted from Table 9 in full-text version of TAD Guidelines
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Risk Factors for Development of Thoracic Aortic Dissection (continued)
Conditions Associated With Aortic Media Abnormalities (continued)
Inflammatory vasculitides• Takayasu arteritis• Giant cell arteritis• Behçet arteritis
Other• Pregnancy• Autosomal dominant polycystic kidney disease• Chronic corticosteroid or immunosuppression agent
administration• Infections involving the aortic wall either from bacteremia or
extension of adjacent infection
Note: Information on this slide is adapted from Table 9 in full-text version of TAD Guidelines 2010
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Pathophysiology and pathoanatomy• Medial degeneration (cystic medial necrosis is no longer used) : a process
of degeneration characterized by loss of smooth muscle cells and elastic tissue that is accompanied by scarring, fibrosis, hyalin-like changes. > mechanism: medial degeneration, repeated flexion of the aorta,
and hydrodynamic stresses on the aortic intima, an aortic dissection occurs
• 2 important factors determine the continued dissection of aorta:
> degree of hypertension and
> the steepness (slope) of the pulse wave (dP/dT)
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PAIn
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Proximal Distal
Acute: less than 2 weeksChronic: more than 2 weeks
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Physical Examination
– Pulse deficits and discrepancies in BP between limbs are key diagnostic clues
– Pulse deficits (50%)
– Aortic regurgitation (50%)
– Neurologic findings (20%): altered sensorium, hemiplegia, hemianesthesia, gaze preference to the affected side
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Estimation of Pretest Risk of Thoracic Aortic Dissection
* Loeys-Dietz syndrome, vascular Ehlers-Danlos syndrome, Turner syndrome, or other connective tissue disease.
†Patients with mutations in genes known to predispose to thoracic aortic aneurysms and dissection, such as FBN1, TGFBR1, TGFBR2, ACTA2, and MYH11.
High Risk Conditions
• Marfan Syndrome• Connective tissue disease*• Family history of aortic disease• Known aortic valve disease• Recent aortic manipulation (surgical or catheter-based)• Known thoracic aortic aneurysm• Genetic conditions that predispose to AoD†
1
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Estimation of Pretest Risk of Thoracic Aortic Dissection
High Risk Pain FeaturesChest, back, or abdominal pain features described as pain that:• is abrupt or instantaneous in onset. • is severe in intensity. • has a ripping, tearing, stabbing, or sharp quality.•Patients are restless, cannot get comfortable
2
Anterior pain only: 90% ascendingInterscapular pain only: 90% descending
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Estimation of Pretest Risk of Thoracic Aortic Dissection
High Risk Examination Features
• Pulse deficit• Systolic BP limb differential > 20mm Hg• Focal neurologic deficit • Murmur of aortic regurgitation (new or not known to be old and in conjunction with pain)
3
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Risk-based Diagnostic Evaluation:Patients with Low Risk of TAD
Patients with no high-risk features of TAD present are considered atlow risk for TAD. The following clinical steps are recommended for low-riskTAD patients:
Proceed with diagnosticevaluation as clinically
indicated by presentation.
Initiate appropriateTherapy.
Alternative diagnosisidentified?
Unexplainedhypotension or
widenedmediastinum on CXR?
Consider aortic imaging study for TAD based onclinical scenario (particularly in patients with advanced
age, risk factors for aortic disease, or syncope)
• TEE (preferred if clinically unstable)• CT scan (image entire aorta: chest to pelvis)• MR (image entire aorta: chest to pelvis)
Expedited aortic imaging
Yes
No
No
Yes
Yes
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Risk-based Diagnostic Evaluation:Patients with Intermediate Risk of TAD
EKG consistentwith STEMI?
CXR with clearAlternate diagnosis?
History and physical exam stronglysuggestive of specific alternate diagnosis?
Initiate appropriate therapy.
Alternate diagnosis confirmed by further testing?
Likely primary ACS. In absence of otherperfusion deficits, strongly consider
immediate coronary re-perfusion therapy. IfPTCA performed, is culprit lesion identified?
The following steps for patients with intermediate risk of TAD should be followed when any single high-risk feature is present.
Yes
Yes
Yes
No
No
No
• TEE (preferred if clinically unstable)• CT scan (image entire aorta: chest to pelvis)• MR (image entire aorta: chest to pelvis)
Expedited aortic imagingNo
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Risk-based Diagnostic Evaluation:Patients with High Risk of TAD
Patients at high-risk for TAD are those that present with at least 2 high-risk features.
The recommended course of action for high-risk TAD patients is to seek immediate surgical consultation and arrange for expedited aortic imaging.
• TEE (preferred if clinically unstable)• CT scan (image entire aorta: chest to pelvis)• MR (image entire aorta: chest to pelvis)
Expedited aortic imaging
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Radiography (I)• Chest X ray
– mediastinal widening(75%)
– “calcium sign” -uncommon but highly specific, >5mm– double-density appearance of the aorta– a localized bulge along a normally smooth aortic contour– a disparity in the caliber between the descending and
ascending aorta– obliteration of the aortic knob– displacement of the trachea or nasogastric tube to the
right by the dissection– pleural effusions(left)
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Radiography(II)
• Echocardiography– transthoracic approach: M-mode & 2-D=low
sensitivity and specificity– transesophageal = more accuracy and very
sensitive, can be done in ER (safer).
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Radiography (III)
• Computed Tomography– dilatation of the aorta– identification of an intimal flap– differential rates of flow in true and false lumina– the clear demonstration of both the true and false lumina
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Radiography(IV)• limitations of CT scan:
– no information about the presence of AR– no information about the relationship of the dissection to
the major branches of the aorta– time-consuming and requires the patient to be outside ER
• advantages over aortography:– greater contrast resolution and detects small or delayed
differences in the opacification of true and false channels– may be able to detect a thrombosed false lumen despite
nonopacification– does not require arterial catheterization
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Radiology(V)• Aortography
– filling of a false channel or channels with or without an intervening intimal flap
– distortion of the true lumen by either a patent or thrombosed false lumen
– thickening of the aortic wall by more than 5-6 mm caused by a thrombosed false lumen
– displaced intimal calcification
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Radiography(VI)• disadvantages of aortography:
– most invasive, most expensive– risks of intravenous contrast material– inadequate detection of pleural leak
• advantages of aortography:– accurate for determining the site of the initmal
tear and extent of the dissection– easily demonstrated aortic regurgitation– the only procedure that demonstrates the extent
and location of dissection into aortic side branches
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Radiography(VII)
• Magnetic Resonance Imaging– shows the site of intimal tear, type and extent of
dissection, presence of aortic insufficiency, and differential flow velocities in the true and false channels and in the aortic side branches
• advantages:– no contrast material, no ionizing radiation,
noninvasive
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Diagnostic Imaging
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Recommendations for Screening Tests (continued)
Urgent and definitive imaging of the aorta using transesophageal echocardiogram, computed tomographic imaging, or magnetic resonance imaging is recommended to identify or exclude thoracic aortic dissection in patients at high risk for the disease by initial screening.
A negative chest x-ray should not delay definitive aortic imaging in patients determined to be high risk for aortic dissection by initial screening.
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
III IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIII IIaIIaIIa IIbIIbIIb IIIIIIIIIIIaIIaIIa IIbIIbIIb IIIIIIIII
http://content.onlinejacc.org/cgi/content/full/j.jacc.2010.02.015/DC1
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Differential Diagnosis– Chest pain is the most common symptom in AD– Acute myocardial infarction
• pain is more typically pressurelike but may radiate to the arms or neck
• pain does not typically migrate over time
• CK-MB levels are elevated
– Pulmonary embolus• pain is generally respirophasic
• hypoxemia secondary to ventilation/perfusion mismatch
– Pericarditis• pain typically changes with position
• auscultation may reveal a pericardial friction rub
• EKG is common diagnostic(ST-segment elevation prominent in V5-6 and lead I)
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Acute AoD Management Pathway
STEP 1: Immediate post-diagnosis management and disposition considerations
• Arrange for definitive management:– Appropriate surgical consultation– Inter-facility transfer if indicated based on institutional capabilities
• If transfer required, initiate aggressive medical management until transfer occurs.
http://content.onlinejacc.org/cgi/content/full/j.jacc.2010.02.015/DC1
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Acute AoD Management Pathway
STEP 2: Initial management of aortic wall stress
• Obtain accurate blood pressure prior to beginning treatment.
• Measure in both arms.• Base treatment goals on highest blood pressure
reading.
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Rate/Pressure Control
Intravenous beta blockade or Labetalol
(If contraindication to beta blockadesubstitute diltiazem or verapamil)
Titrate to heart rate <60
1
Pain Control
Intravenous opiates
Titrate to pain control
Intravenous rate and pressure control
2
+
Hypotensionor shock state?
No
Yes
Systolic BP >120mm HG?
BP Control Intravenous vasodilator
Titrate to BP <120mm HG (Goal is lowest possible BP that maintains adequate end organ perfusion)
Secondary pressure control
3
Anatomic based management
Acute AoD Management Pathway STEP 2: Initial management of aortic
wall stress
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Acute AoD Management Pathway STEP 2: Initial management of aortic wall stress
Anatomic based management
Urgent surgical consultation +
Arrange for expeditedoperative management
Intravenous fluid bolus•Titrate to MAP of 70mm HG or Euvolemia
(If still hypotensive begin intravenous vasopressor agents)
Review imaging study for:• Pericardial tamponade• Contained rupture• Severe aortic insufficiency
1
2
3
Type A dissection
Intravenous fluid bolus •Titrate to MAP of 70mm HG or Euvolemia
(If still hypotensive begin intravenous vasopressor agents)
Evaluate etiology of hypotension
• Review imaging study for evidence of contained rupture • Consider TTE to evaluate
cardiac function
Urgent surgical consultation
2
3
Type B dissection
1
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Acute AoD Management Pathway
STEP 3: Definitive management
• Depending on the results from the pressure control or anatomic based management, continued treatment will involve either:
– ongoing medical management, or
– operative or interventional management.
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Acute AoD Management Pathway STEP 3: Definitive management
Based on results from intravenousrate and pressure control:
Based on results from anatomicbased management:
Dissection involving the ascending aorta?
Close hemodynamic monitoringMaintain systolic BP < 120mm Hg
(Lowest BP that maintainsend organ perfusion)
Ongoing medical management
Limb or mesenteric ischemiaProgression of dissection
Aneurysm expansionUncontrolled hypertension
Complications requiring operativeor interventional management?
Operative orinterventionalmanagement
Yes
NoEtiology of hypotension Amenable to operative
management?
Operative orinterventionalmanagement
Yes
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Acute AoD Management Pathway
STEP 4: Transition to outpatient management and disease surveillance
• If no complications present requiring operative or interventional management, transition to:
– Oral medications (beta blockade/ antihypertensives regimen)
– Outpatient disease surveillance imaging
Note: For full algorithm, see Figure 26 in full-text version of TAD Guidelines
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Treatment(II)• Definite Therapy– Type A: acute aortic dissections require surgical
treatment– the only contradiction to immediate surgical repair of a
type A dissection is the simultaneous occurrence of a progressing stroke
– Type B : medical management mortality is 15-20%(same as surgery done)
– Surgery indications: persistent pain, uncontrolled hypertension, occlusion of a major arterial trunk, frank aortic leaking or rupture, or development of a localized anerysm.
– Chronic aortic dissection: control of blood pressure using beta-blocking agents(most common)
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Acute Surgical Management Pathway for AoD
The following steps outline ascending TAD by imaging study.
STEP 1: Determine patient suitability for surgery
• If not suitable, begin medical management.
STEP 2: Determine stability for pre-op testing
• If not sufficiently stable, proceed with urgent operative management.
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Acute Surgical Management Pathway for AoD
STEP 3: Determine likelihood of coexistent CAD
Is patient age >40?Assess need for
preoperative coronaryangiography
Plan for CABG ifappropriate at time
of AoD repair
• Known CAD? • Significant risk factors for CAD?
Significant CAD byangiography?
Urgent operativemanagement
Yes
Yes
Yes
No
No
No
Yes
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Acute Surgical Management Pathway for AoD
STEP 4: Intra-operative evaluation of aortic valve
• Perform intra-operative assessment of aortic valve by TEE.
Aortic Regurgitation?or
Dissection of aortic sinuses?
Graft replacementof ascending aorta
+/- aortic archand
repair/ replacementof aortic valve
Graft replacementof ascending aorta
+/- aortic arch
STEP 5: Surgicalintervention
Yes No
Note: For full algorithm, see Figure 22 in full-text version of TAD Guidelines.
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Aortic coarctation
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Clinical Features
• c/o : headache, cold feet• o/e :
HPT,
vigorous carotid pulsations
week pulse in the LL
under sized LL relative to the UL
LVH
mid systolic murmur
Echo, CT, MRI > cofirm the diagnosis
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Treatment of A. coarctation
• Balloon dilatation
• Stent implantation
• Surgical TTT
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Acute aortic occlusion• Infrarenal aorta at bifurcation• Saddle embolus• Af / RHD, MI, DCM, aneurysm• Bilateral leg pain, weakness, numbness, paresthesia, • Cold, cyanosis, absent pulse, diminished or absent deep
tendon reflexes• Aortogram• Heparin, transcatheter, operation • life-long anticoagulant
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Ahmed Shafea MD, FACC
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Atypical aortic dissection
Intramural hematoma: • rupture of vasa vasorum,
• aortic dissection without intimal flap, • 10% type B dissection, • failed diagnosis in aortography, • high risk for aneurysm formation, • medication (distal) or surgery (proximal)
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Recommendation for Intramural Hematoma Without Intimal Defect
It is reasonable to treat intramural hematoma similar to aortic dissection in the corresponding segment of the aorta.
I IIa IIb III
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Atypical aortic dissection
Penetrating atherosclerotic ulcer: • old, hypertension• no false lumen, • Aortography is standard• no definite treatment
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Aortic atheromatous disease
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Aortic atherothrombotic emboli
• Age, hypertension, DM, hyperlipidemia, vascular disease
• Most common in descending thoracic aorta• Coumadin is for high risk patients to prevent
embolic event• Post-operative stroke
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Cholesterol embolization syndrome
• Cholesterol crystal from ulcerated atheromatous plaques
• “blue-toe” or “purple-toe” syndrome
• Elevated ESR & eosinophil
• Reduced complement level
• No specific therapy
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Primary tumor of aorta
• < 50 Cases
• Equal in thoracic and abdomen aorta
• Back pain
• Aortography, biopsy
• Prevent embolization
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Ahmed Shafea MD, FACC
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Peripheral artery diseases
< 60 y/o population: <3%> 75 y/o population: >20%
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Peripheral artery diseases—risk factors
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Peripheral artery diseases
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Peripheral artery diseasesIntermittent claudication: • pain, ache, fatigue, or discomfort in the affected leg
during exercise, particularly walking (oxygen demand)• resolved with rest within few minutes• Buttock, hip, thigh• Gastrocnemius muscle is most common• Walking Impairment Questionnaire
• Arterial embolism, vasculitis / arteritis, secondary compression, lumbar sacroradiculopathy (neurogenic pseudoclaudication, standing)
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Peripheral artery diseases
Rest pain• Inadequate blood flow• Skin fissure, ulceration, or necorsis• DM neuropathy or ischemic neuropathy
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Peripheral artery diseases
Physical examination:
• Absent pulse distal to the stenotic site
• Bruit of the stenotic site
• Muscle atrophy, hair loss, cool skin, poor healing, pressure sore,
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Peripheral artery diseases
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Peripheral artery diseases
Ankle/brachial index (ABI): • SBP ratio (normal: >=1)• ABI <0.9 : 95% sensitive for PAD• ABI 05—0.8 with claudication: critical limb ischemia• ABI <0.5 or ankle BP <55mmHG: poor ulcer healing
MR angiography: 95% sensitivity and specificity
Contrast angiography
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Peripheral artery diseases—treatment
Risk factor modification
Control DM, HTN, smoking cessation
Antiplatelet therapy: ticlopidine, plavix
Exercise: improve maximal walking distance than PTA
Angioplasty / stents and surgery• Trental: RBC flexibility and anti-inflammatory• Pletal: unknown• Beta-blocker: controversial
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Thromboangitis obliterans
• Young smokers
• Medium and smalll vessels of the arms
• Cause unknown? Type I and III collagen
• Pain, digit ulceration, Raynaud phenomenon
• Abnormal allen test (2/3)
• Tx: Cessation smoking, prostacyclin analogue,
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Acute limb ischemia
• Arterial embolism (Af)
• thrombosis with plaque ruprure
• dissection,
• trauma
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