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Aortic Dissection and Aneurysms. Presented by Dr. Daniel Kranitz Prepared by Mary Edwards September 27, 2005 Tintanalli Chapter 58, Pages 404-409. Abdominal Aortic Aneurysms (AAA). Risk factors Elderly (>60) Familial trend (18% with 1 ° relative) Connective Tissue D/O (Marfan’s)

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aortic dissection and aneurysms

Aortic Dissection and Aneurysms

Presented by Dr. Daniel Kranitz

Prepared by Mary Edwards

September 27, 2005

Tintanalli Chapter 58, Pages 404-409

abdominal aortic aneurysms aaa
Abdominal Aortic Aneurysms (AAA)
  • Risk factors
    • Elderly (>60)
    • Familial trend (18% with 1° relative)
    • Connective Tissue D/O (Marfan’s)
    • Other aneurysms
    • Atherosclerosis (HTN, Lipids, smoking, DM)
slide3
AAA
  • Pathogenesis
    • Intima infiltrated by atherosclerosis and thinned media.
    • Possible intraluminal thrombus and adventitia infiltrated by inflammatory cells
slide4
AAA
  • Average rate of growth 0.25-0.5 cm per year.
  • Larger aneurysms extend more rapidly than smaller ones. (LaPlace law)
slide5
AAA
  • Clinical Features
    • Syncope (10-12%)
    • Back and/or Abdominal Pain –severe and abrupt, ripping or tearing sensation (50%)
    • Shock –intraperitoneal rupture, massive blood loss
    • Sudden death
slide6
AAA
  • Physical Exam
    • Pain on palpation or not
    • Retroperitoneal hematoma
      • Cullen sign (periumbilical ecchymosis)
      • Grey-Turner sign (flank ecchymosis)
      • Scrotal hematoma or inguinal mass (blood dissecting to these areas)
      • Iliopsoas sign
      • Femoral nerve neuropathy
slide7
AAA
  • Found aneurysms refer to follow up
  • >5cm diameter –increased chance of rupture
  • <5cm –decreased chance of rupture
  • Symptomatic aneurysms of any size = Emergency!!
slide8
AAA
  • Diagnosis
    • Includes differential diagnoses of syncope, abd pain, CP, back pain and shock.
    • If with combo of two or more think aortic dz.
slide9
AAA
  • Radiologic Evaluation
  • Should not delay operative treatment!!
    • Plain abd film (calcified bulging)
    • US (bedside, up to 100% sensitive, not reliable to detect rupture)
    • CT (with IV contrast only if stable)
    • MRI
slide10
AAA
  • ED Treatment
    • Urgent surgical consult
    • Make diagnosis & assist rapid transfer to OR
    • 2 large bore IVs
    • Cardiac Monitor
    • O2
    • ? Blood transfusion
    • IV fluid resuscitation –controversial amount b/c too much can be harmful
  • RADIOGRAPHIC STUDIES ONLY IF UNLIKELY TO HAVE RUPTURED AAA!!!
slide11
AAA
  • ½ of patients with ruptured AAA who reach the OR die!
a bit about thoracic aortic aneursym
A Bit About Thoracic Aortic Aneursym
  • Presenting symptoms include esophageal, tracheal, bronchial, or even neurologic disorders.
  • If it erodes to adjacent structures it is immediately fatal!!
aortic dissection
Aortic Dissection
  • Pathogenesis
    • Prominent cause of sudden death
    • Presents with severe abd., chest, and back pain
    • Violation of intima that allows blood to enter media and dissect b/w intimal and adventitial layers
    • Common site is ascending aorta at ligamentum arteriosum
aortic dissection14
Aortic Dissection
  • Common presenting groups
    • >50 yoa with HTN
    • 2/3 male
    • Marfan’s syndrome
    • Congenital heart disease
    • Pregnancy
aortic dissection15
Aortic Dissection
  • Stanford Classification
    • Type A -involves ascending aorta
    • Type B –involves descending aorta
  • DeBakey Classification
    • Type I –ascending, arch & descending aorta
    • Type II –ascending only
    • Type III –descending only
aortic dissection16
Aortic Dissection
  • Clinical Features
    • >85% abrupt, severe pain in chest or b/w scapula
    • 50% ripping or tearing
    • Pain in anterior chest –ascending aorta (70%)
    • Back pain (less common) –descending aorta (63%)
    • If dissection into carotid classic neuro symptoms
aortic dissection17
Aortic Dissection
  • Clinical Features
    • 40% with neurologic sequelae (ex. paraplegia)
    • Nausea, vomiting, diaphoresis
    • Most have sense of impending doom!
aortic dissection18
Aortic Dissection
  • Physical Exam
    • Usually normal heart and lung exam
    • May have aortic insufficiency
    • <20% with decreased radial, femoral or carotid pulse
    • HTN
    • Tachycardia
    • Hypotension
aortic dissection19
Aortic Dissection
  • Physical Exam
    • Pericardial tamponade (muffled heart tones, JVD, pulsus paradoxus)
    • Hoarseness (compression of recurrent laryngeal nerve)
    • Horner’s Syndrome (compression of superior cervical sympathetic ganglion)
aortic dissection20
Aortic Dissection
  • Diagnosis
    • Ischemic end-organ manifestation such as MI, pericardial dz, pulmonary d/o, stroke, SCI, musculoskeletal dz of extremities, intraabdominal ischemia.
    • Can change location with time as dissects.
aortic dissection21
Aortic Dissection
  • Thoracic Dissection
    • 90% have abnormal CXR
      • Widened mediastinum
      • Abnormal aortic contour
      • Pleural effusion
      • Deviation of trachea, mainstem bronchi, or esophagus
      • Intimal calcium visable & distant from edge (calcium sign)
aortic dissection22
Aortic Dissection
  • Diagnosis
    • CT
      • 83-100% sensitive
      • 87-100% specific
      • Use spiral CT with IV contrast
      • Will not give anatomic details of arterial branches or aortic valve competence.
      • Modality of choice in unstable patient
aortic dissection23
Aortic Dissection
  • Diagnosis
    • Angiography
      • “Gold standard”
      • Shows all anatomy and involvement
      • 94% specific
      • 88% sensitive
    • TEE
      • 97-100% sensitive
      • 97-99% specific
      • Esophageal dz contraindication
aortic dissection24
Aortic Dissection
  • In contrast to ruptured AAA, SUSPECTED DISSECTIONS MUST BE CONFIRMED RADIOLOGICALLY PRIOR TO SENDING TO OR!!!
aortic dissection25
Aortic Dissection
  • ED Treatment
    • Treat hypertension
      • -blocker
        • Esmolol 500g/kg IV bolus over 1 minute then 50-150 g/kg minute
        • Metoprolol 5mg q2min x3 IV then 2-5mg/hr
        • Propranolol 20mg IV then 40mg, 8-mg q10min to 300mg total
      • Calcium channel blocker if -blocker contraindicated
aortic dissection26
Aortic Dissection
  • ED Treatment
    • Vasodilator
      • Nitroprusside 0.3 g/kg/min IV
    • Surgery
      • OR for ascending aortic dissection
      • Descending aortic dissection worse surgical risks –controversial for repair
questions
Questions
  • 1. A patient with a suspected aortic dissection should be immediately tranferred to OR without radiographic studies.
  • A. True
  • B. False
slide29
2. Females are more likely than males to develop aortic dissection.
    • A. True
    • B. False
  • 3. Dissection of the ascending aorta only is DeBakey classification
    • A. Type I
    • B. Type II
    • C. Type III
    • D. Type A
    • E. Type B
slide30
4. Patients with a ruptured AAA can present with all of the following symptoms except
    • A. Shock
    • B. Syncope
    • C. Sudden death
    • D. Nausea and vomiting
    • E. Headache
slide31
5. Which of the following radiologic modalities is considered the “gold standard” for diagnosing an aortic dissection?
    • A. CT
    • B. MRI
    • C. TEE
    • D. Angiography
    • E. CXR
answers
Answers
  • 1. B
  • 2. B
  • 3. B
  • 4. E
  • 5. D