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Everything you wanted to know about the aorta but were afraid to ask!

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  1. Everything you wanted to know about the aorta but were afraid to ask! By Michael Roberts Aortic ANP

  2. The Role of the Aortic Nurse Practitioner at the LHCH. Commenced September 2011 Patient & relative clinical and follow-up support Coordination of Aortic Patient Forum Link for GP / dietician / physiotherapy / occupational therapy / cardiac rehab Advanced practice Msc and clinically trained

  3. Aims : • Anatomy & Physiology of the Thoracic Aorta • Surgical Procedures • Aortic Dissection • Plans for the future?

  4. Anatomy & Physiology of the Thoracic Aorta Blood Flow The Heart The Aorta The Abdomen Limbs & Feet

  5. The Heart & the Aortic Valve

  6. Aortic Root, Ascending & Arch

  7. The Descending Aorta

  8. The Coeliac Axis

  9. Other useful arteries!!! • The Hepatic Artery • Lt & Rt Renal Arteries • Mesenteric Arteries The Liver The Kidneys The Gut

  10. The Iliac Arteries … to the Iliac arteries that divide downwards, carrying blood to the legs and feet.

  11. Lets cut right through to the heart of the matter – the surgery

  12. Thoracic Aortic Aneurysm • Thinning and dilitation of the aortic wall • Life threatening condition • Atherosclerotic in origin • Secondary to Marfan’s, aortitis, trauma, chronic • dissection or infection • Categorized by position on the aorta

  13. Shape & Location of the Aneurysm A Fusiform Aneurysm A Saccular Aneurysm

  14. Aortic Valve & Aortic Root & Ascending Performed when patient is either symptomatic because of the aortic stenosis or if the aorta is 5.5cm or more. Median Sternotomy. Tissue or Mechanical Valve.

  15. Thoraco-abdominal aneurysm repair

  16. Thoraco-abdominal aneurysm repair Extent I – sub-clavian artery extending to level with the renal arteries Extent II – sub-clavian artery extending to the bifurcation of the aorta in the pelvis Extent III – from the middle of the descending aorta extending to the bifurcation of the aorta in the pelvis Extent IV – upper abdominal aorta and extends to the bifurcation of the aorta in the pelvis ***Bifurcation – to divide into 2 parts****

  17. Crawford Classification of Thoraco-abdominal aneurysms

  18. TEVAR (Thoracic Endo-vascular Aortic Repair ) Pre / post op CT imaging Less invasive femoral approach For patients unfit for surgery Thoracic + Vascular surgeons Spinal drain required Fabric tube + metal wire stents.

  19. TAVI (Trans Aortic Valve Implant) TAVI (Apical / Femoral) Cardiology + Surgical Procedure High co-morbidity / older patients Less invasive than open heart

  20. Aortic Dissection

  21. Aortic Dissection (Acute / Chronic) • Dissection • Split in the medial layer of the aorta resulting in two • lumen with active flow in both • Dissecting aortic aneurysm • Dissection in an aortic aneurysm • Aortic dissection that has subsequently become • aneurysmal

  22. Classification (DeBakey and Stanford) Stanford Type A Stanford Type B

  23. Incidence • Stanford Type A 2 – 3 x commoner than • a ruptured AAA • True incidence unknown • Males >Females • 80% Hypertensive

  24. Natural History • 50 % Untreated acute Proximal Aortic • Dissections succumb within 48 HRS. • 1% per/hour death risk • 70% die within 2 months • 90% die within 3 – 6 months

  25. Aetiology • Marfans or other heritable elastic tissue disorders: • Turners, Noonan, Ehler-Danlos • Unicuspid / Bicuspid Aortic Valves have 5 x more • incidence of disseection • In absence of elastic tissue disorders: • Pregnancy and hypertension • Iatrogenic • Most believe that Atherosclerosis is coincidental rather than • causative

  26. Clinical Presentation • Chest Pain: sudden, worst at onset but constant • and may be migratory • Marked anxiety • Hypertension • High incidence of suspicion essential for diagnosis

  27. Patterns of Chest Pain in Dissection

  28. Physical Signs • New pulse deficit • New murmur of aortic regurtiation • Hypertension • Hypotension: rupture, tamponade, obstruction of main coronary • arteries • Neurological deficits: paraplegia, ischaemic paralysis, Horner’s • Signs of intrathoracic compression: SVC Syndrome, Vocal cord • Paralysis

  29. Radiology • Chest X-ray: • bulging of the descending aortic • deformity of the aorta knuckle • displacement of the oesophagus • mediastinal widening • hazy aortic shadow • tracheal or bronchial displacement • pleural effusion

  30. Further investigations: CT or MRI

  31. Echo

  32. Protocol from ward to rehab

  33. Aortic ANP + Cardiac Rehab Team = Happy Patient

  34. Contact Details: Michael Roberts Aortic Nurse Practitioner Liverpool Heart & Chest Hospital 0151 600 1616 bleep: 2006 Office Tel No. 0151 600 1006 Email michael.roberts@lhch.nhs.uk