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Dissecting Aortic Aneurysm

Dissecting Aortic Aneurysm. Case I. 23 y American male visiting his girlfriend Seen in ER because of chest pain few hours duration Sudden central , severe radiating to back No realtion to exertion Associated mild SOB. History. No cough ,hemoptysis, orthopnea , PND No fever , leg pain

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Dissecting Aortic Aneurysm

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  1. Dissecting Aortic Aneurysm

  2. Case I • 23 y American male visiting his girlfriend • Seen in ER because of chest pain few hours duration • Sudden central , severe radiating to back • No realtion to exertion • Associated mild SOB

  3. History • No cough ,hemoptysis, orthopnea , PND • No fever , leg pain • No similar episode in the past • SR : 1-2 minutes loss of vision Rt eye

  4. Examination • BP 245 / 140 HR 95 SR afebrile RR 18 Sat 95% RA • Chest : clear , good BS • CVS : S1+ S2 +? S4 • Abd & LL : NAD • CNS N

  5. Investigation • CBC , PTT , INR N • BUN , Creat & Lytes N • EKG borderline LVH • CXR

  6. Hospital Course • Initially patient was discharged from ER • Called back because of radiologist report • When reevaluated  chest pain minimal Still BP 240/140 • CT chest oredered

  7. Hospital Course • Patient was admitted under CVT • Labetalol for HTN • Repair of Type A Aortic dissection • Uneventful OR • Recovering inhospital flying back to Hawaii

  8. Pathophysiology • Tear in aortic intima • Degeneration of aortic media {cystic medial necrosis} • Blood pass through intimal tear separation of intima from surrounding layers false lumen creation

  9. Incidence • 464 pt 12 centers 1996  1998 International registry of aortic dissection IRAD • Incidence 2-3 /100,000 • Male with age 68-80 • HTN major risk factor Jama Feb 2000

  10. Predisposition • Congenital : preexisting aneurysm , coarctation & Bicuspid aortic valve • Collagen disorders Marfan syndrome & Ehlers- Danols Syndrome • Vasculitis : Takayasu & Giant cell arteritis • Cocaine • Trauma : Cardiac cath , blunt chest injury

  11. Classification • Daily or Stanford system Type A involving the ascending aorta Type B  all other dissections • DeBakey system Type I dissection  ascending & descending Type II  confined to the ascending aorta Type III  confined to the descending aorta

  12. Presentation • Pain : chest , back or abdomen • Hypertension • Organ related : CVS  AR , tamponade , MI CNS  neurological deficits Gut , renal or limb ischemia

  13. Diagnosis • 250 pt  prediction model • Multivariate analysis 3 predictors Pain immediate tearing Pulse or BP differentials Mediastinal or aortic widening All 3 –ve probability of having dissection 7% All 3 +ve  84% Arch Intern Med 2000 Oct

  14. Diagnosis • CXR 464 pt IRAD Mediastinal widening 63% Ttype A 56% Type B CXR N  11% Type A 16% Type B Jama Feb 2000

  15. Diagnosis • Smooth muscle myosin heavy chain 30 minute serum assay 95 aortic dissection , 48 MI , 131 control Aortic dissection Vs control  sensitivity 91% & specificity 98% Aortic dissection Vs MI  specificity 85% Ann Intern Med 2000 Oct

  16. Diagnosis • MRI Vs TEE 35 pt with clinically suspected dissection TTE Vs TEE Vs MRI Gold standard autopsy , Angiography intraoperative findings TTE less reliable for type B TEE & MRI sensitivity > 93% Int Jr Card Imaging Mar 1994

  17. Management • Type A surgical Rx Type B medical Rx surgical if dissection continued or impair organ perfusion • Pain & BP control decrease DP/DT B blocker

  18. Management • 35 pt type A with tamponade shock 17 pt standard Rx (IVF +pressors +Sx) Vs 18 standard Rx +ACTH 10 mg upon ER arrival (20-40 from emergency call) Higher MAP in ACTH 30 day survival 87% ACTH Vs 48% P<0.02 Lancet 2001 Mar

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