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Aortic Aneurysms and Dissection: Overview and Treatment Modalities

Delve into the anatomy, physiology, clinical features, diagnostic imaging, and treatment options for abdominal aortic aneurysm, thoracic aortic aneurysm, and aortic dissection. Learn about risk factors, classification, manifestations, and urgent therapeutic strategies.

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Aortic Aneurysms and Dissection: Overview and Treatment Modalities

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  1. Diseasesof aorta Jakub Honěk Kardiologická klinika 2.LF UK a FN Motol

  2. Overview • Anatomy and physiology • Abdominal aortic aneurysm (AAA) • Aneurysm of thoracic aorta • Aortic dissection

  3. Anatomy • Ascending aorta • Aortic root • ST junction • Tubular part • Aortic arch • Aortic isthmus • Descending aorta • Abdominal aorta • Suprarenal segment • Infrarenal segment • Bifurcation

  4. PhysiologyElasticity, pulse wave

  5. PhysiologyArterialstiffness Zieman SJ. Arterioscler Thromb Vasc Biol 2005;25:932-943.

  6. AAA • Localizeddistension • ofaorticdiameter>50% (>3.0cm in women, >3.4 cm in men) • 90 % subrenal • Progressesovertime • 5x more frequent in men • Prevalence ↑withage • Multifactorial etiology • Risk factorssimillar to atherosclerosis, pathophysiologyisdifferent - aorticwallremodelling

  7. AAAClinicalfeatures • Mostlyasymptomatic! • Rarelypatientpalpatespulsatilemass, orfeelspulsations • Mostlyfirstsmyptomsoccurdue to complications • Peripheralthromboembolism • AAA rupture (first sign in 40%!)

  8. AAA rupture • Emergent, lifethreateningsituation • Mortality 80–90 % whenoptimallytreated • 90% retroperitonealrupture • Clinicaltriad • PAIN (amdominal/lumbar, radiation to groins) • PULSATILE MASS • HYPOTENSION (circulatoryshock)

  9. AAA diagnosticimaging • Duplex ultrasound • Fast, cheap, screeningofpts. in risk, follow-up • CTA/MRA • Optimalresolution, anatomy • DSA • Invasivetreatment, luminography • Screening • Effective in risk groups (pts. Withfamilyhistory, CAD, PAD, male smokers>65 yrs…) • Preventionoffatalcomplications, electiveoperation/inetervention

  10. Treatment – stable AAA • Lifestylechanges, follow-up, bloodpressurecontrol (beta-blockers) • Preventiveoperation/intervention Indicationbased on AAA diameter: > 55 mm > 10 mm increase/year Modifiedby BSA, sex, comorbidities

  11. Treatment – stable AAA • Surgery • Resection of aneurysmal sac, implantation of vascular prosthesis • Endovascular treatment • Implantation of stentgraft • Femoral approch • Simila longterm results to surgery • Conservative • Follow-up, risk of rupture

  12. Treatment – ruptured AAA • Emergent surgery/endovascular tretament • Patient stabilization, fast imaging • Up to 50% pts. die before reaching hospital • 30-40% die die before reaching op. Theatre • 40-50% of the operated die • Overall mortality 80-90%

  13. Aneurysmofthoracic aorta • Lessfrequentthan AAA (10/100 000) • Same definition • 60% ascending, 5-10% arch, 30-35% descendning • Anuloaortic ectasia

  14. Aneurysmofthoracic aorta • Multiple etiologies – genetic, degenerative, infectious, inflammatory • Bicuspid aortopathy • Cystic medial degeneration • Mostly assymptomatic • Symptoms of complications: Ao regurgitation, embolization, compression sy., dissection, rupture • Iamging: TTE, TEE, CTA, MRA, DSA

  15. AneurysmofthoracicaortaTreatment • BP control • Follow-up • Elective surgery Bonow et al. Braunwalds heart disease.

  16. Aorticdissection • Incidence: 3/100 000 per year • High mortality • Untreated: 25%/24h, 50%/week • Optimal treatment: 20%/30 days • Intimal tear – entry • Intimal flap, false lumen • Reentry

  17. Aorticdissectionrisk factors

  18. AorticDissection - classification Stanford De Bakey Entry: 65% root, 20% isthmus, 15% other

  19. AorticdissectionClinicalmanifestation • Pain • severe, sudden, sharp – stabbing, tearing („stabbed in the chestwhit a knife“) • Retrosternal (+radiation to neck, jaw), between scapulae, abdominal, back • Acute heart failure, MI, syncope, stroke, paraplegia…

  20. AorticdissectionDiagnosticapproach • Urgent situation – fast diagnosis • Rare disease vs. Common diseases • Physical exam, ECG, lab (D dimers) • Ideal imaging test – fast, available, good resolution – CTA • Trasthoracic echo - bediside

  21. AorticdissectionTherapy • Urgent situation, high mortality in first hours • Multidisciplinary approach • Initial management: • BP control (beta blockers) • Pain control • Hemodynamic stabilization • In type A – plan urgent surgery • In type B – conservative/ surgery/endovascular

  22. Aortic dissectionTherapy

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