Aortic Dissection and Aneurysms Presented by Dr. Daniel Kranitz



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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)
    • Other aneurysms
    • Atherosclerosis (HTN, Lipids, smoking, DM)


AAA

  • Pathogenesis

    • Intima infiltrated by atherosclerosis and thinned media.
    • Possible intraluminal thrombus and adventitia infiltrated by inflammatory cells


AAA

  • Average rate of growth 0.25-0.5 cm per year.

  • Larger aneurysms extend more rapidly than smaller ones. (LaPlace law)



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


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


AAA

  • Found aneurysms refer to follow up

  • >5cm diameter –increased chance of rupture

  • <5cm –decreased chance of rupture

  • Symptomatic aneurysms of any size = Emergency!!



AAA

  • Diagnosis

    • Includes differential diagnoses of syncope, abd pain, CP, back pain and shock.
    • If with combo of two or more think aortic dz.


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


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!!!



AAA

  • ½ of patients with ruptured AAA who reach the OR die!



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

  • 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 Dissection

  • Common presenting groups

    • >50 yoa with HTN
    • 2/3 male
    • Marfan’s syndrome
    • Congenital heart disease
    • Pregnancy


Aortic Dissection

  • Stanford Classification

  • DeBakey Classification

    • Type I –ascending, arch & descending aorta
    • Type II –ascending only
    • Type III –descending only


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 Dissection

  • Clinical Features

    • 40% with neurologic sequelae (ex. paraplegia)
    • Nausea, vomiting, diaphoresis
    • Most have sense of impending doom!


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 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 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 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 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 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 Dissection

  • In contrast to ruptured AAA, SUSPECTED DISSECTIONS MUST BE CONFIRMED RADIOLOGICALLY PRIOR TO SENDING TO OR!!!



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 Dissection

  • ED Treatment

    • Vasodilator
      • Nitroprusside 0.3 g/kg/min IV
    • Surgery


  • Any Questions????



Questions

  • 1. A patient with a suspected aortic dissection should be immediately tranferred to OR without radiographic studies.

  • A. True

  • B. False



  • 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


  • 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


  • 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

  • 1. B

  • 2. B

  • 3. B

  • 4. E

  • 5. D




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