Aortic Dissection and Aneurysms Presented by Dr. Daniel Kranitz
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)
Familial trend (18% with 1° relative)
Connective Tissue D/O (Marfan’s)
Atherosclerosis (HTN, Lipids, smoking, DM)
Intima infiltrated by atherosclerosis and thinned media.
Possible intraluminal thrombus and adventitia infiltrated by inflammatory cells
Average rate of growth
0.25-0.5 cm per year.
Larger aneurysms extend more rapidly than smaller ones. (LaPlace law)
Back and/or Abdominal Pain –severe and abrupt, ripping or tearing sensation (50%)
Shock –intraperitoneal rupture, massive blood loss
Pain on palpation or not
Cullen sign (periumbilical ecchymosis)
Grey-Turner sign (flank ecchymosis)
Scrotal hematoma or inguinal mass (blood dissecting to these areas)
Femoral nerve neuropathy
Found aneurysms refer to follow up
>5cm diameter –increased chance of rupture
<5cm –decreased chance of rupture
Symptomatic aneurysms of any size = Emergency!!
Includes differential diagnoses of syncope, abd pain, CP, back pain and shock.
If with combo of two or more think aortic dz.
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)
Urgent surgical consult
Make diagnosis &
assist rapid transfer to OR
2 large bore IVs
? Blood transfusion
IV fluid resuscitation –controversial amount b/c too much can be harmful
RADIOGRAPHIC STUDIES ONLY IF UNLIKELY TO HAVE RUPTURED 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!!
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
Common presenting groups
>50 yoa with HTN
Congenital heart disease
A -involves ascending aorta
Type B –involves descending aorta
Type I –ascending, arch & descending aorta
Type II –ascending only
Type III –descending only
>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
40% with neurologic sequelae (ex. paraplegia)
Most have sense of
Usually normal heart and lung exam
May have aortic insufficiency
<20% with decreased radial, femoral or carotid pulse
Pericardial tamponade (muffled heart tones, JVD, pulsus paradoxus)
Hoarseness (compression of recurrent laryngeal nerve)
Horner’s Syndrome (compression of superior cervical sympathetic ganglion)
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.
90% have abnormal CXR
Abnormal aortic contour
Deviation of trachea, mainstem bronchi, or esophagus
Intimal calcium visable & distant from edge (calcium sign)
Use spiral CT with IV contrast
Will not give anatomic details of arterial branches or aortic valve competence.
Modality of choice in unstable patient
Shows all anatomy and involvement
Esophageal dz contraindication
In contrast to ruptured AAA, SUSPECTED DISSECTIONS MUST BE CONFIRMED RADIOLOGICALLY PRIOR TO SENDING TO OR!!!
Esmolol 500g/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
Nitroprusside 0.3 g/kg/min IV
ascending aortic dissection
Descending aortic dissection worse surgical risks –controversial for repair
1. A patient with a suspected aortic dissection should be immediately tranferred to OR without radiographic studies.
2. Females are more likely than males to develop aortic dissection.
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
C. Sudden death
D. Nausea and vomiting
5. Which of the following radiologic modalities is considered the “gold standard” for diagnosing an aortic dissection?
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