Diseases of the aorta Heart Disease



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Diseases of the aorta

  • Heart Disease

  • Braunwald


Aorta

  • Intima, media, adventitia

  • ascending, arch, descending

  • Aortic isthmus: arch-descending junction



Aortic aneurysm

  • Definition: pathological dilatation of the normal aortic lumen involving one or several segments

  • Fusiform (common), saccular

  • Pseudoaneurysm: well-defined collection of blood and connective tissue outside the vessel wall



Abdominal aortic aneurysm

  • Age (M>55 y/o; F>70 y/o)

  • Atherosclerosis

  • Infrarenal arota: no vasa vasorum at media

  • Gene (Marfan, Ehlers-Danlos syndrome)

  • Prevalence: >3%

  • Aneurysm rupture: 80% into left retroperitonium cavity



Abdominal aortic aneurysm

  • Pain: most common, at hypogastrium or back, not affected by movement

  • Asymptom

  • Rupture triad: abdominal or back pain; palpable/ pulsatile abdominal mass; hypotension (<1/3 cases)

  • Bruit (+/-)

  • Abdomianl echo, CT, MRA, aortography



Abdominal aortic aneurysm

  • Surgical indication: rupture; size >4—5 cm; expanding rapidly (>0.5 cm/year)

  • Coronary angiography

  • Medication control: Hyperlipidemia, hypertension, cigarette smoking

  • CT follow up every 3—6 months



Thoracic aortic aneurysm

  • Descending aorta > ascending aorta

  • Cystic media degeneration: weakening aortic wall (elastic fiber degeneration)

  • Marfan syndrome: autosomal dominant

  • Ahterosclerosis

  • Syphilis: ascending aorta

  • Infectious aortitis / mycotic aneurysm



Thoracic aortic aneurysm

  • 40% asymptom, pain

  • A-V shunt, superior vena cava syndrome (mass effect), tracheal deviation, hematemesis

  • CT, TEE > TTE

  • Surgery: >5cm (mean expansion rate= 0.43 cm/year)

  • Op risk: 5%





Thoracic aortic aneurysm

  • Annuloaortic ectasia: elastic fiber degeneration + aortic regurgitation

  • Aortic valve replacement



Aortic dissection

  • Tear in aortic intima

  • Antegrade, retrograde

  • false lumen, intimal flap, true lumen

  • Acute (2/3), chronic (1/3)

  • Ascending (65%), arch (20%), descending thoracic (10%), abdominal (5%)

  • Mortality: 1% per hour



Aortic dissection

  • Peak: 60—70 y/o

  • Hypertension, bicuspid aortic valve

  • Marfan syndrome (cystic media degeneration)

  • 3rd trimester pergnancy

  • Blunt trauma

  • IABP

  • Prior cardiac surgery



Aortic dissection

  • Severe tearing pain (sudden onset), CHF, syncope, CVA, ischemic peripheral neuropathy, paraplegia, cardiac arrest, sudden death

  • Anterior pain only: 90% ascending

  • Interscapular pain only: 90% descending



Aortic dissection

  • Hypertension (descending), hypotension (ascending)

  • Pseudohypotension (involving brachiocephalic vessel)

  • Pulse deficit (transient), AR, neurological finding (proximal, conscious level or spinal cord ischemia)

  • AMI (RCA > LCA)

  • Pleural effusion (left side), cardiac tamponade

  • Horner syndrome





Aortic dissection

  • Calcium sign: 1.0cm (suggestive, not diagnostic)

  • Normal CXR cannot exclude dissection

  • EKG: LVH (1/3); absence of ST and T change; AMI (involving coronary a.)

  • Initial diagnosis rate: 62%











Aortic dissection

  • Mortality: 25% (<24h), 50% (1w), 75% (1m), 90% (1y)

  • BP favor RA

  • BP on LA if higher BP in LA than RA

  • SBP: 100—120mmHg,

  • mean BP: 60—75mmHg

  • Pain control, beta-blocker, nitroprusside, ACEI

  • Hypotension: prefer levophed

  • Pericardiocentesis for cardiac tamponade





Atypical aortic dissection

  • Intramural hematoma:

  • rupture of vasa vasorum,

  • aortic dissection without intimal flap,

  • 10% type B dissection,

  • failed diagnosis in aortography,

  • high risk for aneurysm formation,

  • medication (distal) or surgery (proximal)





Atypical aortic dissection

  • Penetrating atherosclerotic ulcer:

  • old, hypertension

  • no false lumen,

  • Aortography is standard

  • no definite treatment





Aortic atheromatous disease



Aortic atherothrombotic emboli

  • Age, hypertension, DM, hyperlipidemia, vascular disease

  • Most common in descending thoracic aorta

  • Coumadin is for high risk patients to prevent embolic event

  • Post-operative stroke



Cholesterol embolization syndrome

  • Cholesterol crystal from ulcerated atheromatous plaques

  • “blue-toe” or “purple-toe” syndrome

  • Elevated ESR & eosinophil

  • Reduced complement level

  • No specific therapy



Acute aortic oolusion

  • Infrarenal aorta at bifurcation

  • Saddle embolus

  • Af / RHD, MI, DCM, aneurysm

  • Bilateral leg pain, weakness, numbness, paresthesia,

  • Cold, cyanosis, absent pulse, diminished or absent deep tendon reflexes

  • Aortogram

  • Heparin, transcatheter, operation

  • life-long anticoagulant



Primary tumor of aorta

  • < 50 Cases

  • Equal in thoracic and abdomen aorta

  • Back pain

  • Aortography, biopsy

  • Prevent embolization



Peripheral artery diseases

  • Heart Disease

  • Braunwald Zipes Libby

  • sixth edition, 2001



Peripheral artery diseases



Peripheral artery diseases—risk factors



Peripheral artery diseases



Peripheral artery diseases

  • Intermittent claudication:

  • pain, ache, fatigue, or discomfort in the affected leg during exercise, particularly walking (oxygen demand)

  • resolved with rest within few minutes

  • Buttock, hip, thigh

  • Gastrocnemius muscle is most common

  • Walking Impairment Questionnaire

  • Arterial embolism, vasculitis / arteritis, secondary compression, lumbar sacroradiculopathy (neurogenic pseudoclaudication, standing)



Peripheral artery diseases

  • Rest pain

  • Inadequate blood flow

  • Skin fissure, ulceration, or necorsis

  • DM neuropathy or ischemic neuropathy





Peripheral artery diseases

  • Physical examination:

  • Absent pulse distal to the stenotic site

  • Bruit of the stenotic site

  • Muscle atrophy, hair loss, cool skin, poor healing, pressure sore,



Peripheral artery diseases



Peripheral artery diseases

  • Ankle/brachial index (ABI):

  • SBP ratio (normal: >=1)

  • ABI <0.9 : 95% sensitive for PAD

  • ABI 05—0.8 with claudication: critical limb ischemia

  • ABI <0.5 or ankle BP <55mmHG: poor ulcer healing

  • MR angiography: 95% sensitivity and specificity

  • Contrast angiography



Peripheral artery diseases—treatment

  • Risk factor modification

  • Control DM, HTN, smoking cessation

  • Antiplatelet therapy: ticlopidine, plavix

  • Exercise: improve maximal walking distance than PTA

  • Angioplasty / stents and surgery

  • Trental: RBC flexibility and anti-inflammatory

  • Pletal: unknown

  • Beta-blocker: controversial



Thromboangitis obliterans

  • Young smokers

  • Medium and smalll vessels of the arms

  • Cause unknown? Type I and III collagen

  • Pain, digit ulceration, Raynaud phenomenon

  • Abnormal allen test (2/3)

  • Tx: Cessation smoking, prostacyclin analogue,



Acute limb ischemia

  • Arterial embolism (Af)

  • thrombosis with plaque ruprure

  • dissection,

  • trauma








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