1. R4 Kim Min Kyung/ Prof. Kim Won Aortic Dissection

2. Question 1. 54 세 남자 환자가 갑작스러운 찢어지는 듯한 흉통을 주소로 내원하였 다. 이는 interscapula area 로 전파되어 점점 아래로 퍼졌다고 하여, 혈압은 190/115 mmHg, 맥박은 분당 98 회였고, 흉부 X 선 검사에서 종격동 확장 소견을 보였고 심비대 소견을 보였다. 이 환자의 진단을 위한 검사로 적절한 것은 ? 가. Chest CT and Abdominal CT 나. Coronary angiogram 다. Transechopahgeal echocardiography 라. Plasma renin activity 1) 가, 나, 다 2) 가, 다 3) 나, 라 4) 라 5) 가, 나, 다, 라

3. Aortic Dissection Acute Aortic Syndrome –Heterogeneous group of conditions that cause a common set of signs and symptoms –Aortic dissection (AD), Penetrating aortic ulcer (PAU), Intramural hematoma (IMH), and Aortic rupture (Harrison‘s 17 th edition) Aortic Dissection(AD) –Most common catastrophic event affecting the aorta –Prevalence of aortic dissection ranged from 0.2% to 0.8% –The early mortality rate in acute aortic dissection is very high, with a mortality rate up to 1% to 2% per hour reported in the first several hours after dissection occurs –Peak incidence: sixth – seventh decades –Men:Women 2:1 ADIMH PAU

4. Aortic Dissection Pathophysiology: two hypothesis –A, Primary tear in the intima  blood entering the media (arrow)  development of a cleavage plane (dissection) creating the true and false lumen –B, Primary rupture of the vasa vasorum  hemorrhage in the aortic wall(precipitates an intimal disruption,arrow)  creating the intimal tear and aortic dissection

5. Aortic Dissection Precipitating factor –Disruption of the normal architecture and integrity of the aortic wall –HTN: intimal thickening, calcification, adventitial fibrosis  change in elastic properties of the arterial wall, increasing stiffness –Cystic Medial Degeneration Marfan syndrome, Bicuspid AV, Loeys-Dietz syndrome, Vascular Ehlers-Danlos syndrome Aging, HTN –Arteritis, Cocaine abuse, Pregnancy/postpartum period, Blunt trauma, Iatrogenic trauma, Thoracic aortic aneurysm

6. Aortic Dissection

7. Classification: Based on location of the dissection DeBakey classification Stanford classification  Duration Acute AD ≤ 2 weeks Chronic AD > 2 weeks StanfordA DeBakeyⅠⅡ 60%10-15% Proximal BⅢ 25-30% Distal

8. Aortic Dissection Clinical manifestation  Most clinical manifestations reflect complications resulting from the dissection occluding the major arteries –Symptom variable and mimic those of more common conditions  Emphasizing the importance of a high index of suspicion Symptom –Pain severe and of sudden onset, being at max. intensity 96% (sense of doom, sharp, severe, tearing, stabbing) Migratory in 17% of patients : follow the path of the dissection through the aorta –Ascending aorta: neck, throat, jaw, head –Descending aorta: back, abdomen, lower extremities

9. Aortic Dissection –Other symptom Heart Failure 7%, neurologic 17%, Spinal ischemia in type B AD: 2-10%, ect (AMI, Paraplegia, Cardiac arrest, Sudden death) Painless AD(<5%): DM, prior aortic aneurysm, prior cardiac surgery, chronic AD, more frequent-Syncope(33%) HF(20%), stroke(11%) and higher mortality rate in 33% Physical Ex –Hypertension, hypotension –Suggestion of proximal involvement: AR, AMI, pericardial effusion, neurologic manifestations –Suggestion of abdominal aorta involvement renal ischemia, infarction, renal insufficiency, or refractory hypertension, mesenteric ischemia or infarction, acute limb ischemia

10. Aortic Dissection Laboratory Findings –Chest X ray:nonspecific, interobserver variability abnormal aortic contour or widening of the aortic silhouette, which appears in 80% to 90% of cases (83%, type A; 72%, type B) Nonspecific widening of the superior mediastinum the calcium sign: a separation of the intimal calcification from the outer aortic soft tissue border by more than 0.5 to 1.0 cm Pleural effusions (inflammatory reaction >hemothorax) –ECG Most: nonspecific, myocardial ischemia/infarction, low- voltage QRS complexes, pericarditis

11. C D A B Aortic Dissection

13. Diagnostic Imaging Selecting imaging modality –Contrast CT: usually the test of first choice for the diagnosis Role of coronary angiography –Routine CAG is not recommended before surgery for acute type A aortic dissection –Unstable conditions are contraindications to CAG SensitivitySpecificity Contrast enhanced CT83-100%87-100% MRI95-100%94-98% TTE59-83%63-93% TEE-98%94-97% Aortography90%94%

14. Hagan PG et al. JAMA. 2000;283:897-903 The International Registry of Acute Aortic Dissection (IRAD) - New Insights Into an Old Disease Definitive therapy –All patient with acute ascending aortic dissection: emergent surgery –Initial medical therapy provides for uncomplicated type B aortic dissection –Surgical treatment goal: 1) excise the intimal tear 2) obliterate the false channel 3) reconstitute the aorta Type A: med Type B: op Type B: med Type A: op

15. Aortic Dissection Type B aortic dissection Surgical Management of Descending Thoracic Aortic Disease. Circulation. 2010;121:2780-2804.

16. Aortic Dissection Management –Medical treatment: Drug of choice: beta blocker Goal: stabilize, control pain, lower BP(SBP;100-120), reduce the rate of rise or force of Lt ventricular ejection(HR<60 bpm) Calcium channel blocker (verapamil, diltiazem): when β- blocker are contraindicated Others: nitroprusside with β-blocker, iv nitroglycerin Contrainidation: Direct vasodilator(diazoxide, hydralazine)  Refractory HTN: uncontrolled pain, cocaine, renal artery involvment  Hypotension: rapid volume expansion should be considered

17. Aortic Dissection Long term therapy and Follow up –Blood pressure goal Drug of choice: beta blocker Others: calcium channel blocker, ARB –Evaluation of the cause: genetically triggered disorder, image first degree relatives –Regular imaging of the aorta: aneurysmal change, false lumen expansion Typical protocol: every 1,2,3,6,12,18, 24 month, thereafter yearly at least –Lifestyle modification Smoking cessation Avoidance of the isometric activities

18. Aortic Dissection

19. Question 1. 54 세 남자 환자가 갑작스러운 찢어지는 듯한 흉통을 주소로 내원하였 다. 이는 interscapula area 로 전파되어 점점 아래로 퍼졌다고 하여, 혈압은 190/115 mmHg, 맥박은 분당 98 회였고, 흉부 X 선 검사에서 종격동 확장 소견을 보였고 심비대 소견을 보였다. 이 환자의 진단을 위한 검사로 적절한 것은 ? 가. Chest CT and Abdominal CT 나. Coronary angiogram 다. Transechopahgeal echocardiography 라. Plasma renin activity 1) 가, 나, 다 2) 가, 다 3) 나, 라 4) 라 5) 가, 나, 다, 라

20. Question 1. 54 세 남자 환자가 갑작스러운 찢어지는 듯한 흉통을 주소로 내원하였 다. 이는 interscapula area 로 전파되어 점점 아래로 퍼졌다고 하여, 혈압은 190/115 mmHg, 맥박은 분당 98 회였고, 흉부 X 선 검사에서 종격동 확장 소견을 보였고 심비대 소견을 보였다. 이 환자의 진단을 위한 검사로 적절한 것은 ? 가. Chest CT and Abdominal CT 나. Coronary angiogram 다. Transechopahgeal echocardiography 라. Plasma renin activity 1) 가, 나, 다 2) 가, 다 3) 나, 라 4) 라 5) 가, 나, 다, 라

21. Question 2. 다음 중 aortic dissection 을 유발 할 수 있는 질환은 ? 가. Pregnancy 나. Marfan syndrome 다. Hypertension 라. Syphilic aortitis 1) 가, 나, 다 2) 가, 다 3) 나, 라 4) 라 5) 가, 나, 다, 라

22. Question 2. 다음 중 aortic dissection 을 유발 할 수 있는 질환은 ? 가. Pregnancy 나. Marfan syndrome 다. Hypertension 라. Syphilic aortitis 1) 가, 나, 다 2) 가, 다 3) 나, 라 4) 라 5) 가, 나, 다, 라

23. Aortic Dissection Complicated acute type B aortic dissection Surgical Management of Descending Thoracic Aortic Disease. Circulation. 2010;121:2780-2804.  In-hospital complications - EVAR 20% vs open repair 40%  In-hospital death rate - EVAR 11% vs open repair 33% Thus, although long-term data are not available, stent-graft repair is emerging as an attractive alternative to open surgical repair for patients with ischemic complications.

24. Aortic Dissection Complicated chronic type B aortic dissection –Long-term outcome with medical therapy alone delayed expansion of the false lumen in 20% to 50% of patients at 4 years mortality rate of 50% at 5 years Surgical Management of Descending Thoracic Aortic Disease. Circulation. 2010;121:2780-2804.