1. Diseases of the aorta Heart Disease Braunwald CV R4 李威廷醫師 Supervisor: 李貽恆醫師

2. Aorta Intima, media, adventitia ascending, arch, descending Aortic isthmus: arch-descending junction

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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%

10. Thoracic aortic aneurysm Annuloaortic ectasia: elastic fiber degeneration + aortic regurgitation Aortic valve replacement

11. 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

12. Aortic dissection Peak: 60—70 y/o Hypertension, bicuspid aortic valve Marfan syndrome (cystic media degeneration) 3 rd trimester pergnancy Blunt trauma IABP Prior cardiac surgery

13. 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

14. 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

16. 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%

21. 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

23. 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)

25. Atypical aortic dissection Penetrating atherosclerotic ulcer: old, hypertension no false lumen, Aortography is standard no definite treatment

27. Aortic atheromatous disease

28. 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

29. Cholesterol embolization syndrome Cholesterol crystal from ulcerated atheromatous plaques “blue-toe” or “purple-toe” syndrome Elevated ESR & eosinophil Reduced complement level No specific therapy

30. 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

31. Primary tumor of aorta < 50 Cases Equal in thoracic and abdomen aorta Back pain Aortography, biopsy Prevent embolization

32. Peripheral artery diseases Heart Disease Braunwald Zipes Libby sixth edition, 2001 CV R4 李威廷醫師 Supervisor: 李貽恆醫師 Jul 1 st, 2004

33. Peripheral artery diseases < 60 y/o population: <3% > 75 y/o population: >20%

34. Peripheral artery diseases— risk factors

35. Peripheral artery diseases

36. 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)

37. Peripheral artery diseases Rest pain Inadequate blood flow Skin fissure, ulceration, or necorsis DM neuropathy or ischemic neuropathy

39. 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,

40. Peripheral artery diseases

41. 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

42. 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

43. 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,

44. Acute limb ischemia Arterial embolism (Af) thrombosis with plaque ruprure dissection, trauma