1. Everything you wanted to know about the aorta but were afraid to ask! By Michael Roberts Aortic ANP

2. The Role of the Aortic Nurse Practitioner at the LHCH. Commenced September 2011 Patient & relative clinical and follow-up support Coordination of Aortic Patient Forum Link for GP / dietician / physiotherapy / occupational therapy / cardiac rehab Advanced practice Msc and clinically trained

3. Aims : Anatomy & Physiology of the Thoracic Aorta Surgical Procedures Aortic Dissection Plans for the future?

4. Anatomy & Physiology of the Thoracic Aorta Blood Flow The Heart The Aorta The Abdomen Limbs & Feet

5. The Heart & the Aortic Valve

6. Aortic Root, Ascending & Arch

7. The Descending Aorta

8. The Coeliac Axis

9. Other useful arteries!!! The Hepatic Artery Lt & Rt Renal Arteries Mesenteric Arteries The Liver The Kidneys The Gut

10. The Iliac Arteries … to the Iliac arteries that divide downwards, carrying blood to the legs and feet.

11. Lets cut right through to the heart of the matter – the surgery

12. Thoracic Aortic Aneurysm Thinning and dilitation of the aortic wall Life threatening condition Atherosclerotic in origin Secondary to Marfan’s, aortitis, trauma, chronic dissection or infection Categorized by position on the aorta

13. Shape & Location of the Aneurysm A Fusiform AneurysmA Saccular Aneurysm

14. Aortic Valve & Aortic Root & Ascending Performed when patient is either symptomatic because of the aortic stenosis or if the aorta is 5.5cm or more. Median Sternotomy. Tissue or Mechanical Valve.

15. Thoraco-abdominal aneurysm repair

16. Extent I – sub-clavian artery extending to level with the renal arteries Extent II – sub-clavian artery extending to the bifurcation of the aorta in the pelvis Extent III – from the middle of the descending aorta extending to the bifurcation of the aorta in the pelvis Extent IV – upper abdominal aorta and extends to the bifurcation of the aorta in the pelvis ***Bifurcation – to divide into 2 parts****

17. Crawford Classification of Thoraco-abdominal aneurysms

18. TEVAR (Thoracic Endo-vascular Aortic Repair ) Pre / post op CT imaging Less invasive femoral approach For patients unfit for surgery Thoracic + Vascular surgeons Spinal drain required Fabric tube + metal wire stents.

19. TAVI (Trans Aortic Valve Implant) TAVI (Apical / Femoral) Cardiology + Surgical Procedure High co-morbidity / older patients Less invasive than open heart

20. Aortic Dissection

21. Aortic Dissection (Acute / Chronic) Dissection Split in the medial layer of the aorta resulting in two lumen with active flow in both Dissecting aortic aneurysm Dissection in an aortic aneurysm Aortic dissection that has subsequently become aneurysmal

22. Classification (DeBakey and Stanford) Stanford Type AStanford Type B

23. Incidence Stanford Type A 2 – 3 x commoner than a ruptured AAA True incidence unknown Males >Females 80% Hypertensive

24. Natural History 50 % Untreated acute Proximal Aortic Dissections succumb within 48 HRS. 1% per/hour death risk 70% die within 2 months 90% die within 3 – 6 months

25. Aetiology Marfans or other heritable elastic tissue disorders: Turners, Noonan, Ehler-Danlos Unicuspid / Bicuspid Aortic Valves have 5 x more incidence of disseection In absence of elastic tissue disorders: Pregnancy and hypertension Iatrogenic Most believe that Atherosclerosis is coincidental rather than causative

26. Clinical Presentation Chest Pain: sudden, worst at onset but constant and may be migratory Marked anxiety Hypertension High incidence of suspicion essential for diagnosis

27. Patterns of Chest Pain in Dissection

28. Physical Signs New pulse deficit New murmur of aortic regurtiation Hypertension Hypotension: rupture, tamponade, obstruction of main coronary arteries Neurological deficits: paraplegia, ischaemic paralysis, Horner’s Signs of intrathoracic compression: SVC Syndrome, Vocal cord Paralysis

29. Radiology Chest X-ray: bulging of the descending aortic deformity of the aorta knuckle displacement of the oesophagus mediastinal widening hazy aortic shadow tracheal or bronchial displacement pleural effusion

30. Further investigations: CT or MRI

31. Echo

32. Protocol from ward to rehab ProcedureStage of Rehab Aortic Root Replacement +/- AVR Full Rehab no special treatment Aortic Root Replacment + Hemiarch awaiting 2 nd stage Light active rehab No pushing or heavy lifting

33. ProcedureStage of Rehab Thoraco-abdominal aortic repair Full rehab no special treatment Type B Dissection Awaiting surgery Very light rehab active rehab Tevar / Evar (stent) Light active rehab No pushing or heavy lifting

34. ProcedureStage of Rehab Tavi (apical / femoral) Full rehab no special treatment Type A repair with residual dissection Light active rehab No pushing or heavy lifting

35. Aortic ANP + Cardiac Rehab Team = Happy Patient

36. Contact Details: Michael Roberts Aortic Nurse Practitioner Liverpool Heart & Chest Hospital 0151 600 1616 bleep: 2006 Office Tel No. 0151 600 1006 Email michael.roberts@lhch.nhs.uk