1. AORTIC DISSECTION Prof. Dr. Suat Nail ÖMEROĞLU

2. The most catastrophic disease of the aorta The most catastrophic disease of the aorta 5-10 patients/ 1 milion per year 5-10 patients/ 1 milion per year Incidence is 0.2-0.8 % in autopsy series Incidence is 0.2-0.8 % in autopsy series M/F: 2.5-3 M/F: 2.5-3 Most frequently seen 5.-6. decade of age. Most frequently seen 5.-6. decade of age.

3. Mortality First 24-48 hours20-50% First 24-48 hours20-50% –Increases 1% every passing hour First 2 weeks75% First 2 weeks75% First 3 months90% First 3 months90%

4. Definition Aortic dissection is an aortic wall disease. Aortic dissection is an aortic wall disease. Intimal layer separates from the medial layer and this separation continues in general to the distal of the Aorta. Intimal layer separates from the medial layer and this separation continues in general to the distal of the Aorta.

5. Patogenesis 1. Primary intimal tear theory 1. Primary intimal tear theory –Proxymal dissections 95-100% –Distal dissections 90-95% 2. Occurence of intramural hematoma theory 2. Occurence of intramural hematoma theory –Vasovasorum rupture –Rupture of penetrating atherosclerotic ulcers

6. Intimal tear 60-70% Ascending aorta 60-70% Ascending aorta 10-20% Arcus aorta 10-20% Arcus aorta 25% Descending aorta 25% Descending aorta

7. Intimal tear Intimal layer separates and it results in 2 lumens: True lumen and False lumen. Intimal layer separates and it results in 2 lumens: True lumen and False lumen.

8. Ethiology Hypertension Hypertension Medial degenerative disease Medial degenerative disease Genetic diseases Genetic diseases Congenital heart and vascular diseases Congenital heart and vascular diseases Atherosclerosis Atherosclerosis Inflammatory aortic diseases Inflammatory aortic diseases Travmatic injuries Travmatic injuries Iatrogenic injuries Iatrogenic injuries Drug abuse Drug abuse Pregnancy Pregnancy

9. Classifications Clinical classification Clinical classification Topografical classification Topografical classification –De Bakey –Stanford –Svensson

10. Clinical Classification Acute:0-14 days Acute:0-14 days Subacute:14 days- 2 months Subacute:14 days- 2 months Chronic:After 2 months Chronic:After 2 months

11. Topografical Classification Stanford StanfordClassification

12. Topografical Classification De Bakey De Bakey

13. Rupture Rupture is the most frequent cause of death and usually occurs at the site of intimal tear. Rupture is the most frequent cause of death and usually occurs at the site of intimal tear. Type A dissectionIntrapericardial Type A dissectionIntrapericardial Dissection of arcus aortaIntramediastinal Dissection of arcus aortaIntramediastinal Type B dissectionLeft pleura Type B dissectionLeft pleura

14. Organ malperfusion Serebral ischemia Serebral ischemia Spinal ischemia Spinal ischemia Renal ischemia Renal ischemia Visceral ischemia Visceral ischemia Lower extremity ischemia Lower extremity ischemia Cardiac ischemia Cardiac ischemia

15. Clinical Findings Pain Pain Serebrovascular accidents (Syncope, stroke) Serebrovascular accidents (Syncope, stroke) CHF CHF Acute aortic valve insufficiency Acute aortic valve insufficiency Hypovolemia Hypovolemia Cardiac tamponade Cardiac tamponade Malperfusion signs Malperfusion signs

16. Pain in Acute Type A Dissection

17. Pain in Acute Type B Dissection

18. Clinical Findings Typical patient: 60 year old male patient with hypertension, sudden severe pain Typical patient: 60 year old male patient with hypertension, sudden severe pain

19. Differential Diagnosis Coronary ischemia Coronary ischemia MI MI AI AI Aortic aneurysms Aortic aneurysms Mediastinal tumors Mediastinal tumors Perikarditis Perikarditis Pulmonary embolus Pulmonary embolus Stroke Stroke Visceral or lower extremity ischemia Visceral or lower extremity ischemia

20. Physical Examination Pale Pale Anxiety Anxiety Shock Shock Periferik perfüzyon bozukluğu Periferik perfüzyon bozukluğu Hypertension80 % Hypertension80 % Hypotention20 % Hypotention20 % Neurologic dysorders20 % Neurologic dysorders20 % BP Difference BP Difference

21. Diagnosis ECG ECG –Low voltage –ST-T wave changes Blood tests Blood tests

22. Diagnosis Chest x-ray Chest x-ray CT CT MRI MRI TTE TTE TEE TEE Aortography Aortography

29. To whom shall we perform angiography? No need for patients with Acute type A dissection No need for patients with Acute type A dissection It can be performed to patients with Acute type B dissection, because CAD is frequent It can be performed to patients with Acute type B dissection, because CAD is frequent It must be performed to patients with chronic dissection It must be performed to patients with chronic dissection

30. Treatment Surgical treatment Surgical treatment Medical treatment Medical treatment Endovascular treatment Endovascular treatment Hybrid treatment Hybrid treatment

31. Treatment-Aim Stabilize the dissection Stabilize the dissection Avoid the rupture Avoid the rupture Avoid organ ischemia Avoid organ ischemia Systolic BP100-110 mmHg Systolic BP100-110 mmHg Mean BP60-75 mmHg Mean BP60-75 mmHg Urine output and neurologic status should be monitorized Urine output and neurologic status should be monitorized

32. Treatment-Emergency Unit Fluid replacement Fluid replacement ECG ECG Blood tests Blood tests Chest x-ray Chest x-ray O 2 O 2 Analgesia (Morphine) Analgesia (Morphine) Invasive arterial monitoring Invasive arterial monitoring B-blocker B-blocker

33. Surgical Treatment Acute Type AEmergent surgical treatment Acute Type AEmergent surgical treatment Acute Type BEndovascular or medical treatment (surgery for rupture, intractable sympoms or organ ischemia) Acute Type BEndovascular or medical treatment (surgery for rupture, intractable sympoms or organ ischemia) Chronic Type AElective surgical treatment Chronic Type AElective surgical treatment Chronic Type BSurgery for aneurysmatic aorta, organ ischemia. Chronic Type BSurgery for aneurysmatic aorta, organ ischemia.

34. 41 year-old female with 8 children 41 year-old female with 8 children ECG: Paroxysmal AF ECG: Paroxysmal AF Entubated Entubated Diagnosis: Acute Stanford type A Aortic Dissection Diagnosis: Acute Stanford type A Aortic Dissection Hypertension Hypertension Case Report

38. Femoral or axillary arterial cannulation Femoral or axillary arterial cannulation Venous cannulation Venous cannulation Venting from RUPV Venting from RUPV Surgical Technique

54. Result 464 patients, 12 centers 464 patients, 12 centers Mortality: Mortality: Type A Type B Surgery28 % 31 % Medical58 % 10 % The results are even worse for the patients with paraplegia, visceral or renal ischemia.