1. Aortic Dissection and Aneurysms Presented by Dr. Daniel Kranitz Prepared by Mary Edwards September 27, 2005 Tintanalli Chapter 58, Pages 404-409

2. Abdominal Aortic Aneurysms (AAA)  Risk factors Elderly (>60) Familial trend (18% with 1° relative) Connective Tissue D/O (Marfan’s) Other aneurysms Atherosclerosis (HTN,  Lipids, smoking, DM)

3. AAA  Pathogenesis Intima infiltrated by atherosclerosis and thinned media. Possible intraluminal thrombus and adventitia infiltrated by inflammatory cells

4. AAA  Average rate of growth 0.25-0.5 cm per year.  Larger aneurysms extend more rapidly than smaller ones. (LaPlace law)

5. AAA  Clinical Features Syncope (10-12%) Back and/or Abdominal Pain –severe and abrupt, ripping or tearing sensation (50%) Shock –intraperitoneal rupture, massive blood loss Sudden death

6. AAA  Physical Exam Pain on palpation or not Retroperitoneal hematoma Cullen sign (periumbilical ecchymosis) Grey-Turner sign (flank ecchymosis) Scrotal hematoma or inguinal mass (blood dissecting to these areas) Iliopsoas sign Femoral nerve neuropathy

7. AAA  Found aneurysms refer to follow up  >5cm diameter –increased chance of rupture  <5cm –decreased chance of rupture  Symptomatic aneurysms of any size = Emergency!!

8. AAA  Diagnosis Includes differential diagnoses of syncope, abd pain, CP, back pain and shock. If with combo of two or more think aortic dz.

9. AAA  Radiologic Evaluation  Should not delay operative treatment!! Plain abd film (calcified bulging) US (bedside, up to 100% sensitive, not reliable to detect rupture) CT (with IV contrast only if stable) MRI

10. AAA  ED Treatment Urgent surgical consult Make diagnosis & assist rapid transfer to OR 2 large bore IVs Cardiac Monitor O2 ? Blood transfusion IV fluid resuscitation –controversial amount b/c too much can be harmful  RADIOGRAPHIC STUDIES ONLY IF UNLIKELY TO HAVE RUPTURED AAA!!!

11. AAA  ½ of patients with ruptured AAA who reach the OR die!

12. A Bit About Thoracic Aortic Aneursym  Presenting symptoms include esophageal, tracheal, bronchial, or even neurologic disorders.  If it erodes to adjacent structures it is immediately fatal!!

13. Aortic Dissection  Pathogenesis Prominent cause of sudden death Presents with severe abd., chest, and back pain Violation of intima that allows blood to enter media and dissect b/w intimal and adventitial layers Common site is ascending aorta at ligamentum arteriosum

14. Aortic Dissection  Common presenting groups >50 yoa with HTN 2/3 male Marfan’s syndrome Congenital heart disease Pregnancy

15. Aortic Dissection  Stanford Classification Type A -involves ascending aorta Type B –involves descending aorta  DeBakey Classification Type I –ascending, arch & descending aorta Type II –ascending only Type III –descending only

16. Aortic Dissection  Clinical Features >85% abrupt, severe pain in chest or b/w scapula 50% ripping or tearing Pain in anterior chest –ascending aorta (70%) Back pain (less common) –descending aorta (63%) If dissection into carotid classic neuro symptoms

17. Aortic Dissection  Clinical Features 40% with neurologic sequelae (ex. paraplegia) Nausea, vomiting, diaphoresis Most have sense of impending doom!

18. Aortic Dissection  Physical Exam Usually normal heart and lung exam May have aortic insufficiency <20% with decreased radial, femoral or carotid pulse HTN Tachycardia Hypotension

19. Aortic Dissection  Physical Exam Pericardial tamponade (muffled heart tones, JVD, pulsus paradoxus) Hoarseness (compression of recurrent laryngeal nerve) Horner’s Syndrome (compression of superior cervical sympathetic ganglion)

20. Aortic Dissection  Diagnosis Ischemic end-organ manifestation such as MI, pericardial dz, pulmonary d/o, stroke, SCI, musculoskeletal dz of extremities, intraabdominal ischemia. Can change location with time as dissects.

21. Aortic Dissection  Thoracic Dissection 90% have abnormal CXR Widened mediastinum Abnormal aortic contour Pleural effusion Deviation of trachea, mainstem bronchi, or esophagus Intimal calcium visable & distant from edge (calcium sign)

22. Aortic Dissection  Diagnosis CT 83-100% sensitive 87-100% specific Use spiral CT with IV contrast Will not give anatomic details of arterial branches or aortic valve competence. Modality of choice in unstable patient

23. Aortic Dissection  Diagnosis Angiography “Gold standard” Shows all anatomy and involvement 94% specific 88% sensitive TEE 97-100% sensitive 97-99% specific Esophageal dz contraindication

24. Aortic Dissection  In contrast to ruptured AAA, SUSPECTED DISSECTIONS MUST BE CONFIRMED RADIOLOGICALLY PRIOR TO SENDING TO OR!!!

25. Aortic Dissection  ED Treatment Treat hypertension  -blocker  Esmolol 500  g/kg IV bolus over 1 minute then 50-150  g/kg minute  Metoprolol 5mg q2min x3 IV then 2-5mg/hr  Propranolol 20mg IV then 40mg, 8-mg q10min to 300mg total Calcium channel blocker if  -blocker contraindicated

26. Aortic Dissection  ED Treatment Vasodilator Nitroprusside 0.3  g/kg/min IV Surgery OR for ascending aortic dissection Descending aortic dissection worse surgical risks – controversial for repair

27. Any Questions????

28. Questions  1. A patient with a suspected aortic dissection should be immediately tranferred to OR without radiographic studies.  A. True  B. False

29.  2. Females are more likely than males to develop aortic dissection. A. True B. False  3. Dissection of the ascending aorta only is DeBakey classification A. Type I B. Type II C. Type III D. Type A E. Type B

30.  4. Patients with a ruptured AAA can present with all of the following symptoms except A. Shock B. Syncope C. Sudden death D. Nausea and vomiting E. Headache

31.  5. Which of the following radiologic modalities is considered the “gold standard” for diagnosing an aortic dissection? A. CT B. MRI C. TEE D. Angiography E. CXR

32. Answers  1. B  2. B  3. B  4. E  5. D