1. Jakub Honěk Kardiologická klinika 2.LF UK a FN Motol

2.  Anatomy and physiology  Abdominal aortic aneurysm (AAA)  Aneurysm of thoracic aorta  Aortic dissection

3.  Ascending aorta ◦ Aortic root ◦ ST junction ◦ Tubular part  Aortic arch ◦ Aortic isthmus  Descending aorta  Abdominal aorta ◦ Suprarenal segment ◦ Infrarenal segment ◦ Bifurcation

5. Zieman SJ. Arterioscler Thromb Vasc Biol 2005;25:932-943.

6.  Localized distension  of aortic diameter >50% (>3.0cm in women, >3.4 cm in men)  90 % subrenal  Progresses over time  5x more frequent in men  Prevalence ↑ with age  Multifactorial etiology  Risk factors simillar to atherosclerosis, pathophysiology is different - aortic wall remodelling

7.  Mostly asymptomatic!  Rarely patient palpates pulsatile mass, or feels pulsations  Mostly first smyptoms occur due to complications ◦ Peripheral thromboembolism ◦ AAA rupture (first sign in 40%!)

8.  Emergent, life threatening situation  Mortality 80–90 % when optimally treated  90% retroperitoneal rupture  Clinical triad ◦ PAIN (amdominal/lumbar, radiation to groins) ◦ PULSATILE MASS ◦ HYPOTENSION (circulatory shock)

9.  Duplex ultrasound ◦ Fast, cheap, screening of pts. in risk, follow-up  CTA/MRA ◦ Optimal resolution, anatomy  DSA ◦ Invasive treatment, luminography  Screening ◦ Effective in risk groups (pts. With family history, CAD, PAD, male smokers >65 yrs…) ◦ Prevention of fatal complications, elective operation/inetervention

10.  Lifestyle changes, follow-up, blood pressure control (beta-blockers)  Preventive operation/intervention Indication based on AAA diameter: > 55 mm > 10 mm increase/year Modified by BSA, sex, comorbidities

11.  Surgery ◦ Resection of aneurysmal sac, implantation of vascular prosthesis  Endovascular treatment ◦ Implantation of stentgraft ◦ Femoral approch ◦ Simila longterm results to surgery  Conservative ◦ Follow-up, risk of rupture

13.  Emergent surgery/endovascular tretament  Patient stabilization, fast imaging  Up to 50% pts. die before reaching hospital  30-40% die die before reaching op. Theatre  40-50% of the operated die  Overall mortality 80-90%

14.  Less frequent than AAA (10/100 000)  Same definition  60% ascending, 5-10% arch, 30-35% descendning  Anuloaortic ectasia

16.  Multiple etiologies – genetic, degenerative, infectious, inflammatory  Bicuspid aortopathy  Cystic medial degeneration  Mostly assymptomatic  Symptoms of complications: Ao regurgitation, embolization, compression sy., dissection, rupture  Iamging: TTE, TEE, CTA, MRA, DSA

17.  BP control  Follow-up  Elective surgery Bonow et al. Braunwalds heart disease.

18.  Incidence: 3/100 000 per year  High mortality ◦ Untreated: 25%/24h, 50%/week ◦ Optimal treatment: 20%/30 days  Intimal tear – entry  Intimal flap, false lumen  Reentry

19. Arterial hypertension Genetically triggered thoracic aortic disease Marfan syndrome Bicuspid aortic valve (bicuspid aortopathy) Ehlers-Danlos syndrome Congenital diseases Coarctation of aorta Tetralogy of Fallot Atherosclerosis of aorta Iatrogenic or blunt trauma Catheterisation or stenting Surgery (CABG, valve replacement, operation of aorta) Intraaortic balloon contrapulsation Trauma (road traffic accidents) Gravidity Cocaine abuse Inflammatory and infectious diseases Takayasu arteritis, giant cell arteritis, syphilis

20. Stanford De Bakey Entry: 65% root, 20% isthmus, 15% other

21.  Pain ◦ severe, sudden, sharp – stabbing, tearing („stabbed in the chestwhit a knife“) ◦ Retrosternal (+radiation to neck, jaw), between scapulae, abdominal, back  Acute heart failure, MI, syncope, stroke, paraplegia…

22.  Urgent situation – fast diagnosis  Rare disease vs. Common diseases  Physical exam, ECG, lab (D dimers)  Ideal imaging test – fast, available, good resolution – CTA  Trasthoracic echo - bediside

24.  Urgent situation, high mortality in first hours  Multidisciplinary approach  Initial management:  BP control (beta blockers)  Pain control  Hemodynamic stabilization  In type A – plan urgent surgery  In type B – conservative/ surgery/endovascular