2. Introduction
• Usually asymptomatic until complication-
imaging required for detection and monitoring
– Masking diagnostic (CAD, malperfusions)
• Identification of genetic alterations
– Potential for early detection
– Targeted therapy
3. • Aneurysm:permanent localized dilatation of
an artery with at least 50% increase in
diameter compared with the expected normal
diameter.Covered by all 3 layers
• Aortic dissection:disruption of media layer of
aorta with bleeding within and along the wall
of aorta
4.
5.
6.
7.
8.
9.
10. Class I rec.for medical management
• i.v beta blockade titrated to HR<60/min
• CCB alternative if beta blocker contra.
• After HR controlled,i.v vasodilators to reduce
B.P to a level that maintains organ perfusion
• Beta blocker used cautiously in setting of a/c
AR
• Vasodilator should not be given prior to rate
control(classIII)
11. Recommendation for definitive
management(classI)
• Ascending aorta involved-emergent surgical
repair
• Desc. Aorta involved-managed medically
unless lifethreatening complications
– Malperfusion syndrome
– Progression of dissection
– Enlarging aneurysm
– Inability to control BP or symptoms
12. Recommendations for surgical
management(classI)
• Ascending ao.dissection-aneurysmal aorta and
proximal extent of dissection should be resected
• Prtially dissected root-repaired with valve
resuspension
• Extensive dissection of aortic root-aortic root
replacement with a composite graft or with a
valve sparing root replacement
• DeBakey type II-entire dissected aorta should be
replaced
13. • Use of beta blockers slowed aortic root
dilatation(Shores J et al;nejm 1994,Ladouceur M
et al;Am J Cardiol 2007)
• Beta blockers reduced aortic dilatation in c/c type
B dissection(Genoni M et al;2001)
• ACEI perindopril-reduced aortic root dilatation in
marfans(Ahimastos AA et al;JAMA2007)
• ARB-reduced aortic root dilatation in Marfans
syn(Brooks BS et al;nejm2008)
• Statin use a/w decreased long term mortality in
abd aortic aneurysm(Diehm N et al;2008)
14. Thoracic aortic aneurysms
• Rec.for medical Rx:classI
– Antihypertensives to a goal<140/90(goal<130/80 for
DM&CKD)
– Beta blocker in Marfans syn.&aortic aneurysm
– Smoking cessation
• classIIa-
– Reduce B.P to the lowest point pt can tolerate with
beta blocker and ACEI or ARB
– ARB (losartan) for pt with Marfans syn.
– Treatment with statin to target LDL-C<70mg%
15. Surgical management-asymptomatic
pt.(classI)
• Ascending aortic aneurysm degenerative
etiology-surgical repair if diameter>5.5cm
• Genetic syn.-elective surgery at diameter 4.0
to 5.0 cm
• Growth rate>0.5cm/yr
• Patients undergoing AVR at a diameter>4.5cm
16. Rec.for surgery-classII a
• Genetic syn.-ratio of aortic root
area(cm²)devided by height (m)>10-surgery
indicated
• Loeys Diets syn,TGFBR1&2 mutation-diameter
>4.2 by TEE,or >4.4 by CT or MRI
17. Recommendations for desc.thoracic
aorta(classI)
• Endovascular stent grafting-
– Degenerative or traumatic aneurysm>5.5cm
– Saccular aneurysm
– Post op.pseudoaneurysm
• Open repair
– c/c dissection
– a/w connective tissue d/s
– Desc.thoracic aorta>5.5 cm
18.
19. Organ protection
• Class II a-
– deep hypothermic circulatory arrest for brain
protection
– Optimisation of spinal cord perfusion pressure and
moerate systemic hypothermia
• Class II b-preop.hydration and intra
op.mannitol for preservation of renal fn
during open repairs of desc.aorta
26. Acute aortic syndromes
• Consists of 3 conditions-aortic
dissection,IMH,PAU
• 15% of AoD have an IMH without an intimal
tear
• Incidence 2-3.5/1,00,000 person years
• Mean age of presentation 63yrs
• Male predominance-65%
28. • DeBakey classification:
– Type I: Dissection originates in Asc.aorta and
propagates to include at least the aortic arch
– Type II: Dissection originates in and confined to the
Asc.aorta
– Type III: Dissection originates in the desc.aorta and
propagates most often distally
• Stanford classification system
– Type A:dissections involving the asc.aorta regardless
of the site of origin
– Type B:dissections that do not involve the asc.aorta
29. Evaluation
• High risk conditions-(class I)
– Genetic syndromes like Marfan syn.,Ehlers-Danlos
– Connective tissue diseases
– F/h of aortic dissection
– Known aortic valve disease
– Recent aortic manipulation
– Known aortic aneurysm
30. • High risk pain features(classI)
– Chest,back or abdominal pain
– Abrupt in onset
– Severe intensity
– Ripping,tearing,stabbing or sharp
33. Recommendations for screening
tests(classI)
• STEMI in ECG should be treated as primary
cardiac event without delay for aortic imaging
unless pt. is high risk
• Low and intermediate risk patients should be
screened by CXR-
– Findings s/o aortic d/s-definitive aortic imaging
– Alternate diagnosis-manage accordingly
• High risk patients should directly undergo TEE,CT
or MRI
• Class III- negative CXR should not delay definitive
aortic imaging in high risk pt
34. Diagnostic imaging studies(classI)
• Selection of imaging modality based on pt
variables and institutional capabilities
• If high clinical suspicion exists in spite of
negative initial imaging a second study should
be performed
35. Recommendations for management
• BP mesured in both arms-treatment strategy
based on highest reading
• Patient not in shock-i.v drugs for rate and B.P
control
38. • Endovascular interventions-not approved for
dissection involving asc.aorta or arch
• Intimal defect without IMH-
– Asc.aorta-emergency surgery
– Desc.aorta-endograft
• Intimal defect with IMH
– Stable pt-delay def.Rx until IMH resorbs
– Desc.aorta-endovascular Rx
39.
40.
41. • Patients with symptoms s/o expansion of
aneurysm-prompt surgical intervention(classI)
• Endovascular stent grafts have not been
approved by the US FDA for treatment of
aneurysms or other conditions of asc. aorta.
42. Rec.for open surgery(asc.aortic
aneurysm)-class I
• Separate valve and asc.aortic replacement in
patients without significant root dilatation
• Patients with significant root dilatation-
excision of sinuses&modified David
reimplantation or root replacement with
valved graft conduit
43. Rec. for arch aneurysms-classII
• Partial arch replacement-asc.aortic aneurysm
involves proximal arch
• Replacement of entire aortic arch-
– A/c or c/c dissection in an aneurysmal arch
– Aneurysm of entire arch
– Distal arch aneurysm that involves prox.desc.aorta
– Asymptomatic pts. With diameter>5.5cm
• Annual reimaging-aneurysms<4cm
• Endovascular stent graft not approved
44. • Thoraco abdominal aneurysm-surgery when
diameter >6cm
• End organ ischemia-additional
revascularisation procedure recommended
45. Recommendations for genetic syn.
• classI-
– Marfan syn.-echo to assess aortic root and asc.aorta at
diagnosis &6 months after to determine rate of growth
• Annual imaging if stable and <4.5cm
• More frequent imaging otherwise
– Loeys-Dietz syn,other gen. mutations –complete aortic
imaging at diagnosis,6months
– Loeys-Dietz syn-annual MRI from cerebrovasc.circulation
to pelvis
– Turner syn-imaging at diagnosis for BAV,CoA,dilatation of
asc.aorta.
• If any abnormalities-annual imaging
• Otherwise-repeat 5 to 10yr
46. • Class IIa
– Marfan syn planning pregnancy-replacement of
aortic root and asc.aorta if >4.5cm
47.
48. Recommendations for familial thoracic
aortic aneurysms
• ClassI
– Aortic imaging for first degree relatives of pts with
thoracic aortic aneurysm or dissection
– If a mutant gene a/w aneurysm identified-first
degree relatives should undergo genetic
screening-those with genetic mutation undergo
imaging
49. • classIIa
– If one or more first degree relatives of a patient
affected-imaging of second degree relatives
– Sequencing of ACTA2 gene in patients with f/h of
thoracic aortic aneurysm or dissection
50.
51. Recommendations for BAV
(class I)
• First degree relatives of pts with
BAV,premature onset of thoracic aortic
d/s,familial form of aortic aneurysm and
dissection-should be evaluated for presence
of BAV&aortic d/s
• All pts with BAV should be evaluated for aortic
dilatation
52. Recommendations for takayasu
arteritis &GCA(classI)
• Initial evaluation should include CT or MRI of
thoracic aorta and branches
• Initial therapy-corticosteroids at high dose
• Periodic evaluation-physical examination&ESR
or CRP
• Elective revasc.after a/c inflammatory state is
quiescent
• Class II a –use of anti inflammatory agents
53. Recommendations in pregnancy
• classI
– Marfans syn and aortic d/s-counselled about risk
of dissection,heritable nature
– Strict BP control for pts with predisposition to
dissection
– Aortic root or asc.aortic dilatation-monthly echo
– Arch,descending or abd.aortic dilatation-MRI
54. • ClassIIa
– CS for pts with significant aortic dilatation
• Class IIb
– If progressive aortic dilatation-prophylactic
surgery recommended
55. Aortic dissection in pregnancy
• Type A-
– 1st
or 2nd
TM-urgent surgical repair and fetal
monitoring
– 3rd
TM-urgent CS f/b aortic repair
• Type B-medical therapy preferred
56. Aortic arch atheroma
• classIIa-Rx with a statin
• Class IIb-oral anticoagulation with warfarin or
antiplatelets in stroke pts with atheroma≥ 4
mm
57. Pre op evaluation for CAD
• Class I-
– thoracic aortic d/s undergoing intervention-evaluated
for CAD
– unstable cor syn-undergo revascularisation prior to at
time of aortic surgery or intervention
• classIIa-
– Asc.aortic or arch d/s undergoing surgery-
concomitant CABG for stable significant CAD
• Class IIb-
– Descending thoracic aortic d/s-stable significant CAD-
benefits not certain
Notas del editor
Results of treatment better in asymptomatic stage
Pseudoaneurysm:disruption of arterial wall&extravasation of blood contained by periarterial connective tissue
Intramural hematoma:clinical picture of dissection with hematoma in arterial wall,without an intimal disruption.no flow in false lumen
Penetrating atherosclerotic ulcer:atherosclerotic lesion with ulceration that penetrates the internal elastic lamina.
1.classic dissection
2.IMH
3.intimal tear without IMH
4.PAU
5.iatrogenic/traumatic
Normal aortic size
Depends on
Age
Sex
Body size
Location of measurement
Method of measurement
Diameter increases by 0.12-o.29mm/yr at each level
Measurements should be taken at reproducible anatomic landmarks,perpendicular to axis of flow
CT&MRI-ext.diameter taken
Echo-internal diameter
For aortic root-the widest diameter at mid sinus level
Abnormalities of aortic morphology reported separately
Minimise cumulative radiation exposure
classIIa-aortic diameter should be related to patient&apos;s age and body size
MRI
Advantage
No radiation
Identification of anatomic variants of AoD
branch vessel invt
Disadvantage
Prolonged duration
Pt.inaccessible to care providers
Gadolinium contrast not used in renal impairment
ECHO
Proximal AoD-
TEE sensitivity 88-98%,specificity 90-95%
TTE 77-80% and 93-96%
Distal AoD-TEE better
TEE blind spot-distal ascending aorta&prox.arch-interposition of trachea &lt.main bronchus