aortic syndromes

1. Acute Aortic Syndromes
By
Dr.TamerTahaIsmail
AssociateProfessorofCardiology,GMU
SpecialistCardiology,ThumbayHospital,Dubai

2. Acute aortic syndrome is a modern term, that
consists of interrelated emergency conditions with
similar clinical characteristics and challenges.

3. Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A, et al. Diagnosis and management of aortic dissection. Eur Heart J
2001;22:1642-81.

5. Hayter RG, Radiology 2006; 238:841-852

6. Suspected Acute Aortic Syndrome
MDCT in 373 Emergency Evaluation
Hayter RG, Radiology 2006; 238:841-852

7. 0% 5% 10% 15% 20% 25%
Percentage
Aortic dissection
No clear diagnosis
Cardiac arrhythmia
Vasovagal
Pulmonary disease
Neuro-radicular pain
Acute coronary syndromes
ED Diagnosis
von Kodolitsch Y, et al. Arch Intern Med. 2000;160:2977-82.

8. Contributing conditions for aortic dissection
Epidemiology
75%

9. Contributing conditions for aortic dissection

10. Genetic risk factors
• Usually Autosomal Dominant.
• Strongest in younger patients, particularly aortic
dissection and thoracic aneurysm.
• 20% of patients have an underlying genetic disorder
and altered connective tissues (Marfan syndrome,
Turner syndrome, or Ehlers–Danlos syndrome,
especially Type IV).

11. AORTIC DISSECTION

12. Classification
According to time from onset of symptoms to
presentation, dissection is classified into:
1- Acute dissection: within 2 weeks of onset.
2- Subacute: 2 to 6 weeks from onset.
3- Chronic: > 6 weeks from onset.

13. Anatomical Classification
• Aortic dissection can be classified according to the
origin of intimal tear or whether the dissection involves
the ascending aorta (regardless of the site of origin).
• Accurate classification is important as it drives
decisions regarding surgical vs. non-surgical treatment.
• The two most commonly used classification schemes
are the DeBakey and the Stanford systems.

14. For purposes of classification, the ascending
aorta refers to the aorta proximal to the
brachiocephalic artery, and the descending
aorta refers to the aorta distal to the left
subclavian artery.

16. The DeBakey classification system is based on the origin
of the intimal tear and the extent of the dissection
• Type I: Dissection originates in the AA and propagates
distally to include at least the aortic arch and typically the
DA (surgery usually recommended).
• Type II: Dissection originates in and is confined to the AA
(surgery usually recommended).

17. The DeBakey classification system is based on the origin of the
intimal tear and the extent of the dissection.
• Type III: Dissection originates in the DA and
propagates most often distally (non-surgical treatment usually
recommended)
* Type IIIa: Limited to the descending thoracic aorta
* Type IIIb: Extending below the diaphragm

18. The Stanford classification system classifies
dissections into 2 categories, those that involve the
AA and those that do not.
• Type A: involve the AA regardless of the site of origin (surgery
usually recommended)
• Type B: do not involve the AA (non-surgical treatment usually
recommended)
Involvement of the aortic arch without involvement of AA in the
Stanford classification is labelled as Type B.

19. Aortic dissection classification
DeBakey and Stanford classifications

20. Intramural Hematoma

21. Penetrating atherosclerotic ulcer

22. Clinical symptoms associated with AASs

23. Clinical signs associated with AASs

24. Clinical symptoms associated with AASs

25. Prognostic considerations
 Risk of death is increased in patients who present with
or develop complications of pericardial tamponade,
involvement of coronary arteries causing AMI, or
malperfusion of the brain.
 Other predictors of increased in-hospital death include
age (≥70 years), hypotension or cardiac tamponade,
RF, and pulse deficits.

26. Prognostic considerations
 In the absence of immediate surgery, medical treatment
of proximal dissection is associated with a mortality of
20% by 24 h after presentation, 30% by 48 h, 40% by Day
7, and 50% by 1 month.
 Even with surgical repair, mortality rates are 10% by 24 h,
13% by 7 days, and 20% by 30 days.

27. Prognostic considerations
 Patients with uncomplicated Type B dissection have a 30-
day mortality of 10%.
 However, patients who develop ischaemic complications
such as RF, visceral ischaemia, or contained rupture often
require urgent aortic repair which carries a mortality of
20% by Day 2 and 25% by Day 3.

28. Diagnostic evaluation by imaging modalities
Clinical suspicion of AAS
 Non Imaging Tests:
ECG, chest radiography, biomarkers
(Troponin and D-dimer tests).
 Imaging tests: TEE & MDCT with CTA

29. Aim of imaging tests :
1. Confirmation of clinical suspicion.
2. Classification of dissection.
3. Localization of tears.
4. Assessment of both the extent of dissection and
indicators of emergency (e.g. pericardial,
mediastinal, or pleural haemorrhage).

30. •Selection of most appropriate imaging study depends
upon:
•Initial imaging modality was CT(61%),TEE(33%),
MRI(1%)

31. MDCT

34. MRI
This disadvantage is the main
reason why MRI is not currently included in the
diagnostic workup of AASs.

35. Echocardiography

36. Treatment concepts
• AASs (dissection or IMH) involving the ascending aorta
are surgical emergencies.
• In selected cases, hybrid approaches of an endovascular
and open surgery may be considered.

37. Treatment concepts
Conversely, acute aortic pathology confined to the
descending aorta is treated medically unless complicated
by organ or limb malperfusion, progressive dissection, extra
aortic blood collection (impending rupture), intractable pain
or uncontrolled hypertension.

38. Type A

39. Type B

40. Initial medical therapy
 Initial management of AAS, particularly
dissection, is directed at limiting propagation of
dissected wall by control of BP and reduction in
dP/dt (shear force ).
 Reduction in BP to just maintain sufficient end-
organ perfusion.

41. Initial medical therapy
 First-line therapy is intravenous b-blockade is useful for
lowering both BP and dP/dt, with a target SBP of 100–
120 mmHg and HR of 60–80 bpm.
 Often multiple agents are required, with patients ideally
managed in an ICU.
 Opiate analgesia should be prescribed to attenuate the
sympathetic release of catecholamines to pain with
resultant tachycardia and hypertension.

42. Initial medical therapy
 Endovascular intervention is dictated by the site
of the lesion and evidence of complications
(persisting pain, organ malperfusion), as well as
evidence of disease progression on serial
imaging
 There is no evidence for endovascular repair of
uncomplicated Type B dissection.

43. Long-term follow-up
 The 10-year survival rate of patients with AAS
who leave the hospital ranges from 30 - 60% in
different studies.
 Dissection of the aorta represents a systemic
problem with the entire aorta and its branches
predisposed to dissection, aneurysm formation,
and/or aortic rupture in the future.

44. Long-term follow-up
 Systemic hypertension, advanced age, aortic size, and the
presence of a patent false lumen are all predictors of late
complications.
 Therefore, medical therapy including b-blockers is needed to
minimize aortic wall stress, and serial imaging to detect signs
of progression, redissection, or aneurysm formation.

45. Conclusions

46.  Technological advances in imaging techniques and better
understanding of the pathophysiology of acute aortic
conditions have lead to the discovery of variants known as
AAS.
 Furthermore, various surgical and percutaneous
endovascular treatment strategies are established and
continue to improve.
 As a result of increasing scientific interest, outcomes of
patients treated for AASs have also improved.

47.  However, clinical pathways that facilitate efficient care
similar to ACS or stroke are not yet implemented.
 Meanwhile, emerging serum biomarkers may soon offer
hope for easier identification of patients with AAS.
 Finally, continued enthusiasm and further technical
improvement will eventually improve the management of
low-incidence–high-impact AAS.

48. THANK YOU