SlideShare una empresa de Scribd logo
1 de 80
Aortic Dissection  Zahir Rahman MD 10/14/02
ED History – 9:55 A.M. ,[object Object],[object Object]
Neurosurgery PE – 10:30 AM ,[object Object],[object Object],[object Object],[object Object]
Neurosurgery A/P ,[object Object],[object Object],[object Object]
MRA  ,[object Object],[object Object],[object Object],[object Object],[object Object]
RCA RSC LCA INTIMA TRUE LUMEN FALSE LUMEN PULMONARY TRUNK RSC
THROMBUS IN FALSE LUMEN TRUE LUMEN
FALSE LUMEN LRA TRUE LUMEN
 
CV Fellow Called: 12:30 P.M. ,[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object]
PE ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Labs: 7/30/02 9:35 AM  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
EKG
Management ,[object Object],[object Object]
Intraoperative TEE Ascend Aorta
Intraoperative TEE – Aortic Arch
Descend Aorta – Communication back into true lumen
Descend Aorta – Multiple Intimal Flaps
Intraoperative TEE ,[object Object],[object Object],[object Object],[object Object]
Surgery  ,[object Object],[object Object],[object Object]
Course:  ,[object Object],[object Object],[object Object],[object Object]
Hospital Course ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Aortic Dissection  Zahir Rahman MD 10/14/02
Classifications ,[object Object],[object Object],[object Object]
Common Classification Systems Braunwald
Common Classifications of Aortic Dissection
Variants of Aortic Dissection
Predisposing Factors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Predisposing Factors ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Predisposing Factors ,[object Object],[object Object],[object Object],[object Object],[object Object]
Cystic Medial Degeneration ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Pathogenesis ,[object Object],[object Object],[object Object],[object Object]
Proposed Mechanism of Initiation of Dissection
Natural History ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Symptoms of Aortic Dissection  According to a report on 464 patients from the  International Registry of Acute Aortic Dissection. (Hagan et al. Jama 2000; 283:897-903)
Clues to Proximal Dissection ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Aortic Regurgitation ,[object Object],[object Object],[object Object],[object Object],[object Object],Hagan et al. IRAD. JAMA 2000;283:897-903.
Mechanisms of Aortic Regurgitation in Proximal AD
Hypotension with Proximal Dissection ,[object Object],[object Object],[object Object],[object Object],[object Object]
Predicting Death in Type A Aortic Dissection  (Mehta et al. Circulation. 2002;105:200-206) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Variables Associated with High In-Hospital Mortality Rates. (Mehta et al. Circulation. 2002;105:200-206)
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Clues to Distal Dissection
Clinical Prediction of Acute Aortic Dissection  (von Kodolitsch et al, Arch Intern Med 2000;160:2977-2982) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
(von Kodolitsch et al, Arch Intern Med 2000;160:2977-2982)
(von Kodolitsch et al, Arch Intern Med 2000;160:2977-2982)
[object Object],[object Object],[object Object],(von Kodolitsch et al, Arch Intern Med 2000;160:2977-2982)
EKG ,[object Object],[object Object],[object Object],[object Object]
CXR  ,[object Object],[object Object],[object Object]
Normal Aorta in CXR 3 years Prior
Enlargement of the Aortic Knob A Case of Proximal Aortic Dissection
Comparison of Imaging Modalities (Braunwald)
Aortography ,[object Object],[object Object],[object Object],[object Object]
Thoracic Aortagram in AP view
CT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Contrast-Enhanced CT at level of Ventricle
Left Anterior Oblique View Contrast Enhanced CT Intimal Flap originates beyond Left SC Artery
TEE ,[object Object],[object Object],[object Object],[object Object],[object Object]
Descend Aorta – Communication back into true lumen
MRI ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RCA RSC LCA INTIMA TRUE LUMEN FALSE LUMEN PULMONARY TRUNK RSC
Practical Assessment of Imaging Modalities
Smooth Muscle Myosin Heavy Chain ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],(Suzuki et al. Circulation 1996;93:1244-1249)
MANAGEMENT ,[object Object],[object Object],[object Object],[object Object],[object Object]
Sodium Nitroprusside ,[object Object],[object Object],[object Object],[object Object]
Labetolol ,[object Object],[object Object],[object Object],[object Object]
Esmolol ,[object Object],[object Object],[object Object],[object Object],[object Object]
Contraindications to BB ,[object Object],[object Object],[object Object],[object Object],[object Object]
Other Considerations ,[object Object],[object Object],[object Object],[object Object],[object Object]
Cardiac Tamponade ,[object Object],[object Object],[object Object],[object Object],Isselbacher et al, Circulation 1994: 90;2375-2378.
Cardiac Tamponade ,[object Object],[object Object]
Indications for Definitive Surgical and Medical Therapy in AD
Surgical Repair of Proximal Dissections
Surgery ,[object Object],[object Object],[object Object]
Surgery with AR ,[object Object],[object Object],[object Object],[object Object]
Endovascular techniques ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Long Term  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Intramural Hematoma (H)
Crescenteric Hematoma that does not Enhance confirming a intramural Hematoma that does not communicate with the Aortic Lumen.
Evolution of a Penetrating atherosclerotic Ulcer of Aorta

Más contenido relacionado

La actualidad más candente

Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathyHypertrophic cardiomyopathy
Hypertrophic cardiomyopathyFuad Farooq
 
Aortic dissection nikku ppt
Aortic dissection nikku pptAortic dissection nikku ppt
Aortic dissection nikku pptNikhil Vaishnav
 
Aortic dissection
Aortic  dissectionAortic  dissection
Aortic dissectionSMSRAZA
 
Echocardiographic Evaluation of Hypertrophic Cardiomyopathy
Echocardiographic Evaluation of Hypertrophic CardiomyopathyEchocardiographic Evaluation of Hypertrophic Cardiomyopathy
Echocardiographic Evaluation of Hypertrophic CardiomyopathyHatem Soliman Aboumarie
 
Acute aortic syndromes
Acute aortic syndromesAcute aortic syndromes
Acute aortic syndromesDIPAK PATADE
 
Double outlet right ventricle
Double outlet right ventricleDouble outlet right ventricle
Double outlet right ventricleRamachandra Barik
 
Ebstein anomaly
Ebstein anomalyEbstein anomaly
Ebstein anomalyAmit Verma
 
Second Step of Coronary Angiography
Second Step of Coronary AngiographySecond Step of Coronary Angiography
Second Step of Coronary AngiographyDr Naresh Sen
 
Abdominal aortic aneurysm
Abdominal aortic aneurysmAbdominal aortic aneurysm
Abdominal aortic aneurysmArthurMpower
 
Surgery for aortic root pathologies
Surgery for aortic root pathologiesSurgery for aortic root pathologies
Surgery for aortic root pathologiesmshihatasite
 
SYNTAX Score in Patients With Diabetes Undergoing Coronary Revascularization ...
SYNTAX Score in Patients With Diabetes Undergoing Coronary Revascularization ...SYNTAX Score in Patients With Diabetes Undergoing Coronary Revascularization ...
SYNTAX Score in Patients With Diabetes Undergoing Coronary Revascularization ...vaibhavyawalkar
 
SINUS OF VALSALVA ANEURYSM
SINUS OF VALSALVA ANEURYSMSINUS OF VALSALVA ANEURYSM
SINUS OF VALSALVA ANEURYSMJyotindra Singh
 
Surgical treatment for aortic arch aneurysms
Surgical treatment for aortic arch aneurysmsSurgical treatment for aortic arch aneurysms
Surgical treatment for aortic arch aneurysmsuvcd
 
TGA-Dr.Elamaran
TGA-Dr.ElamaranTGA-Dr.Elamaran
TGA-Dr.ElamaranEla Maran
 

La actualidad más candente (20)

Hypertrophic cardiomyopathy
Hypertrophic cardiomyopathyHypertrophic cardiomyopathy
Hypertrophic cardiomyopathy
 
Aortic dissection nikku ppt
Aortic dissection nikku pptAortic dissection nikku ppt
Aortic dissection nikku ppt
 
Aortic Dissection
Aortic DissectionAortic Dissection
Aortic Dissection
 
Aortic dissection
Aortic  dissectionAortic  dissection
Aortic dissection
 
Echocardiographic Evaluation of Hypertrophic Cardiomyopathy
Echocardiographic Evaluation of Hypertrophic CardiomyopathyEchocardiographic Evaluation of Hypertrophic Cardiomyopathy
Echocardiographic Evaluation of Hypertrophic Cardiomyopathy
 
Aortic dissection
Aortic dissectionAortic dissection
Aortic dissection
 
Acute aortic syndromes
Acute aortic syndromesAcute aortic syndromes
Acute aortic syndromes
 
Acute Aortic Syndrome
Acute Aortic SyndromeAcute Aortic Syndrome
Acute Aortic Syndrome
 
Double outlet right ventricle
Double outlet right ventricleDouble outlet right ventricle
Double outlet right ventricle
 
Aortic disection
Aortic disectionAortic disection
Aortic disection
 
Aortic dissection Nightmare
Aortic dissection NightmareAortic dissection Nightmare
Aortic dissection Nightmare
 
Ebstein anomaly
Ebstein anomalyEbstein anomaly
Ebstein anomaly
 
Second Step of Coronary Angiography
Second Step of Coronary AngiographySecond Step of Coronary Angiography
Second Step of Coronary Angiography
 
Abdominal aortic aneurysm
Abdominal aortic aneurysmAbdominal aortic aneurysm
Abdominal aortic aneurysm
 
Surgery for aortic root pathologies
Surgery for aortic root pathologiesSurgery for aortic root pathologies
Surgery for aortic root pathologies
 
SYNTAX Score in Patients With Diabetes Undergoing Coronary Revascularization ...
SYNTAX Score in Patients With Diabetes Undergoing Coronary Revascularization ...SYNTAX Score in Patients With Diabetes Undergoing Coronary Revascularization ...
SYNTAX Score in Patients With Diabetes Undergoing Coronary Revascularization ...
 
Left ventricular aneurysm
Left ventricular aneurysmLeft ventricular aneurysm
Left ventricular aneurysm
 
SINUS OF VALSALVA ANEURYSM
SINUS OF VALSALVA ANEURYSMSINUS OF VALSALVA ANEURYSM
SINUS OF VALSALVA ANEURYSM
 
Surgical treatment for aortic arch aneurysms
Surgical treatment for aortic arch aneurysmsSurgical treatment for aortic arch aneurysms
Surgical treatment for aortic arch aneurysms
 
TGA-Dr.Elamaran
TGA-Dr.ElamaranTGA-Dr.Elamaran
TGA-Dr.Elamaran
 

Destacado

Aortic dissection 2015
Aortic dissection  2015Aortic dissection  2015
Aortic dissection 2015samirelansary
 
Aortic dissection 01
Aortic dissection 01Aortic dissection 01
Aortic dissection 01Rakesh Sharma
 
Imaging of Aortic Dissection
Imaging of Aortic DissectionImaging of Aortic Dissection
Imaging of Aortic DissectionSakher Alkhaderi
 
How to Market Your Nonprofit's Impact to Maximize Your Fundraising ROI
How to Market Your Nonprofit's Impact to Maximize Your Fundraising ROIHow to Market Your Nonprofit's Impact to Maximize Your Fundraising ROI
How to Market Your Nonprofit's Impact to Maximize Your Fundraising ROIHubSpot
 
13 the phillips curve and expectations theory
 13 the phillips curve and expectations theory 13 the phillips curve and expectations theory
13 the phillips curve and expectations theoryNepDevWiki
 
AS Macro Fiscal Policy Questions
AS Macro Fiscal Policy QuestionsAS Macro Fiscal Policy Questions
AS Macro Fiscal Policy Questionstutor2u
 
Ventricular septal defect, congenital heart disease
Ventricular septal defect,  congenital heart diseaseVentricular septal defect,  congenital heart disease
Ventricular septal defect, congenital heart diseaseShabnam Mohammadzadeh
 
Government fiscal policy and the economy
Government fiscal policy and the economyGovernment fiscal policy and the economy
Government fiscal policy and the economytutor2u
 
Civil Family Law - Promise to Marry (Betrothal)
Civil Family Law - Promise to Marry (Betrothal)Civil Family Law - Promise to Marry (Betrothal)
Civil Family Law - Promise to Marry (Betrothal)Azrin Hafiz
 
Pengelolaan keu desa
Pengelolaan keu desaPengelolaan keu desa
Pengelolaan keu desaDodik mer
 
AS Macro: The Effectiveness of UK Macro-Economic Policies
AS Macro: The Effectiveness of UK Macro-Economic PoliciesAS Macro: The Effectiveness of UK Macro-Economic Policies
AS Macro: The Effectiveness of UK Macro-Economic Policiestutor2u
 
Lra 2016 professional development
Lra 2016 professional development Lra 2016 professional development
Lra 2016 professional development Erin Elizabeth
 
Requirement Gathering & Rapid Prototyping
Requirement Gathering & Rapid PrototypingRequirement Gathering & Rapid Prototyping
Requirement Gathering & Rapid PrototypingAurobindo Nayak
 
Comprehensive Agrarian Reform
Comprehensive Agrarian ReformComprehensive Agrarian Reform
Comprehensive Agrarian Reformlowell0916
 
Causes & Effects of Inflation
Causes & Effects of InflationCauses & Effects of Inflation
Causes & Effects of Inflationmattbentley34
 
Year 1 Macro: Supply-Side Policies
Year 1 Macro: Supply-Side PoliciesYear 1 Macro: Supply-Side Policies
Year 1 Macro: Supply-Side Policiestutor2u
 

Destacado (20)

Aortic dissection 2015
Aortic dissection  2015Aortic dissection  2015
Aortic dissection 2015
 
Aortic dissection 01
Aortic dissection 01Aortic dissection 01
Aortic dissection 01
 
Imaging of Aortic Dissection
Imaging of Aortic DissectionImaging of Aortic Dissection
Imaging of Aortic Dissection
 
Terrence Allison Resume 1
Terrence Allison Resume 1Terrence Allison Resume 1
Terrence Allison Resume 1
 
How to Market Your Nonprofit's Impact to Maximize Your Fundraising ROI
How to Market Your Nonprofit's Impact to Maximize Your Fundraising ROIHow to Market Your Nonprofit's Impact to Maximize Your Fundraising ROI
How to Market Your Nonprofit's Impact to Maximize Your Fundraising ROI
 
13 the phillips curve and expectations theory
 13 the phillips curve and expectations theory 13 the phillips curve and expectations theory
13 the phillips curve and expectations theory
 
AS Macro Fiscal Policy Questions
AS Macro Fiscal Policy QuestionsAS Macro Fiscal Policy Questions
AS Macro Fiscal Policy Questions
 
Doppler ultrasound of the kidneys 1
Doppler ultrasound of the kidneys 1Doppler ultrasound of the kidneys 1
Doppler ultrasound of the kidneys 1
 
Ventricular septal defect, congenital heart disease
Ventricular septal defect,  congenital heart diseaseVentricular septal defect,  congenital heart disease
Ventricular septal defect, congenital heart disease
 
Government fiscal policy and the economy
Government fiscal policy and the economyGovernment fiscal policy and the economy
Government fiscal policy and the economy
 
Civil Family Law - Promise to Marry (Betrothal)
Civil Family Law - Promise to Marry (Betrothal)Civil Family Law - Promise to Marry (Betrothal)
Civil Family Law - Promise to Marry (Betrothal)
 
Pengelolaan keu desa
Pengelolaan keu desaPengelolaan keu desa
Pengelolaan keu desa
 
AS Macro: The Effectiveness of UK Macro-Economic Policies
AS Macro: The Effectiveness of UK Macro-Economic PoliciesAS Macro: The Effectiveness of UK Macro-Economic Policies
AS Macro: The Effectiveness of UK Macro-Economic Policies
 
karen torres cv
karen torres cvkaren torres cv
karen torres cv
 
Lra 2016 professional development
Lra 2016 professional development Lra 2016 professional development
Lra 2016 professional development
 
Doppler us of the kidneys 2
Doppler us of the kidneys 2Doppler us of the kidneys 2
Doppler us of the kidneys 2
 
Requirement Gathering & Rapid Prototyping
Requirement Gathering & Rapid PrototypingRequirement Gathering & Rapid Prototyping
Requirement Gathering & Rapid Prototyping
 
Comprehensive Agrarian Reform
Comprehensive Agrarian ReformComprehensive Agrarian Reform
Comprehensive Agrarian Reform
 
Causes & Effects of Inflation
Causes & Effects of InflationCauses & Effects of Inflation
Causes & Effects of Inflation
 
Year 1 Macro: Supply-Side Policies
Year 1 Macro: Supply-Side PoliciesYear 1 Macro: Supply-Side Policies
Year 1 Macro: Supply-Side Policies
 

Similar a Aortic Dissection

Pulmonary Embolism
Pulmonary EmbolismPulmonary Embolism
Pulmonary Embolismcairo1957
 
Stop That Clot
Stop That ClotStop That Clot
Stop That Clotmbuiduy
 
Bui duy icu
Bui duy icuBui duy icu
Bui duy icumbuiduy
 
Left-Right Shunt Natural history & Principles of Management
Left-Right ShuntNatural history & Principles of ManagementLeft-Right ShuntNatural history & Principles of Management
Left-Right Shunt Natural history & Principles of Managementdrranjithmp
 
Clinical Cases In Cardiology
Clinical Cases In CardiologyClinical Cases In Cardiology
Clinical Cases In Cardiologyhospital
 
Clinical Cardiology
Clinical CardiologyClinical Cardiology
Clinical Cardiologyhospital
 
Superior vena cava syndrome
Superior vena cava syndromeSuperior vena cava syndrome
Superior vena cava syndromeRanjita Pallavi
 
Drs. Escobar, Pikus, and Blackwell’s CMC X-Ray Mastery Project: January Cases
Drs. Escobar, Pikus, and Blackwell’s CMC X-Ray Mastery Project: January CasesDrs. Escobar, Pikus, and Blackwell’s CMC X-Ray Mastery Project: January Cases
Drs. Escobar, Pikus, and Blackwell’s CMC X-Ray Mastery Project: January CasesSean M. Fox
 
Acute Pulmonary Embolism Overview lecture.ppt
Acute Pulmonary Embolism Overview lecture.pptAcute Pulmonary Embolism Overview lecture.ppt
Acute Pulmonary Embolism Overview lecture.pptBasilQuran
 
Fellows Conference
Fellows ConferenceFellows Conference
Fellows Conferencecallroom
 
Constriction
ConstrictionConstriction
Constrictioncallroom
 
Endovascular management of Aortic Dissection
Endovascular management of Aortic DissectionEndovascular management of Aortic Dissection
Endovascular management of Aortic DissectionSatyam Rajvanshi
 
Aortic disasters ahmed
Aortic disasters ahmedAortic disasters ahmed
Aortic disasters ahmedEM OMSB
 
Pulmonary Embolism, Case Report of b/l PE & Literature Review
Pulmonary Embolism, Case Report of b/l PE & Literature ReviewPulmonary Embolism, Case Report of b/l PE & Literature Review
Pulmonary Embolism, Case Report of b/l PE & Literature ReviewBadarJamal4
 
Clinical conundrum in Perioperative Evaluation
Clinical conundrum in Perioperative EvaluationClinical conundrum in Perioperative Evaluation
Clinical conundrum in Perioperative EvaluationMedPeds Hospitalist
 
Matters heart armc 7 11-2011
Matters heart armc 7 11-2011Matters heart armc 7 11-2011
Matters heart armc 7 11-2011Troy Pennington
 

Similar a Aortic Dissection (20)

Aortic dissection
Aortic dissectionAortic dissection
Aortic dissection
 
Pulmonary Embolism
Pulmonary EmbolismPulmonary Embolism
Pulmonary Embolism
 
Stop That Clot
Stop That ClotStop That Clot
Stop That Clot
 
Bui duy icu
Bui duy icuBui duy icu
Bui duy icu
 
Pad slide
Pad slidePad slide
Pad slide
 
Left-Right Shunt Natural history & Principles of Management
Left-Right ShuntNatural history & Principles of ManagementLeft-Right ShuntNatural history & Principles of Management
Left-Right Shunt Natural history & Principles of Management
 
Clinical Cases In Cardiology
Clinical Cases In CardiologyClinical Cases In Cardiology
Clinical Cases In Cardiology
 
Clinical Cardiology
Clinical CardiologyClinical Cardiology
Clinical Cardiology
 
Cardiac Us
Cardiac UsCardiac Us
Cardiac Us
 
Superior vena cava syndrome
Superior vena cava syndromeSuperior vena cava syndrome
Superior vena cava syndrome
 
Drs. Escobar, Pikus, and Blackwell’s CMC X-Ray Mastery Project: January Cases
Drs. Escobar, Pikus, and Blackwell’s CMC X-Ray Mastery Project: January CasesDrs. Escobar, Pikus, and Blackwell’s CMC X-Ray Mastery Project: January Cases
Drs. Escobar, Pikus, and Blackwell’s CMC X-Ray Mastery Project: January Cases
 
Acute Pulmonary Embolism Overview lecture.ppt
Acute Pulmonary Embolism Overview lecture.pptAcute Pulmonary Embolism Overview lecture.ppt
Acute Pulmonary Embolism Overview lecture.ppt
 
Fellows Conference
Fellows ConferenceFellows Conference
Fellows Conference
 
Constriction
ConstrictionConstriction
Constriction
 
Gerber Pulmonary Embolism
Gerber Pulmonary EmbolismGerber Pulmonary Embolism
Gerber Pulmonary Embolism
 
Endovascular management of Aortic Dissection
Endovascular management of Aortic DissectionEndovascular management of Aortic Dissection
Endovascular management of Aortic Dissection
 
Aortic disasters ahmed
Aortic disasters ahmedAortic disasters ahmed
Aortic disasters ahmed
 
Pulmonary Embolism, Case Report of b/l PE & Literature Review
Pulmonary Embolism, Case Report of b/l PE & Literature ReviewPulmonary Embolism, Case Report of b/l PE & Literature Review
Pulmonary Embolism, Case Report of b/l PE & Literature Review
 
Clinical conundrum in Perioperative Evaluation
Clinical conundrum in Perioperative EvaluationClinical conundrum in Perioperative Evaluation
Clinical conundrum in Perioperative Evaluation
 
Matters heart armc 7 11-2011
Matters heart armc 7 11-2011Matters heart armc 7 11-2011
Matters heart armc 7 11-2011
 

Último

College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...
College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...
College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...perfect solution
 
Bangalore Call Girl Whatsapp Number 100% Complete Your Sexual Needs
Bangalore Call Girl Whatsapp Number 100% Complete Your Sexual NeedsBangalore Call Girl Whatsapp Number 100% Complete Your Sexual Needs
Bangalore Call Girl Whatsapp Number 100% Complete Your Sexual NeedsGfnyt
 
Call Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...
Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...
Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...Call Girls in Nagpur High Profile
 
Lucknow Call girls - 8800925952 - 24x7 service with hotel room
Lucknow Call girls - 8800925952 - 24x7 service with hotel roomLucknow Call girls - 8800925952 - 24x7 service with hotel room
Lucknow Call girls - 8800925952 - 24x7 service with hotel roomdiscovermytutordmt
 
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escorts
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore EscortsCall Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escorts
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escortsvidya singh
 
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...Garima Khatri
 
Top Rated Bangalore Call Girls Richmond Circle ⟟ 8250192130 ⟟ Call Me For Gen...
Top Rated Bangalore Call Girls Richmond Circle ⟟ 8250192130 ⟟ Call Me For Gen...Top Rated Bangalore Call Girls Richmond Circle ⟟ 8250192130 ⟟ Call Me For Gen...
Top Rated Bangalore Call Girls Richmond Circle ⟟ 8250192130 ⟟ Call Me For Gen...narwatsonia7
 
Russian Escorts Girls Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls Delhi
Russian Escorts Girls  Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls DelhiRussian Escorts Girls  Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls Delhi
Russian Escorts Girls Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls DelhiAlinaDevecerski
 
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...chandars293
 
Call Girls Faridabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Faridabad Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Faridabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Faridabad Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Call Girls Jabalpur Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Jabalpur Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Jabalpur Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Jabalpur Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
Call Girls Gwalior Just Call 8617370543 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 8617370543 Top Class Call Girl Service AvailableCall Girls Gwalior Just Call 8617370543 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 8617370543 Top Class Call Girl Service AvailableDipal Arora
 
VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋
VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋
VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋TANUJA PANDEY
 
Call Girls Service Jaipur Grishma WhatsApp ❤8445551418 VIP Call Girls Jaipur
Call Girls Service Jaipur Grishma WhatsApp ❤8445551418 VIP Call Girls JaipurCall Girls Service Jaipur Grishma WhatsApp ❤8445551418 VIP Call Girls Jaipur
Call Girls Service Jaipur Grishma WhatsApp ❤8445551418 VIP Call Girls Jaipurparulsinha
 
Bangalore Call Girls Nelamangala Number 7001035870 Meetin With Bangalore Esc...
Bangalore Call Girls Nelamangala Number 7001035870  Meetin With Bangalore Esc...Bangalore Call Girls Nelamangala Number 7001035870  Meetin With Bangalore Esc...
Bangalore Call Girls Nelamangala Number 7001035870 Meetin With Bangalore Esc...narwatsonia7
 
Call Girls Bareilly Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bareilly Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Bareilly Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bareilly Just Call 9907093804 Top Class Call Girl Service AvailableDipal Arora
 
VIP Call Girls Indore Kirti 💚😋 9256729539 🚀 Indore Escorts
VIP Call Girls Indore Kirti 💚😋  9256729539 🚀 Indore EscortsVIP Call Girls Indore Kirti 💚😋  9256729539 🚀 Indore Escorts
VIP Call Girls Indore Kirti 💚😋 9256729539 🚀 Indore Escortsaditipandeya
 
(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...
(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...
(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...Taniya Sharma
 
Call Girls Service Surat Samaira ❤️🍑 8250192130 👄 Independent Escort Service ...
Call Girls Service Surat Samaira ❤️🍑 8250192130 👄 Independent Escort Service ...Call Girls Service Surat Samaira ❤️🍑 8250192130 👄 Independent Escort Service ...
Call Girls Service Surat Samaira ❤️🍑 8250192130 👄 Independent Escort Service ...CALL GIRLS
 

Último (20)

College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...
College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...
College Call Girls in Haridwar 9667172968 Short 4000 Night 10000 Best call gi...
 
Bangalore Call Girl Whatsapp Number 100% Complete Your Sexual Needs
Bangalore Call Girl Whatsapp Number 100% Complete Your Sexual NeedsBangalore Call Girl Whatsapp Number 100% Complete Your Sexual Needs
Bangalore Call Girl Whatsapp Number 100% Complete Your Sexual Needs
 
Call Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Aurangabad Just Call 9907093804 Top Class Call Girl Service Available
 
Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...
Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...
Book Paid Powai Call Girls Mumbai 𖠋 9930245274 𖠋Low Budget Full Independent H...
 
Lucknow Call girls - 8800925952 - 24x7 service with hotel room
Lucknow Call girls - 8800925952 - 24x7 service with hotel roomLucknow Call girls - 8800925952 - 24x7 service with hotel room
Lucknow Call girls - 8800925952 - 24x7 service with hotel room
 
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escorts
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore EscortsCall Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escorts
Call Girls Horamavu WhatsApp Number 7001035870 Meeting With Bangalore Escorts
 
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
VIP Mumbai Call Girls Hiranandani Gardens Just Call 9920874524 with A/C Room ...
 
Top Rated Bangalore Call Girls Richmond Circle ⟟ 8250192130 ⟟ Call Me For Gen...
Top Rated Bangalore Call Girls Richmond Circle ⟟ 8250192130 ⟟ Call Me For Gen...Top Rated Bangalore Call Girls Richmond Circle ⟟ 8250192130 ⟟ Call Me For Gen...
Top Rated Bangalore Call Girls Richmond Circle ⟟ 8250192130 ⟟ Call Me For Gen...
 
Russian Escorts Girls Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls Delhi
Russian Escorts Girls  Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls DelhiRussian Escorts Girls  Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls Delhi
Russian Escorts Girls Nehru Place ZINATHI 🔝9711199012 ☪ 24/7 Call Girls Delhi
 
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
The Most Attractive Hyderabad Call Girls Kothapet 𖠋 6297143586 𖠋 Will You Mis...
 
Call Girls Faridabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Faridabad Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Faridabad Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Faridabad Just Call 9907093804 Top Class Call Girl Service Available
 
Call Girls Jabalpur Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Jabalpur Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Jabalpur Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Jabalpur Just Call 9907093804 Top Class Call Girl Service Available
 
Call Girls Gwalior Just Call 8617370543 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 8617370543 Top Class Call Girl Service AvailableCall Girls Gwalior Just Call 8617370543 Top Class Call Girl Service Available
Call Girls Gwalior Just Call 8617370543 Top Class Call Girl Service Available
 
VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋
VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋
VIP Hyderabad Call Girls Bahadurpally 7877925207 ₹5000 To 25K With AC Room 💚😋
 
Call Girls Service Jaipur Grishma WhatsApp ❤8445551418 VIP Call Girls Jaipur
Call Girls Service Jaipur Grishma WhatsApp ❤8445551418 VIP Call Girls JaipurCall Girls Service Jaipur Grishma WhatsApp ❤8445551418 VIP Call Girls Jaipur
Call Girls Service Jaipur Grishma WhatsApp ❤8445551418 VIP Call Girls Jaipur
 
Bangalore Call Girls Nelamangala Number 7001035870 Meetin With Bangalore Esc...
Bangalore Call Girls Nelamangala Number 7001035870  Meetin With Bangalore Esc...Bangalore Call Girls Nelamangala Number 7001035870  Meetin With Bangalore Esc...
Bangalore Call Girls Nelamangala Number 7001035870 Meetin With Bangalore Esc...
 
Call Girls Bareilly Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bareilly Just Call 9907093804 Top Class Call Girl Service AvailableCall Girls Bareilly Just Call 9907093804 Top Class Call Girl Service Available
Call Girls Bareilly Just Call 9907093804 Top Class Call Girl Service Available
 
VIP Call Girls Indore Kirti 💚😋 9256729539 🚀 Indore Escorts
VIP Call Girls Indore Kirti 💚😋  9256729539 🚀 Indore EscortsVIP Call Girls Indore Kirti 💚😋  9256729539 🚀 Indore Escorts
VIP Call Girls Indore Kirti 💚😋 9256729539 🚀 Indore Escorts
 
(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...
(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...
(👑VVIP ISHAAN ) Russian Call Girls Service Navi Mumbai🖕9920874524🖕Independent...
 
Call Girls Service Surat Samaira ❤️🍑 8250192130 👄 Independent Escort Service ...
Call Girls Service Surat Samaira ❤️🍑 8250192130 👄 Independent Escort Service ...Call Girls Service Surat Samaira ❤️🍑 8250192130 👄 Independent Escort Service ...
Call Girls Service Surat Samaira ❤️🍑 8250192130 👄 Independent Escort Service ...
 

Aortic Dissection