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Aortic Dissection & Aneurysm

Aortic Dissection & Aneurysm. Aortic Dissection Epidemiology. 2-3 x more common than aortic aneurysm rupture Male to Female (3:1) Mean age is 63 Incidence 3.5 per 100,000 Risk Factors: Systemic HTN (present in 70-90%)

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Aortic Dissection & Aneurysm

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  1. Aortic Dissection & Aneurysm

  2. Aortic Dissection Epidemiology • 2-3 x more common than aortic aneurysm rupture • Male to Female (3:1) • Mean age is 63 • Incidence 3.5 per 100,000 • Risk Factors: • Systemic HTN (present in 70-90%) • Connective Tissue disorders (Ehlers-Danlos; Marfan’s; Lupus; Giant Cell Arteritis; Cystic Medial Necrosis) • Pregnancy (3rd Trimester) • Congenital Heart Disease (bicuspid aortic valve; coarctation) • Turner’s • Trauma • Aortic Valve Stenosis • ID: Syphilis, endocarditis • Drug: Tobacco; Cocaine; Methamphetamines

  3. Pathophysiology • Intimal tear that allows blood to leak through the media and adventitia • Propagation depends on BP and the pulse wave (rate of change in pressure/time) • High BP and rapid ventricular contractions = further migration

  4. Natural History • If untreated • 33% die within 24 hours • 50% die within 48 hours • >75% die within 2 weeks • 90% die within 3 months

  5. Classification • Debakey • Type I ascending aorta & part of distal aorta • Type II ascending aorta only • Type III descending aorta only • IIIa extension limited to diaphragm • IIIb continuation beyond diaphragm • Stanford • Type A: ascending aorta (debakey I & II) • Type B: descending aorta (debakey III)

  6. Clinical Presentation • Pain: most common symptom; usually aburpt, tearing/ripping, migrating, and maximal at onset • Pain & neurologic symptoms think dissection • Syncope (9%); decreased LOC (20%); Paraplegia (5%); Monoplegia (6%); Vision changes (2%) • Physical Exam: • 49% have absent or decreased pulses distal to dissection • Difference in BP (20mmHg between upper extremities or 30mmHg between upper and lower extremities) • 20% have new murmur (aortic insufficiency) • Signs of cardiac tamponade (Becks)

  7. Diagnosis • Chest Xray – normal in 11% • Mediastinal widening (>8cm) (63%) • Change in the aortic formation • Loss of A/P window • Eggshell sign: Extension of aortic shadow >3mm beyond calcified aortic wall • Blurred aortic knob • Lt. Pleural effusion (19%) • Double Density sign of the aorta • ECG • 20% showed evidence of ischemia • Varying AV blocks • Signs of LVH

  8. myweb.lsbu.ac.uk/dirt/museum/679-659.html www.mudphudder.com/2008/11/aortic-dissection/ Diagnosis

  9. Diagnosis • Transesophageal Echocardiography • Sensitivity & specificity nearly 100% • Can confirm diagnosis, define intimal tear site, aortic regurgitation, pericardial effusion, does not require IV contrast, performed in ED • Disadvantage: not readily available in all EDs • CT • Almost 100% sensitivity and specificity • Can confirm the diagnosis, define the extent of dissection, and distinguish between Type A and Type B • Disadvantage: patient leaves ED, requires IV contrast

  10. Treatment • All patients require 10-15 units of blood on stand-by and immediate thoracic surgery consultation • All initial treatment is medical • Decrease pulse rate and BP • Goal is systolic 100-120 mmHg & HR 50-60 • Esmolol gtts & Nitroprusside combination • Labetolol single agent • IV narcotics • Ascending require medical stabilization & then surgery • Descending require medical stabilization & monitoring

  11. Aortic Aneurysm Epidemiology • Defined as dilation of the abdominal aorta > 3cm and consists of all layer of the aorta • 15,000 deaths annually in the US • 97% occur between the renal arteries and inferior mesenteric artery • Clinically important aneurysms over 4 cm in diameter are present in about 1 percent of men between the ages of 55 and 64; the prevalence increases by 2 to 4 percent per decade thereafter • Smoking is the greatest risk factor for aneuryms (OR 5.07) & also aneurysm growth rate • 5 x more likely in men • CAD & PVD are significant risk factors • HTN is a small risk factor (OR 1.15) • 1st degree blood relative increases odds by 4.3-fold

  12. Pathogenesis • Combination of genetic, structural & metabolic factors • Genetic predisposition • Increased levels of elastase/collagnase • Loss of blood vessel elastin • Copper deficiency • Infection (mycotic aneurysms) • Inflammatory disorders • Local Mechanical forces

  13. Clinical Presentation • Non-ruptured are usually incidental findings • Two most common findings of recent expansion: abdominal/ back pain & tender to palpation (usually epigastric region) • Pulsatile & tender mass is highly suggestive of recent rupture (found in 77% of ruptures) • Bruits over aorta or femoral arteries • Unequal distal pulses • Presentation mimics numerous common ED diagnoses

  14. Diagnosis • sensitivity of physical examination for the detection of an abdominal aortic aneurysm ranges from 22 to 96 percent • Most non-ruptured aneurysms are incidental findings • Plan abdominal films: 75% have suspicious findings • Aneurysmal calcification, loss of renal shadow, soft tissue mass • Real-time ultrasonography is the preferred modality for screening and for assessing and following abdominal aortic aneurysms since the sensitivity approaches 100 percent, not good at detecting ruptures • CT with contrast: sensitivity around 100% and can detect rupture plus alternative diagnoses

  15. Fig. 58-2.

  16. Treatment • Mortality rate on elective repair 5% • Mortality rate on emergency repair of ruptured aneurysms 50% • Risk of Rupture (5 cm is the usual surgical cutoff) • Zero in aneurysms less than 4.0 cm in diameter • 0.5 to 5 percent for those 4.0 to 4.9 cm in diameter • 3 to 15 percent for those 5.0 to 5.9 cm in diameter • 10 to 20 percent for those 6.0 to 6.9 cm in diameter • 20 to 40 percent for those 7.0 to 7.9 cm in diameter • 30 to 50 percent for those ≥8.0 cm in diameter

  17. Treatment • Indications for surgical intervention • Patients with symptomatic aneurysms should undergo repair, regardless of aneurysm diameter. • Early repair may be beneficial in patients whose aneurysm increases ≥0.5 cm in diameter in six months. • Repair of suprarenal and/or thoracoabdominal aneurysms involves more extensive surgery and greater operative risk. Repair of such aneurysms may be beneficial at diameters >5.5 to 6.0 cm in diameter. • ED treatment • If suspected rupture • Two large bore Ivs • Type & Cross 10 units • Order ECG • Obtain immediate vascular surgery consultation

  18. Questions

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