1 / 19

Dissecting Aortic Aneurysm

Dissecting Aortic Aneurysm. Case I. 23 y American male visiting his girlfriend Seen in ER because of chest pain few hours duration Sudden central , severe radiating to back No realtion to exertion Associated mild SOB. History. No cough ,hemoptysis, orthopnea , PND No fever , leg pain

mirra
Download Presentation

Dissecting Aortic Aneurysm

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Dissecting Aortic Aneurysm

  2. Case I • 23 y American male visiting his girlfriend • Seen in ER because of chest pain few hours duration • Sudden central , severe radiating to back • No realtion to exertion • Associated mild SOB

  3. History • No cough ,hemoptysis, orthopnea , PND • No fever , leg pain • No similar episode in the past • SR : 1-2 minutes loss of vision Rt eye

  4. Examination • BP 245 / 140 HR 95 SR afebrile RR 18 Sat 95% RA • Chest : clear , good BS • CVS : S1+ S2 +? S4 • Abd & LL : NAD • CNS N

  5. Investigation • CBC , PTT , INR N • BUN , Creat & Lytes N • EKG borderline LVH • CXR

  6. Hospital Course • Initially patient was discharged from ER • Called back because of radiologist report • When reevaluated  chest pain minimal Still BP 240/140 • CT chest oredered

  7. Hospital Course • Patient was admitted under CVT • Labetalol for HTN • Repair of Type A Aortic dissection • Uneventful OR • Recovering inhospital flying back to Hawaii

  8. Pathophysiology • Tear in aortic intima • Degeneration of aortic media {cystic medial necrosis} • Blood pass through intimal tear separation of intima from surrounding layers false lumen creation

  9. Incidence • 464 pt 12 centers 1996  1998 International registry of aortic dissection IRAD • Incidence 2-3 /100,000 • Male with age 68-80 • HTN major risk factor Jama Feb 2000

  10. Predisposition • Congenital : preexisting aneurysm , coarctation & Bicuspid aortic valve • Collagen disorders Marfan syndrome & Ehlers- Danols Syndrome • Vasculitis : Takayasu & Giant cell arteritis • Cocaine • Trauma : Cardiac cath , blunt chest injury

  11. Classification • Daily or Stanford system Type A involving the ascending aorta Type B  all other dissections • DeBakey system Type I dissection  ascending & descending Type II  confined to the ascending aorta Type III  confined to the descending aorta

  12. Presentation • Pain : chest , back or abdomen • Hypertension • Organ related : CVS  AR , tamponade , MI CNS  neurological deficits Gut , renal or limb ischemia

  13. Diagnosis • 250 pt  prediction model • Multivariate analysis 3 predictors Pain immediate tearing Pulse or BP differentials Mediastinal or aortic widening All 3 –ve probability of having dissection 7% All 3 +ve  84% Arch Intern Med 2000 Oct

  14. Diagnosis • CXR 464 pt IRAD Mediastinal widening 63% Ttype A 56% Type B CXR N  11% Type A 16% Type B Jama Feb 2000

  15. Diagnosis • Smooth muscle myosin heavy chain 30 minute serum assay 95 aortic dissection , 48 MI , 131 control Aortic dissection Vs control  sensitivity 91% & specificity 98% Aortic dissection Vs MI  specificity 85% Ann Intern Med 2000 Oct

  16. Diagnosis • MRI Vs TEE 35 pt with clinically suspected dissection TTE Vs TEE Vs MRI Gold standard autopsy , Angiography intraoperative findings TTE less reliable for type B TEE & MRI sensitivity > 93% Int Jr Card Imaging Mar 1994

  17. Management • Type A surgical Rx Type B medical Rx surgical if dissection continued or impair organ perfusion • Pain & BP control decrease DP/DT B blocker

  18. Management • 35 pt type A with tamponade shock 17 pt standard Rx (IVF +pressors +Sx) Vs 18 standard Rx +ACTH 10 mg upon ER arrival (20-40 from emergency call) Higher MAP in ACTH 30 day survival 87% ACTH Vs 48% P<0.02 Lancet 2001 Mar

More Related