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AORTIC DISSECTION

AORTIC DISSECTION. Prof. Dr. Suat Nail ÖMEROĞLU. The most catastrophic disease of the aorta 5-10 patients/ 1 milion per year Incidence is 0.2-0.8 % in autopsy series M/F: 2.5-3 Most frequently seen 5.-6. decade of age. Mortality. First 24-48 hours 20-50% Increases 1% every passing hour

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AORTIC DISSECTION

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  1. AORTIC DISSECTION Prof. Dr. Suat Nail ÖMEROĞLU

  2. The most catastrophic disease of the aorta • 5-10 patients/ 1 milion per year • Incidence is 0.2-0.8 % in autopsy series • M/F: 2.5-3 • Most frequently seen 5.-6. decade of age.

  3. Mortality • First 24-48 hours 20-50% • Increases 1% every passing hour • First 2 weeks 75% • First 3 months 90%

  4. Definition • Aortic dissection is an aortic wall disease. • Intimal layer separates from the medial layer and this separation continues in general to the distal of the Aorta.

  5. Patogenesis • 1. Primary intimal tear theory • Proxymal dissections 95-100% • Distal dissections 90-95% • 2. Occurence of intramural hematoma theory • Vasovasorum rupture • Rupture of penetrating atherosclerotic ulcers

  6. Intimal tear • 60-70% Ascending aorta • 10-20% Arcus aorta • 25% Descending aorta

  7. Intimal tear • Intimal layer separates and it results in 2 lumens: True lumen and False lumen.

  8. Ethiology • Hypertension • Medial degenerative disease • Genetic diseases • Congenital heart and vascular diseases • Atherosclerosis • Inflammatory aortic diseases • Travmatic injuries • Iatrogenic injuries • Drug abuse • Pregnancy

  9. Classifications • Clinical classification • Topografical classification • De Bakey • Stanford • Svensson

  10. Clinical Classification • Acute: 0-14 days • Subacute: 14 days- 2 months • Chronic: After 2 months

  11. Topografical Classification • Stanford Classification

  12. Topografical Classification • De Bakey

  13. Rupture • Rupture is the most frequent cause of death and usually occurs at the site of intimal tear. • Type A dissection Intrapericardial • Dissection of arcus aorta Intramediastinal • Type B dissection Left pleura

  14. Organ malperfusion • Serebral ischemia • Spinal ischemia • Renal ischemia • Visceral ischemia • Lower extremity ischemia • Cardiac ischemia

  15. Clinical Findings • Pain • Serebrovascular accidents (Syncope, stroke) • CHF • Acute aortic valve insufficiency • Hypovolemia • Cardiac tamponade • Malperfusion signs

  16. Pain in Acute Type A Dissection

  17. Pain in Acute Type B Dissection

  18. Clinical Findings • Typical patient: 60 year old male patient with hypertension, sudden severe pain

  19. Differential Diagnosis • Coronary ischemia • MI • AI • Aortic aneurysms • Mediastinal tumors • Perikarditis • Pulmonary embolus • Stroke • Visceral or lower extremity ischemia

  20. Physical Examination • Pale • Anxiety • Shock • Periferik perfüzyon bozukluğu • Hypertension 80 % • Hypotention 20 % • Neurologic dysorders 20 % • BP Difference

  21. Diagnosis • ECG • Low voltage • ST-T wave changes • Blood tests

  22. Diagnosis • Chest x-ray • CT • MRI • TTE • TEE • Aortography

  23. To whom shall we perform angiography? • No need for patients with Acute type A dissection • It can be performed to patients with Acute type B dissection, because CAD is frequent • It must be performed to patients with chronic dissection

  24. Treatment • Surgical treatment • Medical treatment • Endovascular treatment • Hybrid treatment

  25. Treatment-Aim • Stabilize the dissection • Avoid the rupture • Avoid organ ischemia • Systolic BP 100-110 mmHg • Mean BP 60-75 mmHg • Urine output and neurologic status should be monitorized

  26. Treatment-Emergency Unit • Fluid replacement • ECG • Blood tests • Chest x-ray • O2 • Analgesia (Morphine) • Invasive arterial monitoring • B-blocker

  27. Surgical Treatment • Acute Type A Emergent surgical treatment • Acute Type B Endovascular or medical treatment (surgery for rupture, intractable sympoms or organ ischemia) • Chronic Type A Elective surgical treatment • Chronic Type B Surgery for aneurysmatic aorta, organ ischemia.

  28. Case Report • 41 year-old female with 8 children • ECG: Paroxysmal AF • Entubated • Diagnosis: Acute Stanford type A AorticDissection • Hypertension

  29. Surgical Technique • Femoral or axillary arterial cannulation • Venous cannulation • Venting from RUPV

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