A N D R E W D . P E R R O N M D , F A C E PP R O F E S S O R A N D R E S I D E N C Y P R O G R A M D I R E C T O R

D E P T O F E M E R G E N C Y M E D I C I N EM A I N E M E D I C A L C E N T E R

P O R T L A N D , M E

Aortic Catastrophes: Big Red Causing Big Problems!

Disclosures

None No $$, no devices,

no patents No LLCs No family “in the

business” None !

Where are we going?

Going to Cover Spontaneous dissection AAA Traumatic dissection

Caveat: There is NOT a lot NEW in the world ofaortic emergencies…but sometimes it is nice togo over this stuff to be sure we are all on the samepage.

AorticDissection

“A man was seized with pain of the right arm and soon after the left. He was ordered to think seriously and piously of his departure from this mortal life, which was very near at hand and inevitable.”J.B. Morgagni, 1761.

“There is no diagnosis more conducive to clinical humility than dissection of the aorta.”Sir William Osler, 1900.

ED Management

Job #1 Job #2

Find The Disease

HaltProgression

Correct definitive care

Job #3

Here’s The Problem…

We Are Not Very Good At Making The Diagnosis

Giving The Wrong Therapy Hurts Patients

We Can’t CT Every Patient

With Chest Pain

Initial diagnosis correct 15-50%Diagnosis >24 hours in 40%

Klompas M. JAMA 2002.

Type A: involves the ascending aortaType B: does not involve the ascending aorta

“Acute” if ≤14 days of symptoms

Aortic Dissection: Risk Factors

Common: Hypertension Cocaine Trauma Pregnancy

Iatrogenic Heart surgery AVR Catheterization

Congenital Aortic coarctation Bicuspid valve Marfan Ehlers-Danlos Turner

H A G A N P G . J A M A 2 0 0 0 , 2 8 3 : 8 9 7 .

“The International Registry of Acute Aortic Dissection [IRAD]:

New Insight Into An Old Disease.”

N = 46412 Centers

IRAD: Demographics

Hagan PG. JAMA 2000.

Male 65.3%Mean age* 63 yearsType A dissection 62.3%Hypertension 72.1%

*Type B older, Marfans mean age 36 years

IRAD: Clinical Manifestations

Pain reported in 95.5%:

Hagan PG. JAMA 2000.

Chest pain 72.7%Anterior chest pain 60.9%Back pain 53.2%Abdominal pain 29.6%

IRAD: Clinical Manifestations

Quality of pain:

Hagan PG. JAMA 2000.

Abrupt onset 84.4%‘Worst pain ever’ 90.6%Sharp 64.4%Tearing or ripping 50.6%Radiating 28.3%Migratory 16.6%

IRAD: Syncope

Syncope in 9.4% More common with Type A dissection Higher risk of tamponade & stroke

Hagan PG. JAMA 2000.

Mortality

History of Syncope 34%Overall 28%

K L O M P A S M . J A M A 2 0 0 2 , 2 8 7 : 2 2 6 2 .

“Does This Patient Have AnAcute Thoracic Aortic

Dissection?”

N = 184821 Studies

How Good Is Our Assessment?

Review of the accuracy of the history, examination, and chest X-ray in the diagnosis of acute aortic dissection.

Klompas M. JAMA 2002.

Studies enrolling patients with the disease, or with a high likelihood of the disease

overestimate sensitivity.

Klompas M. JAMA 2002.

Most patients have severe pain of sudden onset

[+] LR 2.6

The absence of sudden onset pain lowers likelihood

[-] LR 0.3

The presence of “tearing” or “ripping” pain increases likelihood

[+] LR 1.2-10.8

The presence of pain that migratesincreases likelihood

[+] LR 1.1-7.6

Clinical History

Klompas M. JAMA 2002.

The presence of a pulse deficitincreases likelihood

[+] LR 5.7

The presence of focalneurological deficit increases likelihood

[+] LR 6.6-33.0

The presence or absence of a diastolic murmur is not useful

[+] LR 1.4[-] LR 0.9

Physical Examination

Klompas M. JAMA 2002.

The presence of normal aortic contour & normal mediastinum on CXR decreases likelihood

[-] LR 0.3

Caveat: There is no single radiographic finding that accurately predicts the presence of aortic

dissection.

Chest Radiography

IRAD: Chest X-Ray

Findings:

Hagan PG. JAMA 2000.

Wide mediastinum 66.1%Abnormal aortic contour 49.6%Pleural effusion 19.2%Wall Ca++ displacement 14.1%Normal CXR 12.4%

Egg Shell Sign

Aortic Dissection: D-Dimer?

About a dozen studies between 2004-2015 None large, randomized In an all-comer population where incidence = 5%

(pre-test prob), negative d-dimer would miss 1:1000 patients with the disease, but would generate 440 false positives for every 1,000 patients

ACEP clinical policy says “no”.

Good summary: Spiegel R “D-Dimer for aortic dissection: the evidence.Https://first10em.com/d-dimer-aortic-dissection. Accessed 1/25/20

Aortic Dissection: CT Angio

Study of choice in the stable patient

High sensitivity

Identifies alternative diagnoses

Aortic Dissection: Bedside US

Nice option when the patient can’t move

More sensitive for Type A dissections

ED Management

ED treatment goals: Control dp/dt Reduce blood pressure [<120systolic] Prevent reflex tachycardia Slow the propagation of the dissection

American College of CardiologyAmerican Heart Association

Dissection: Treatment

Type A = Open surgery preferred (at least for now) Even Europe (where they have 3-branch stents and a longer

track record ) do not treat Type A’s with EVAR

Type B = Endovascular (if possible) Lower morbidity Lower mortality

Abdominal Aortic Aneurysm

Essential Demographics

Most common aneurysm Genetics important Smoking cessation the most important

modifiable risk

Greenhalgh R. NEJM 2008.

1.7% of ♀ >65 y/o 5% of ♂ >65 y/o

Essential Demographics

Aortic Rupture: 15,000 death each year Risk significant when >5.5 cm Outcomes:

25% Make it to the hospital10% Make it to the OR5% Make in out of the OR

In Plain English

ElectiveRepair

Repair AfterRupture

95% Survival 5% Survival

Anatomic Considerations

95% are infrarenal

Left of midline

Retroperitoneal

Clinical Manifestations

Classic Triad Abdominal and/or flank pain Hypotension A palpable pulsatile massOnly present 30% of the time!

“Abdominal Palpation for the Diagnosis of Abdominal Aortic

Aneurysm.”

Evidence-Based Emergency MedicineCarpenter CR. Ann Emerg Med 2005, 45;556.

Abdominal Palpation

Methods:Studies after 1966 with >10 patients

We will only look at prospective studies…

Carpenter CR. Ann Emerg Med 2005.

“Positive” Aorta palpable “Negative” Aorta not palpable

Abdominal Palpation

Diameter Sensitivity [+] LR [-] LR3 to 3.9 cm 29% 1.2 0.724 to 4.9 cm 50% 15.6 0.51>5.0 cm 76%

N=2,955, 148 AAA’s detected

Carpenter CR. Ann Emerg Med 2005.

“Helpful if you feel it. Not helpful if you don’t.”

Diagnostic Essentials

Liberal use of ED ultrasound Sensitivity 100% Specificity 98%

Evolving paradigm for CT Early consultation essential Know when to transfer immediately

ED Management Essentials

Things To Do:

Start 2 large-bore IV’s ECG, T&C, CBC, CMP, PT/INR Resuscitate to “BP >85 and talking” Based on animal data… more aggressive resuscitation is

associated with more hemorrhage and increased mortality

Endovascular Repair

First performed in 1991 Less Morbidity / Mortality CT needed Per our high volume operators: “CT Scan so rapid now and

so helpful would be very rare to not be able to get a CT, if they can’t make it to CT they are probably destined to not make it. Usually can get CT quicker than OR can be ready to start.

In theory can size graft off angio in OR but this usually goes very poorly.

EVAR In Rupture

EVAR OpenMortality [all] 5% 28%Mortality [unstable] 14% 56%

Protocol-driven endovascular repair in 126 patients with aortic rupture.

Moore R. J Vasc Surg 2008.

Endovascular Repair

Technical implications: Length to aneurysm neck from renals Shape & angulation of aneurysm neck Diameter & contour of the iliac arteries

Stent eligibility ranges from 15%-50%

Aortic Trauma[TAD]

Chest Radiography In TAD

Wide mediastinum 221 85%Indistinct aortic knob 63 24%Left pleural effusion 49 19%Apical cap 49 19%Tracheal deviation 32 12%NGT deviation 29 11%Bronchus deviation 12 5%Normal chest X-ray 19 7%

Fabian T. J Trauma 1997.

N = 249

Normal BAI

Normal BAI

Helical CT In TAD

Author Total TAD Sensitivity NPV

FabianJ Trauma 98

494 71 100% 100%

MirvisJ Trauma 98

1,104 24 100% 100%

Collier BAJEM 02

232 11 100% 100%

DyerJ Trauma 02

1,338 30 100% 100%

1

43

2

TEE In TAD

Advantages Disadvantages

Portability [ED, OR, ICU] Operator-dependent

Speed of performance Airway protection

Easily repeatable Blind spot

Cardiac assessment Arch vessel problem

No contrast required

TEE In TAD

Meta- analysis [n=724]:

Sensitivity range 56%-99%*

Specificity range 89%-99%*

Combined area under ROC curve 95%

*Performance highest in studies with n ≥ 70

Cinella G. J Trauma 2004.

Life threatening hemorrhage?Operative CNS mass lesion?

StabilizeBP Control

Repair Aorta

Yes No

LaparotomyCraniotomy

Blood Pressure Control

Blood pressure and heart rate control now considered the “standard”…unless paired with brain injury or spinal cord injury.

“That is a tough one. We would aim for normal pressure…not too high not too low. Would depend a little on grade of aortic injury. Would have to individualize based on severity type of neurologic injury and severity of aortic injury”

Endovascular Repair

Prospective, 18-center study Not randomized [operator choice]

Outcome Measures: Mortality Complications Length of stay [LOS]

AAST. J Trauma 2008.

N = 196

125 [65%]Stent

68 [35%]Open

AAST. J Trauma 2008.

MortalityStent Graft Repair* 7.2%Open Repair 23.5%

*Fewer complications & ventilator days, shorter ICU LOS

Questions / Discussion?

perroa@mmc.org