Aortic Dissection and Aneurysms

Presented by Dr. Daniel Kranitz

Prepared by Mary Edwards

September 27, 2005

Tintanalli Chapter 58, Pages 404-409

Abdominal Aortic Aneurysms (AAA)

Risk factors Elderly (>60) Familial trend (18% with 1° relative) Connective Tissue D/O (Marfan’s) Other aneurysms Atherosclerosis (HTN, Lipids, smoking, DM)

AAA

Pathogenesis Intima infiltrated by atherosclerosis and thinned

media. Possible intraluminal thrombus and adventitia

infiltrated by inflammatory cells

AAA

Average rate of growth 0.25-0.5 cm per year.

Larger aneurysms extend more rapidly than smaller ones. (LaPlace law)

AAA

Clinical Features Syncope (10-12%) Back and/or Abdominal Pain –severe and abrupt,

ripping or tearing sensation (50%) Shock –intraperitoneal rupture, massive blood

loss Sudden death

AAA

Physical Exam Pain on palpation or not Retroperitoneal hematoma

Cullen sign (periumbilical ecchymosis)Grey-Turner sign (flank ecchymosis)Scrotal hematoma or inguinal mass (blood dissecting

to these areas) Iliopsoas signFemoral nerve neuropathy

AAA

Found aneurysms refer to follow up >5cm diameter –increased chance of rupture <5cm –decreased chance of rupture Symptomatic aneurysms of any size =

Emergency!!

AAA

Diagnosis Includes differential diagnoses of syncope, abd

pain, CP, back pain and shock. If with combo of two or more think aortic dz.

AAA

Radiologic Evaluation Should not delay operative treatment!!

Plain abd film (calcified bulging) US (bedside, up to 100% sensitive, not reliable

to detect rupture) CT (with IV contrast only if stable) MRI

AAA

ED Treatment Urgent surgical consult Make diagnosis & assist rapid transfer to OR 2 large bore IVs Cardiac Monitor O2 ? Blood transfusion IV fluid resuscitation –controversial amount b/c too much can

be harmful RADIOGRAPHIC STUDIES ONLY IF UNLIKELY

TO HAVE RUPTURED AAA!!!

AAA

½ of patients with ruptured AAA who reach the OR die!

A Bit About Thoracic Aortic Aneursym

Presenting symptoms include esophageal, tracheal, bronchial, or even neurologic disorders.

If it erodes to adjacent structures it is immediately fatal!!

Aortic Dissection

Pathogenesis Prominent cause of sudden death Presents with severe abd., chest, and back pain Violation of intima that allows blood to enter

media and dissect b/w intimal and adventitial layers

Common site is ascending aorta at ligamentum arteriosum

Aortic Dissection

Common presenting groups >50 yoa with HTN 2/3 male Marfan’s syndrome Congenital heart disease Pregnancy

Aortic Dissection

Stanford Classification Type A -involves ascending aorta Type B –involves descending aorta

DeBakey Classification Type I –ascending, arch & descending aorta Type II –ascending only Type III –descending only

Aortic Dissection

Clinical Features >85% abrupt, severe pain in chest or b/w scapula 50% ripping or tearing Pain in anterior chest –ascending aorta (70%) Back pain (less common) –descending aorta

(63%) If dissection into carotid classic neuro symptoms

Aortic Dissection

Clinical Features 40% with neurologic sequelae (ex. paraplegia) Nausea, vomiting, diaphoresis Most have sense of impending doom!

Aortic Dissection

Physical Exam Usually normal heart and lung exam May have aortic insufficiency <20% with decreased radial, femoral or carotid

pulse HTN Tachycardia Hypotension

Aortic Dissection

Physical Exam Pericardial tamponade (muffled heart tones,

JVD, pulsus paradoxus) Hoarseness (compression of recurrent laryngeal

nerve) Horner’s Syndrome (compression of superior

cervical sympathetic ganglion)

Aortic Dissection

Diagnosis Ischemic end-organ manifestation such as MI,

pericardial dz, pulmonary d/o, stroke, SCI, musculoskeletal dz of extremities, intraabdominal ischemia.

Can change location with time as dissects.

Aortic Dissection

Thoracic Dissection 90% have abnormal CXR

Widened mediastinumAbnormal aortic contourPleural effusionDeviation of trachea, mainstem bronchi, or esophagus Intimal calcium visable & distant from edge (calcium

sign)

Aortic Dissection

Diagnosis CT

83-100% sensitive 87-100% specificUse spiral CT with IV contrastWill not give anatomic details of arterial branches or

aortic valve competence.Modality of choice in unstable patient

Aortic Dissection

Diagnosis Angiography

“Gold standard” Shows all anatomy and involvement 94% specific 88% sensitive

TEE 97-100% sensitive 97-99% specific Esophageal dz contraindication

Aortic Dissection

In contrast to ruptured AAA, SUSPECTED DISSECTIONS MUST BE CONFIRMED RADIOLOGICALLY PRIOR TO SENDING TO OR!!!

Aortic Dissection

ED Treatment Treat hypertension

-blocker Esmolol 500g/kg IV bolus over 1 minute then 50-150 g/kg

minute Metoprolol 5mg q2min x3 IV then 2-5mg/hr Propranolol 20mg IV then 40mg, 8-mg q10min to 300mg

total

Calcium channel blocker if -blocker contraindicated

Aortic Dissection

ED Treatment Vasodilator

Nitroprusside 0.3 g/kg/min IV Surgery

OR for ascending aortic dissectionDescending aortic dissection worse surgical risks –

controversial for repair

Any Questions????

Questions

1. A patient with a suspected aortic dissection should be immediately tranferred to OR without radiographic studies.

A. True B. False

2. Females are more likely than males to develop aortic dissection. A. True B. False

3. Dissection of the ascending aorta only is DeBakey classification A. Type I B. Type II C. Type III D. Type A E. Type B

4. Patients with a ruptured AAA can present with all of the following symptoms except A. Shock B. Syncope C. Sudden death D. Nausea and vomiting E. Headache

5. Which of the following radiologic modalities is considered the “gold standard” for diagnosing an aortic dissection? A. CT B. MRI C. TEE D. Angiography E. CXR

Answers

1. B 2. B 3. B 4. E 5. D