Aortic dissection


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Surgical Strategy for type A dissection

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  • Results of treatment better in asymptomatic stage
  • Pseudoaneurysm:disruption of arterial wall&extravasation of blood contained by periarterial connective tissue
    Intramural hematoma:clinical picture of dissection with hematoma in arterial wall,without an intimal flow in false lumen
    Penetrating atherosclerotic ulcer:atherosclerotic lesion with ulceration that penetrates the internal elastic lamina.
    1.classic dissection
    3.intimal tear without IMH
    Normal aortic size
    Depends on
    Body size
    Location of measurement
    Method of measurement
    Diameter increases by 0.12-o.29mm/yr at each level
  • Measurements should be taken at reproducible anatomic landmarks,perpendicular to axis of flow
    CT&MRI-ext.diameter taken
    Echo-internal diameter
    For aortic root-the widest diameter at mid sinus level
    Abnormalities of aortic morphology reported separately
    Minimise cumulative radiation exposure
    classIIa-aortic diameter should be related to patient's age and body size
  • MRI
    No radiation
    Identification of anatomic variants of AoD
    branch vessel invt
    Prolonged duration
    Pt.inaccessible to care providers
    Gadolinium contrast not used in renal impairment
    Proximal AoD-
    TEE sensitivity 88-98%,specificity 90-95%
    TTE 77-80% and 93-96%
    Distal AoD-TEE better
    TEE blind spot-distal ascending aorta&prox.arch-interposition of trachea &lt.main bronchus
  • Aortic dissection

    1. 1. Surgical Management Aortic Aneurysm & Dissection Dicky Aligheri ,MD National Cardiovascular Centre Harapan Kita 2014
    2. 2. Introduction • Usually asymptomatic until complication- imaging required for detection and monitoring – Masking diagnostic (CAD, malperfusions) • Identification of genetic alterations – Potential for early detection – Targeted therapy
    3. 3. • Aneurysm:permanent localized dilatation of an artery with at least 50% increase in diameter compared with the expected normal diameter.Covered by all 3 layers • Aortic dissection:disruption of media layer of aorta with bleeding within and along the wall of aorta
    4. 4. Class I rec.for medical management • i.v beta blockade titrated to HR<60/min • CCB alternative if beta blocker contra. • After HR controlled,i.v vasodilators to reduce B.P to a level that maintains organ perfusion • Beta blocker used cautiously in setting of a/c AR • Vasodilator should not be given prior to rate control(classIII)
    5. 5. Recommendation for definitive management(classI) • Ascending aorta involved-emergent surgical repair • Desc. Aorta involved-managed medically unless lifethreatening complications – Malperfusion syndrome – Progression of dissection – Enlarging aneurysm – Inability to control BP or symptoms
    6. 6. Recommendations for surgical management(classI) • Ascending ao.dissection-aneurysmal aorta and proximal extent of dissection should be resected • Prtially dissected root-repaired with valve resuspension • Extensive dissection of aortic root-aortic root replacement with a composite graft or with a valve sparing root replacement • DeBakey type II-entire dissected aorta should be replaced
    7. 7. • Use of beta blockers slowed aortic root dilatation(Shores J et al;nejm 1994,Ladouceur M et al;Am J Cardiol 2007) • Beta blockers reduced aortic dilatation in c/c type B dissection(Genoni M et al;2001) • ACEI perindopril-reduced aortic root dilatation in marfans(Ahimastos AA et al;JAMA2007) • ARB-reduced aortic root dilatation in Marfans syn(Brooks BS et al;nejm2008) • Statin use a/w decreased long term mortality in abd aortic aneurysm(Diehm N et al;2008)
    8. 8. Thoracic aortic aneurysms • Rec.for medical Rx:classI – Antihypertensives to a goal<140/90(goal<130/80 for DM&CKD) – Beta blocker in Marfans syn.&aortic aneurysm – Smoking cessation • classIIa- – Reduce B.P to the lowest point pt can tolerate with beta blocker and ACEI or ARB – ARB (losartan) for pt with Marfans syn. – Treatment with statin to target LDL-C<70mg%
    9. 9. Surgical management-asymptomatic pt.(classI) • Ascending aortic aneurysm degenerative etiology-surgical repair if diameter>5.5cm • Genetic syn.-elective surgery at diameter 4.0 to 5.0 cm • Growth rate>0.5cm/yr • Patients undergoing AVR at a diameter>4.5cm
    10. 10. Rec.for surgery-classII a • Genetic syn.-ratio of aortic root area(cm²)devided by height (m)>10-surgery indicated • Loeys Diets syn,TGFBR1&2 mutation-diameter >4.2 by TEE,or >4.4 by CT or MRI
    11. 11. Recommendations for desc.thoracic aorta(classI) • Endovascular stent grafting- – Degenerative or traumatic aneurysm>5.5cm – Saccular aneurysm – Post op.pseudoaneurysm • Open repair – c/c dissection – a/w connective tissue d/s – Desc.thoracic aorta>5.5 cm
    12. 12. Organ protection • Class II a- – deep hypothermic circulatory arrest for brain protection – Optimisation of spinal cord perfusion pressure and moerate systemic hypothermia • Class II b-preop.hydration and intra op.mannitol for preservation of renal fn during open repairs of desc.aorta
    13. 13. Mortality risk • Composite valve graft,AVR with asc.aortic repair-1-5% • Valve sparing aortic root reconstruction-less than1.5% • BAV &asc.aorta repair-1.5% • a/c AoD-3.5-10% • Total arch replacement-2-6%mortality,2-7% risk of stroke
    14. 14. CT • Advantages – Availability – Entire aorta imaged – Short time – Branch vessel invt. • Ecg gating,MDCT
    15. 15. Acute aortic syndromes • Consists of 3 conditions-aortic dissection,IMH,PAU • 15% of AoD have an IMH without an intimal tear • Incidence 2-3.5/1,00,000 person years • Mean age of presentation 63yrs • Male predominance-65%
    16. 16. • Acute dissection-within 2 weeks of onset of pain • Subacute-b/w 2-6wks • Chronic->6 wks
    17. 17. • DeBakey classification: – Type I: Dissection originates in Asc.aorta and propagates to include at least the aortic arch – Type II: Dissection originates in and confined to the Asc.aorta – Type III: Dissection originates in the desc.aorta and propagates most often distally • Stanford classification system – Type A:dissections involving the asc.aorta regardless of the site of origin – Type B:dissections that do not involve the asc.aorta
    18. 18. Evaluation • High risk conditions-(class I) – Genetic syndromes like Marfan syn.,Ehlers-Danlos – Connective tissue diseases – F/h of aortic dissection – Known aortic valve disease – Recent aortic manipulation – Known aortic aneurysm
    19. 19. • High risk pain features(classI) – Chest,back or abdominal pain – Abrupt in onset – Severe intensity – Ripping,tearing,stabbing or sharp
    20. 20. • High risk exam features(classI) – Pulse deficit – Syst.BP limb diff.>20mmHg – Focal neurological deficit – Murmur of AR(new) – shock
    21. 21. Recommendations for screening tests(classI) • STEMI in ECG should be treated as primary cardiac event without delay for aortic imaging unless pt. is high risk • Low and intermediate risk patients should be screened by CXR- – Findings s/o aortic d/s-definitive aortic imaging – Alternate diagnosis-manage accordingly • High risk patients should directly undergo TEE,CT or MRI • Class III- negative CXR should not delay definitive aortic imaging in high risk pt
    22. 22. Diagnostic imaging studies(classI) • Selection of imaging modality based on pt variables and institutional capabilities • If high clinical suspicion exists in spite of negative initial imaging a second study should be performed
    23. 23. Recommendations for management • BP mesured in both arms-treatment strategy based on highest reading • Patient not in shock-i.v drugs for rate and B.P control
    24. 24. Class IIa • IMH-treated similar to aortic dissection in the corresponding segment
    25. 25. • Endovascular interventions-not approved for dissection involving asc.aorta or arch • Intimal defect without IMH- – Asc.aorta-emergency surgery – Desc.aorta-endograft • Intimal defect with IMH – Stable pt-delay def.Rx until IMH resorbs – Desc.aorta-endovascular Rx
    26. 26. • Patients with symptoms s/o expansion of aneurysm-prompt surgical intervention(classI) • Endovascular stent grafts have not been approved by the US FDA for treatment of aneurysms or other conditions of asc. aorta.
    27. 27. Rec.for open surgery(asc.aortic aneurysm)-class I • Separate valve and asc.aortic replacement in patients without significant root dilatation • Patients with significant root dilatation- excision of sinuses&modified David reimplantation or root replacement with valved graft conduit
    28. 28. Rec. for arch aneurysms-classII • Partial arch replacement-asc.aortic aneurysm involves proximal arch • Replacement of entire aortic arch- – A/c or c/c dissection in an aneurysmal arch – Aneurysm of entire arch – Distal arch aneurysm that involves prox.desc.aorta – Asymptomatic pts. With diameter>5.5cm • Annual reimaging-aneurysms<4cm • Endovascular stent graft not approved
    29. 29. • Thoraco abdominal aneurysm-surgery when diameter >6cm • End organ ischemia-additional revascularisation procedure recommended
    30. 30. Recommendations for genetic syn. • classI- – Marfan syn.-echo to assess aortic root and asc.aorta at diagnosis &6 months after to determine rate of growth • Annual imaging if stable and <4.5cm • More frequent imaging otherwise – Loeys-Dietz syn,other gen. mutations –complete aortic imaging at diagnosis,6months – Loeys-Dietz syn-annual MRI from cerebrovasc.circulation to pelvis – Turner syn-imaging at diagnosis for BAV,CoA,dilatation of asc.aorta. • If any abnormalities-annual imaging • Otherwise-repeat 5 to 10yr
    31. 31. • Class IIa – Marfan syn planning pregnancy-replacement of aortic root and asc.aorta if >4.5cm
    32. 32. Recommendations for familial thoracic aortic aneurysms • ClassI – Aortic imaging for first degree relatives of pts with thoracic aortic aneurysm or dissection – If a mutant gene a/w aneurysm identified-first degree relatives should undergo genetic screening-those with genetic mutation undergo imaging
    33. 33. • classIIa – If one or more first degree relatives of a patient affected-imaging of second degree relatives – Sequencing of ACTA2 gene in patients with f/h of thoracic aortic aneurysm or dissection
    34. 34. Recommendations for BAV (class I) • First degree relatives of pts with BAV,premature onset of thoracic aortic d/s,familial form of aortic aneurysm and dissection-should be evaluated for presence of BAV&aortic d/s • All pts with BAV should be evaluated for aortic dilatation
    35. 35. Recommendations for takayasu arteritis &GCA(classI) • Initial evaluation should include CT or MRI of thoracic aorta and branches • Initial therapy-corticosteroids at high dose • Periodic evaluation-physical examination&ESR or CRP • Elective revasc.after a/c inflammatory state is quiescent • Class II a –use of anti inflammatory agents
    36. 36. Recommendations in pregnancy • classI – Marfans syn and aortic d/s-counselled about risk of dissection,heritable nature – Strict BP control for pts with predisposition to dissection – Aortic root or asc.aortic dilatation-monthly echo – Arch,descending or abd.aortic dilatation-MRI
    37. 37. • ClassIIa – CS for pts with significant aortic dilatation • Class IIb – If progressive aortic dilatation-prophylactic surgery recommended
    38. 38. Aortic dissection in pregnancy • Type A- – 1st or 2nd TM-urgent surgical repair and fetal monitoring – 3rd TM-urgent CS f/b aortic repair • Type B-medical therapy preferred
    39. 39. Aortic arch atheroma • classIIa-Rx with a statin • Class IIb-oral anticoagulation with warfarin or antiplatelets in stroke pts with atheroma≥ 4 mm
    40. 40. Pre op evaluation for CAD • Class I- – thoracic aortic d/s undergoing intervention-evaluated for CAD – unstable cor syn-undergo revascularisation prior to at time of aortic surgery or intervention • classIIa- – Asc.aortic or arch d/s undergoing surgery- concomitant CABG for stable significant CAD • Class IIb- – Descending thoracic aortic d/s-stable significant CAD- benefits not certain