Aortic dissection

955 views

Published on

Surgical Strategy for type A dissection

Published in: Health & Medicine
0 Comments
6 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
955
On SlideShare
0
From Embeds
0
Number of Embeds
5
Actions
Shares
0
Downloads
0
Comments
0
Likes
6
Embeds 0
No embeds

No notes for slide
  • 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 disruption.no flow in false lumen
    Penetrating atherosclerotic ulcer:atherosclerotic lesion with ulceration that penetrates the internal elastic lamina.
    1.classic dissection
    2.IMH
    3.intimal tear without IMH
    4.PAU
    5.iatrogenic/traumatic
    Normal aortic size
    Depends on
    Age
    Sex
    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
    Advantage
    No radiation
    Identification of anatomic variants of AoD
    branch vessel invt
    Disadvantage
    Prolonged duration
    Pt.inaccessible to care providers
    Gadolinium contrast not used in renal impairment
    ECHO
    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

    ×