Diseases of the aorta


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  • Intimal flap and tear in a patient with acute type A aortic dissection. (A) In the transoesophageal echocardiography short-axis view, a mobile linear flap is seen in the aortic root, just above the aortic valve leaflets (which can also be seen). The tear in the flap, where the small central true lumen communicates with the false lumen, is shown by the white arrow. (B) In the same patient, a 26-year-old man with no other co-morbidities, a short-axis view just below the origin of the flap, showing a bicuspid aortic valve.
  • Visualization of the left coronary ostium. Transoesophageal echocardiography short-axis view: in the left panel, a small true lumen is seen, from which the left coronary artery (asterisk) arises. Separate origins of the left anterior descending and circumflex branches can be seen—this was invaluable information for the cardiac surgeon. In the right panel, colour flow mapping shows unobstructed flow from true lumen into the left coronary branches.
  • Visualization of the head and neck vessels. Off-axis transoesophageal echocardiography view of the aortic arch. (A) A linear dissection flap is seen. The origins of the left common carotid and subclavian arteries as seen to arise from the smaller, true lumen (white arrows). (B) In the right panel, colour flow mapping shows unobstructed flow from true lumen into the head and neck vessels.
  • Intramural haematoma. In the transoesophageal echocardiography short-axis view, a cross-section of the aortic root is shown. The aortic wall is markedly thickened (white arrowheads). The intima has areas of focal echo brightness, characteristic of atherosclerosis—this is one method of distinguishing IMH from thrombus within the lumen of aortic aneurysm. There is an area of echo lucency within the haematoma, but no dissection flap or false lumen is seen. An echo free rim is seen around the aorta, suggestive of free blood.
  • Transesophageal echocardiogram (horizontal, 0-degree view) of an aortic arch with large, multi-lobed, ulcerated protruding atheromas (arrows).
  • Diseases of the aorta

    1. 1. 30thApril 2010Dr. Fateh Ali Tipoo SultanFCPS (Med), FCPS (Card)Diplomate Certification Board of Cardiac CTCertification National Board of EchocardiographyAssistant Professor &Consultant CardiologistAga Khan University HospitalDiseases of the Aorta
    2. 2. Overview• Aortic Dissection• Atypical Aortic Dissection– Intramural Hematoma– Penetrating Atherosclerotic Ulcer• Aortic Aneurysm• Aortic Atherosclerotic Disease• Coarctation• Aortic Trauma Transection2
    3. 3. Aortic Dissection• Deterioration of medial collagen and elastin• A tear in the intimal layer allows blood toenter the intima-media space• Blood then propagates down this new spacecreating a “true” and a “false” lumen3
    4. 4. Factors Predisposing to Dissection• Hypertension• Marfan and Ehler-Danlos• Coarctation and bicuspid aortic valve• Pregnancy• Trauma• Perforation through an intimal atheromatousplaque4
    5. 5. Intimal flap and tear in a patient with acute type A aortic dissectionMeredith E L , Masani N D Eur JEchocardiogr 2009;10:i31-i39
    6. 6. Predicting death in Patients withAcute Type A Aortic Dissection• 547 pts; IRAD; Jan 96-Dec 99• In hospital mortality 32.5%• Age > 70 years• Abrupt onset of chest pain• Hypotension, Shock, Tamponade• Kidney failure• Pulse deficit• ECG abnormalities8Circulation 2002
    7. 7. Clinical Presentation• Pain 85-96%Sudden 85%Severe 90%Tearing/Ripping 50%• SyncopePain, obstruction, barroreceptors• NeurologicalCVA 5%Paraparesis or paraplegia• CHF 7%• MI rare9
    8. 8. Physical Findings• Pulse Deficits ( 50% prox ; 15% distal)• Aortic Regurgitation – 16-67% of cases• Neurological Manifestations -6-19%• CVA – 3-6%• Altered consciousness or coma• Spinal artery perfusion – paraplegia,paraparesis10
    9. 9. Imaging Modality of ChoiceGOALS• Confirm the diagnosis• Classify the dissection and determine extent• Detect pericardial involvement• Detect and grade AICHOICES• TTE/TEE• CT• MRI• Aortography11
    10. 10. Procedure Used for the Diagnosis ofAortic Dissection12Am J Cardiology 2002
    11. 11. Sensitivity of the Four ImagingModalities13Image Modality Overall Type A Type BTEE 88% 90% 80%CT 93% 93% 93%MRI 100% 100% 100%Aortography 87% 87% 89%
    12. 12. TTE in Aortic Dissection14
    13. 13. 15
    14. 14. TEE in Aortic Dissection• Hallmark: Dissection flap and entry site• Dilated aorta• Aortic insufficiency• Pericardial and or pleural effusion16
    15. 15. 17
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    21. 21. TEE in Aortic Dissection: PitfallsTrue Dissection Flap Artifacts, ReverberationsDistinct, well-visualized Vague, blurryUndulates with cardiac cycle Crosses true anatomic barriersPresent in multiple views Does not demonstrate typicalundulation patternSeparates true from false lumen Does not separate true from false23
    22. 22. Aortic Dissection on CT24
    23. 23. 25
    24. 24. 26
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    27. 27. 29
    28. 28. Aortic dissection: Complications• Rupture• Tamponade• Aortic Regurgitation• Coronary Artery Involvement• Other Branch Vessel Involvement30
    29. 29. Aortic Dissection: Mechanism of AR311. Dilatation ofaortic root2. Pressure fromdissecting hematomamay depress one leaflet3. Torn annularsupport of theleaflets4. Intimal flap prolapse
    30. 30. Aortic Dissection – Pulse Loss32Due to directcompressionBlockade due to flapof intima
    31. 31. Visualization of the left coronary ostium.Meredith E L , Masani N D EurJ Echocardiogr 2009;10:i31-i39
    32. 32. Visualization of the head and neck vesselsMeredith E L , Masani N D Eur JEchocardiogr 2009;10:i31-i39
    33. 33. Mortality in AcuteAortic Dissection35
    34. 34. 36
    35. 35. Atypical Aortic Dissection• Intramural Hematoma• Penetrating Atherosclerotic Ulcer37
    36. 36. Intramural Hematoma: Diagnosis• Contained hemorrhage within the mediallayer of the aortic wall• Crescentic area along the aortic wall• Prevalence 10-15% in CT/MRI/TEE• Normal size lumen• False negative aortograms38
    37. 37. Intramural Hematoma39
    38. 38. Intramural Hematoma on CT40
    39. 39. Atypical Aortic Dissection: IHEcho Features• Localized thickening of Ao wall– Usually crescentic– Occasionally circumferential– Echo-lucent spaces common• Relatively smooth luminal surface• Absence of dissection flap• Maintenance of circular lumen41
    40. 40. Intramural haematoma.Meredith E L , Masani N D Eur JEchocardiogr 2009;10:i31-i39
    41. 41. Intramural Hematoma of the AortaPredictors of Progression to Dissection and Rupture– Location in the ascending aorta– Initial hematoma thickness > 11mm– Moderately ectatic aortic diameter with progression43Circulation 2002Circulation 2003
    42. 42. Penetrating Atherosclerotic Ulcer• Almost exclusively in the descending Ao• Usually remains localized• Elderly HTN, evidence for otheratherosclerotic CV disease• Chest and back pain without associated ARor neurological deficits44
    43. 43. Penetrating Atherosclerotic Ulcer• Natural history is unclear• No defined strategy• Surgical repair for– Pseudoaneurysm– Transmural rupture– Continued pain– Distal embolization– Aneurysmal dilatation47
    44. 44. Aortic aneurysm• Definition: pathological dilatation of the normalaortic lumen involving one or several segments• Fusiform (common), saccular• Pseudoaneurysm: well-defined collection ofblood and connective tissue outside the vessel wall
    45. 45. Thoracic aortic aneurysm• Descending aorta > ascending aorta• Cystic media degeneration: weakening aorticwall (elastic fiber degeneration)• Marfan syndrome• Ahterosclerosis• Syphilis: ascending aorta• Infectious aortitis / mycotic aneurysm
    46. 46. Thoracic aortic aneurysm• 40% asymptomatic• pain• Symptoms due to mass effect - superior venacava syndrome, tracheal deviation• CT, TEE > TTE• Surgery: >5cm (mean expansion rate= 0.43 cm/year)• Op risk: 5%
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    49. 49. Aortic Atherosclerosis• Atheroma• Protruding Atheroma• Complex plaque– 4mm or more thick and/or mobile component53
    50. 50. • Atherosclerotic lesions of the aorta detectedby TEE have been recognized as animportant cause of stroke and peripheralembolic disease• Using TEE the prevalence of thoracic aorticatheromas is 27% in patients who haveexperienced a previous embolic event• When atheromas are present the incidenceof stroke is 12% in one yearN Eng J Med 1996;334:1216-21N Eng J Med 1994;331:1474-9J Am Coll Cardiol 2000;35:545-54
    51. 51. • Plaque thickness and plaque composition asassessed by TEE have been identified asmajor risk factors for emboliccomplications• A strong association has been demonstratedbetween protruding non-calcified plaques>4mm in the aorta detected by TEE and therisk of ischemic stroke and peripheralembolismN Eng J Med 1994;331:1474-9Circulation 1997;96:3838-41
    52. 52. • Atheromas in the aortic arch and ascendingor descending aorta identified by TEE maybe the cause of many otherwise unexplainedstrokes• Role of Statins, ACEI, Anticoagulants andAntiplatelet agents uncertain
    53. 53. Trans-esophageal echocardiogram (horizontal, 0-degree view) of an aorticarch with large, multi-lobed, ulcerated protruding atheromas (arrows).Kronzon I , Tunick P A Ann Intern Med1997;126:629-637
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    55. 55. Coarctation of AortaDefinitionA congenital narrowing of upper descendingthoracic aorta adjacent to the site ofattachment of ductus arteriosus
    56. 56. Coarctation of AortaMorphology1. Localized stenosis* Shelf, projection or infolding ofaortic media into the lumen oppositethe ductus arteriosus2. Tubular hypoplasia* Severe with lesser narrowing
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    59. 59. Coarctation on CT63
    60. 60. Coarctation of AortaPathophysiology• Narrowed aorta produces increased leftventricular afterload and wall stress, leftventricular hypertrophy, and congestiveheart failure• Systemic perfusion is dependent on theductal flow and collateralization in severecoarctation
    61. 61. Coarctation of AortaIndications for operation1. Reduction of luminal diameter greaterthan 50% at any age2. Upper body hypertension over 150mmHgin young infant ( not in heart failure )3. CoA with congestive heart failureat any age
    62. 62. Blunt Aortic-Brachiocephalic Trauma66Fisher et al, 1981(n=510)Vignon et al, 1998(n=25)Aorticisthmusmainlyinvolved
    63. 63. Aortic Disruption: Anatomical types67Complete SubtotalPartialTearIntimalTearCirculation 1995
    64. 64. 68Thank You