Emergencies of the Aorta
Howard Blumstein, MD
Wake Forest University
March 2010
Outline
• Aortic Aneurysm
• Aortic Dissection
• Traumatic Aortic Disruption
Objectives
• Understand Relevant Anatomy
• Recognize Typical Clinical Presentations
• Order Appropriate Imaging
• Stabiliz...
Note
• Peter Cameron’s book (Chapter 5.10)
combines
– Aortic Dissection
– Intramural Hematoma
– Aortic Transection
• I wil...
Aorta Anatomy
• Illustration shows isolated aorta
• Major branches
• Not labeled:
– Coronary arteries
– Celiac and mesente...
Abdominal Aortic Aneurysm
• Majority of aortic aneurysms are
abdominal
– Not thoracic
• True aneurysm involves all three l...
True and False Aneurysms
Normal
Aorta
True
Aneurysm
Pseudo-
Aneurysm
Prevelence
• Rare under 50 years of age
• More common in men than women
• Risk factors are same as risks for
atheroscleros...
Aneurysm Location
• 90% of AAA are
infrarenal
• About 70%
rupture into
retroperitoneum
• 10-30% have free
rupture
– Die qu...
Aortic Aneurysm Growth
Other Aortic Aneurism Facts
• Inflammatory Aneurysms
– 5% of aneurysms
– Dense fibrous reaction in aneurysm wall
– Can cau...
AAA Clinical Presentation
• Unruptured aneurysms typically
without symptoms
• Ruptured
– Pain in abdomen, flank, back, gen...
AAA Physical Exam
• Varies with size of aneurysm and body
– Easier to find large aneurysms
– Easier in thin patients
• Pal...
Abdominal X-Rays
• Usually not diagnostic
• Sometimes calcification of wall visible
– “Eggshell calcification”
– Rarely se...
Ultrasound
• Positive • Negative
• Performed at bedside
• Quick and easy
• 100% accurate if
technically adequate
• Can see...
CT Scan
• Positives • Negatives
• Nearly 100% accurate
• Can detect leaking
• Can help define
anatomy
– Plan surgical
appr...
Unruptured Infrarenal AAA
Unruptured Infrarenal AAA
Ruptured AAA
Treatment of Leaking AAA
• Two large bore IVs
• Type and cross for blood transfusion
• Support BP with crystalloid and blo...
How Big?
• Risk of rupture goes up as size of aneurysm
increases
• Typically operate on AAA 5 cm or larger
– Symptoms cons...
Mortality Rates
• Elective surgery for unruptured AAA: 5%
• Emergency surgery, unruptured AAA: 20-
25%
• Emergency surgery...
Aortic Fistula
• Can form fistula with variety of structures
• Can present as
– GI bleeding
– Infection of aorta
– Heart f...
Pitfalls in AAA
• Mistaking ruptured aneurysm for kidney stone
• Failure to contact vascular surgeon quickly
• Failure to ...
Aortic Dissection
• Incidence reported 0.5-1 per 100,000
population annually
• Cameron says this is more common than
AAA r...
Aortic Dissection
• Blood gets into media of the aorta
• “Rips” the intima from the blood vessel
• Required elevated blood...
Aortic Dissection Mechanism
• Two Theories
• Tear in intima layer of
aorta allows blood to
rip into the media
• Elevated p...
Aortic Dissection Mechanism
Dissection requires two things
• Elevated arterial
blood pressure
• Weakness or
degeneration o...
Risk Factors
• Bicuspid aortic valve
(14%)
• Cardiac Surgery
(18%)
• Marfan’s Disease
(5%)
• Other connective
tissue disor...
Two Directions
• Antegrade Dissection • Retrograde
Dissection
Classification
Clinical Presentation
• Pain
– Chest, arms, neck, between scapulae, back
– Tearing or ripping quality
• Occlusion of blood...
Risk Factors
• Bicuspid aortic valve
• Cardiac surgery
• Connective tissue
disorders
– Marfan’s
– Ehlers-Danlos
Syndrome
–...
Physical Exam
• Hypertension
• Aortic valve insufficiency (about 1/3)
– New murmur
– CHF
• Pericardial effusion
– Hypotens...
Physical Exam
• Neurologic abnormalities (obstruction of
carotid artery)
• Interruption of blood flow to limb
– Pulse defi...
EKG
• Many patients can have ischemia or
infarction on EKG
• Can cause confusion with acute myocardial
infarction
• Perica...
Chest X-Ray
• Most have abnormal chest x-rays
– 10-20 percent have normal CXR
• Wide mediastinum
• Abnormalities of aortic...
CT Angiography
• Preferred study most
hospitals in U.S.
• Highly sensitive
• High sensitivity for
inclusion of arch
vessels
CT Aortogram
• Newer Scanners
Preferred
• 32 or 64 slices
• Much faster
• Little motion artifact
• Better detail
• 3 Dimen...
CT Aortogram
• Potential Problems
• Time delay
– Minimized if CT
scanner is in ED
• IV Contrast
– Risk of side effects
• C...
Echocardiography
• Transthoracic echo (TTE)
– Quick, non invasive
– Can show Aortic valve function
– Inadequate sensitivit...
Angiography
• Rarely used in U.S.
– Supplanted by CT scans
• Invasive
• Time consuming
• Not performed in ED
• May be best...
Physiology
• Each pulse transmits
pressure to the blind
pouch of the
dissecting segment
• Will either
– Reenter the lumen
...
Treatment
• Goals • Drugs
• Reduce heart rate
• Reduce blood
pressure
• Reduce pulse
pressure
• Beta Blockers
– Esmolol
– ...
Surgery and Mortality
• Type A
– Surgery is best option
– Mortality 5-21%
• Type B
– Usually treated medically
– Mortality...
Pitfalls of Aortic Dissection
• Missed diagnosis – mistaken for
– Myocardial infarction
– Stroke
• Delay in care
– Call Ca...
Aortic Disruption
• Caused by blunt thoracic trauma
• Several proposed mechanisms
– Compression
– Whiplash effect (deceler...
Mortality
• 60-90% of patients die at scene of accident
or within a few hours of hospital arrival
• If patient goes to OR,...
Diagnostic Strategies
• Chest X-Ray
• CT Scan
• Angiography
Chest X-Ray
• Wide mediastinum
– Classically thought to be useful in ruling out
aortic injury
– Now reported to miss up to...
CT Scan
• Has become the standard test for aortic
injury
• Highly accurate
• Most patients will be getting CT scans of
abd...
Treatment
• Complicated by presence and/or risk of other
injuries
• If possible, treat like aortic dissection
– Pulse and ...
Surgery
• Treatment varies according to grade of injury
• Grade 3 usually gets surgery
• Grade 1 usually doesn’t
• No rand...
Aortic Emergencies - Acute Coronary Syndrome (ACS)
Aortic Emergencies - Acute Coronary Syndrome (ACS)
Aortic Emergencies - Acute Coronary Syndrome (ACS)
Aortic Emergencies - Acute Coronary Syndrome (ACS)
Aortic Emergencies - Acute Coronary Syndrome (ACS)
Aortic Emergencies - Acute Coronary Syndrome (ACS)
Aortic Emergencies - Acute Coronary Syndrome (ACS)
Aortic Emergencies - Acute Coronary Syndrome (ACS)
Aortic Emergencies - Acute Coronary Syndrome (ACS)
Aortic Emergencies - Acute Coronary Syndrome (ACS)
Aortic Emergencies - Acute Coronary Syndrome (ACS)
Aortic Emergencies - Acute Coronary Syndrome (ACS)
Aortic Emergencies - Acute Coronary Syndrome (ACS)
Aortic Emergencies - Acute Coronary Syndrome (ACS)
Aortic Emergencies - Acute Coronary Syndrome (ACS)
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Aortic Emergencies - Acute Coronary Syndrome (ACS)

  1. 1. Emergencies of the Aorta Howard Blumstein, MD Wake Forest University March 2010
  2. 2. Outline • Aortic Aneurysm • Aortic Dissection • Traumatic Aortic Disruption
  3. 3. Objectives • Understand Relevant Anatomy • Recognize Typical Clinical Presentations • Order Appropriate Imaging • Stabilize Patients as Best Possible
  4. 4. Note • Peter Cameron’s book (Chapter 5.10) combines – Aortic Dissection – Intramural Hematoma – Aortic Transection • I will combine these with Aortic Aneurysm
  5. 5. Aorta Anatomy • Illustration shows isolated aorta • Major branches • Not labeled: – Coronary arteries – Celiac and mesenteric arteries
  6. 6. Abdominal Aortic Aneurysm • Majority of aortic aneurysms are abdominal – Not thoracic • True aneurysm involves all three layers of aorta – Intima – Media – Adventitia
  7. 7. True and False Aneurysms Normal Aorta True Aneurysm Pseudo- Aneurysm
  8. 8. Prevelence • Rare under 50 years of age • More common in men than women • Risk factors are same as risks for atherosclerosis • Factors aside from atherosclerosis are probably also involved Diabetes High Blood Pressure Cholesterol Tobacco Abuse Age Family History
  9. 9. Aneurysm Location • 90% of AAA are infrarenal • About 70% rupture into retroperitoneum • 10-30% have free rupture – Die quickly
  10. 10. Aortic Aneurysm Growth
  11. 11. Other Aortic Aneurism Facts • Inflammatory Aneurysms – 5% of aneurysms – Dense fibrous reaction in aneurysm wall – Can cause obstruction of branches of aorta • Distal emboli – Clot and/or atherosclerotic material • Other more rare causes of aneurysms
  12. 12. AAA Clinical Presentation • Unruptured aneurysms typically without symptoms • Ruptured – Pain in abdomen, flank, back, genitals, chest – Syncope – Vomiting – Very similar to renal colic • Classic Triad: Pain, hypotension, mass
  13. 13. AAA Physical Exam • Varies with size of aneurysm and body – Easier to find large aneurysms – Easier in thin patients • Palpable mass (50-85%) • Distal pulses usually intact • Abdominal bruit usually heard in only 10% of patients.
  14. 14. Abdominal X-Rays • Usually not diagnostic • Sometimes calcification of wall visible – “Eggshell calcification” – Rarely seen • Even if AAA see, you cannot tell – Size of aneurysm – If it is leaking
  15. 15. Ultrasound • Positive • Negative • Performed at bedside • Quick and easy • 100% accurate if technically adequate • Can see free fluid if ruptured into peritoneal cavity • Can be difficult with obese patient or bowel gas • Cannot detect retroperitoneal fluid If ultrasonography reveals an AAA in an unstable patient, aneurysm rupture is presumed, and the patient requires immediate aneurysm repair.
  16. 16. CT Scan • Positives • Negatives • Nearly 100% accurate • Can detect leaking • Can help define anatomy – Plan surgical approach • Can detect alternate diagnoses • Takes longer – Can delay surgery in unstable patients • Use of IV contrast – Adds to treatment delay – Risk of contract complications
  17. 17. Unruptured Infrarenal AAA
  18. 18. Unruptured Infrarenal AAA
  19. 19. Ruptured AAA
  20. 20. Treatment of Leaking AAA • Two large bore IVs • Type and cross for blood transfusion • Support BP with crystalloid and blood – Controversial • Definitive treatment is surgery – Call surgeon as soon as possible
  21. 21. How Big? • Risk of rupture goes up as size of aneurysm increases • Typically operate on AAA 5 cm or larger – Symptoms consistent with rupture – No other cause for symptoms
  22. 22. Mortality Rates • Elective surgery for unruptured AAA: 5% • Emergency surgery, unruptured AAA: 20- 25% • Emergency surgery, ruptured AAA: 50% • All patients presenting with acute, ruptured AAA: 80% • Hypotension is strongest predictor of mortality
  23. 23. Aortic Fistula • Can form fistula with variety of structures • Can present as – GI bleeding – Infection of aorta – Heart failure • Erosion into adjacent structures – Graft – Inflammatory aneurysm
  24. 24. Pitfalls in AAA • Mistaking ruptured aneurysm for kidney stone • Failure to contact vascular surgeon quickly • Failure to have blood ready for transfusion • Misinterpretation of ultrasound
  25. 25. Aortic Dissection • Incidence reported 0.5-1 per 100,000 population annually • Cameron says this is more common than AAA rupture. But he combines – Aortic dissection (no trauma) – Aortic disruption (trauma) • With dissection alone, it is less common that AAA
  26. 26. Aortic Dissection • Blood gets into media of the aorta • “Rips” the intima from the blood vessel • Required elevated blood pressure
  27. 27. Aortic Dissection Mechanism • Two Theories • Tear in intima layer of aorta allows blood to rip into the media • Elevated pressure in vaso vasorum causes rupture within the media – Then blood dissection to to the lumen of the aorta
  28. 28. Aortic Dissection Mechanism Dissection requires two things • Elevated arterial blood pressure • Weakness or degeneration of media (“Medial Degeneration”)
  29. 29. Risk Factors • Bicuspid aortic valve (14%) • Cardiac Surgery (18%) • Marfan’s Disease (5%) • Other connective tissue disorders
  30. 30. Two Directions • Antegrade Dissection • Retrograde Dissection
  31. 31. Classification
  32. 32. Clinical Presentation • Pain – Chest, arms, neck, between scapulae, back – Tearing or ripping quality • Occlusion of blood vessels – Stroke or altered mental status – Myocardial ischemia/infarction • Pericardial tamponade • Acute aortic valve insufficiency
  33. 33. Risk Factors • Bicuspid aortic valve • Cardiac surgery • Connective tissue disorders – Marfan’s – Ehlers-Danlos Syndrome – other • Turner’s Syndrome • Pregnancy • Syphilis • Familial hyperlipidemia
  34. 34. Physical Exam • Hypertension • Aortic valve insufficiency (about 1/3) – New murmur – CHF • Pericardial effusion – Hypotension – Muffled heart sounds – Jugular venous distension
  35. 35. Physical Exam • Neurologic abnormalities (obstruction of carotid artery) • Interruption of blood flow to limb – Pulse deficits – Differential blood pressure • 15 mmHg between arms • not very helpful – Ischemic limb
  36. 36. EKG • Many patients can have ischemia or infarction on EKG • Can cause confusion with acute myocardial infarction • Pericardial effusion – Electrical alternans – Low voltages • No EKG findings are specific for dissection
  37. 37. Chest X-Ray • Most have abnormal chest x-rays – 10-20 percent have normal CXR • Wide mediastinum • Abnormalities of aortic arch or knob • Not terribly useful, usually
  38. 38. CT Angiography • Preferred study most hospitals in U.S. • Highly sensitive • High sensitivity for inclusion of arch vessels
  39. 39. CT Aortogram • Newer Scanners Preferred • 32 or 64 slices • Much faster • Little motion artifact • Better detail • 3 Dimension reconstruction
  40. 40. CT Aortogram • Potential Problems • Time delay – Minimized if CT scanner is in ED • IV Contrast – Risk of side effects • Cannot define severity of aortic insufficiency
  41. 41. Echocardiography • Transthoracic echo (TTE) – Quick, non invasive – Can show Aortic valve function – Inadequate sensitivity • Transesophageal echo (TEE) – Much more sensitive – Invasive, may require sedation – Requires specialized operator
  42. 42. Angiography • Rarely used in U.S. – Supplanted by CT scans • Invasive • Time consuming • Not performed in ED • May be best option if TEE and high definition CT not available
  43. 43. Physiology • Each pulse transmits pressure to the blind pouch of the dissecting segment • Will either – Reenter the lumen – Rupture through the wall of aorta
  44. 44. Treatment • Goals • Drugs • Reduce heart rate • Reduce blood pressure • Reduce pulse pressure • Beta Blockers – Esmolol – Labetolol • Other BP lowering drugs – Nitroprusside – Nitroglycerine • Avoid arterial dilating drugs – Hydralazine – Nifedipine
  45. 45. Surgery and Mortality • Type A – Surgery is best option – Mortality 5-21% • Type B – Usually treated medically – Mortality approximately 20%
  46. 46. Pitfalls of Aortic Dissection • Missed diagnosis – mistaken for – Myocardial infarction – Stroke • Delay in care – Call Cardiothoracic surgeon promptly – Establish diagnostic protocols in advance • Failure to adequately control blood pressure
  47. 47. Aortic Disruption • Caused by blunt thoracic trauma • Several proposed mechanisms – Compression – Whiplash effect (deceleration) – Rotational injury • Grade 1: Intimal flap • Grade 2: Subadventitial rupture • Grade 3: Aortic transection with active bleeding
  48. 48. Mortality • 60-90% of patients die at scene of accident or within a few hours of hospital arrival • If patient goes to OR, mortality rates reported 20-50%
  49. 49. Diagnostic Strategies • Chest X-Ray • CT Scan • Angiography
  50. 50. Chest X-Ray • Wide mediastinum – Classically thought to be useful in ruling out aortic injury – Now reported to miss up to 45% of aortic disruptions • Variety of other findings • Ultimately, sensitivity and specificity of CXR is not adequate to rule out aortic injury
  51. 51. CT Scan • Has become the standard test for aortic injury • Highly accurate • Most patients will be getting CT scans of abdomen anyway • Probably overused in U.S.
  52. 52. Treatment • Complicated by presence and/or risk of other injuries • If possible, treat like aortic dissection – Pulse and BP control – Have blood available for transfusion – Prompt involvement of Cardiothoracic and Trauma Surgery
  53. 53. Surgery • Treatment varies according to grade of injury • Grade 3 usually gets surgery • Grade 1 usually doesn’t • No randomize trials or good scientific investigation of appropriate intervention

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