Acute aortic syndrome (AAS) refers to life-threatening pathologies of the thoracic aorta including aortic dissection, penetrating aortic ulcer, intramural hematoma, and leaking aortic aneurysm. Management of AAS involves surgery for ascending aorta pathologies and medical management or potential intervention for descending aorta issues depending on complications. Investigation options include TEE, CTA, MRI, and aortography but have limitations. Surgical and endovascular options aim to prevent complications like rupture but have significant mortality and morbidity risks.

1. HRISTO A. RAHMAN 30/07/20
INTRAMURAL HAEMATOMA
PENETRATING AORTIC ULCER
AORTIC DISSECTION
ACUTE AORTIC
SYNDROME

2. - GROUP OF LIFE-THREATENING THORACIC AORTIC
PATHOLOGIES, INCLUDING:
-1. AORTIC
DISSECTION;
-2. PENETRATING
AORTIC ULCER;
-3. INTRAMURAL
HAEMATOMA;
-4. LEAKING AORTIC
ANEURYSM
WHAT IS ACUTE AORTIC
SYNDROME (AAS)?

3. - MANAGEMENT OF PATIENTS WITH AAS SHOULD BE SIMILAR TO THOSE WITH ACUTE THORACIC AORTIC DISSECTION
-1. ASCENDING AORTA:
-SURGERY
-2. DESCENDING AORTA:
-2,1. MEDICAL MANAGEMENT;
-2,2. BUT STENTING OR SURGERY
-SHOULD BE CONSIDERED IN PATIENTS WITH:
-IMPENDING RUPTURE;
-UNREMITTING PAIN;
-ORGAN MALPERFUSION.
WHAT IS ACUTE AORTIC
SYNDROME (AAS)?

4. WHAT IS INTRAMURAL
HAEMATOMA OF THE
AORTA?BLOOD WITHIN AORTIC MEDIA WITHOUT PRESENCE
OF INTIMAL TEAR
AETIOLOGY:
1. RUPTURE OF VASA VASORUM OF MEDIA;
2. HAEMORRHAGE WITHIN ATHEROSCLEROTIC
PLAQUE;
3. PROGRESSION FROM PENETRATING AORTIC
ULCER
IMHs CAN:
- SPONTANEOUSLY RESOLVE;
- INCREASE IN SIZE
UNLIKE DISSECTIONS, IMHs OCCUR CLOSER TO
ADVENTITIA AND ARE AT GREATER RISK OF
RUPTURE THAN DISSECTIONS

6. WHAT ARE
PENETRATING AORTIC
ULCERS?FOCAL INTIMAL DEFECTS OCCURING AT SITE OF
ATHEROSCLEROTIC PLAQUES
PROGRESSIVE INTIMAL EROSION EVENTUALLY
RESULTS IN PULSATILE BLOOD ENTERING THE MEDIA
AND HENCE PAUs MAY LEAD TO:
- INTRAMURAL HAEMATOMAS;
- DISSECTION;
- RUPTURE;
- ANEURYSM AND PSEUDO-ANEURYSM FORMATION
SURGERY IS INDICATED FOR PATIENTS WITH:
- DESCENDING AORTIC ULCERS >20 MM IN DIAMETER
AND >10 MM DEPTH;
- ASCENDING AORTIC ULCERS

7. -DEFINITION:
- INTIMAL TEAR RESULTING IN SLPLIT IN THE AORTIC WALL BETWEEN THE INTERNAL AND EXTERNAL ELASTIC LAMINAE WITHIN THE
AORTIC MEDIA
-TIMING:
-1. ACUTE (<14 DAYS);
-2. SUB-ACUTE (14 DAYS - 2 MONTHS);
-3. CHRONIC (>2 MONTHS)
-LOCATION:
-STANFORD CLASSIFICATION:
-TYPE A: ASCENDING AORTA INVOLVED;
-TYPE B: ASCENDING AORTA NOT INVOLVED.
-DEBAKEY CLASSICICATION:
-TYPE I: WHOLE AORTA INVOLVED;
-TYPE II: ONLY ASCENDING AORTA INVOLVED;
-TYPE IIIA: ONLY DESCENDING THORACIC AORTA INVOLVED;
-TYPE IIIB: DESCENDING AND ABDOMINAL AORTA INVOLVED
HOW ARE THORACIC
AORTIC DISSECTIONS
CLASSIFIED?

9. -ENTRY TEAR: POINT WHERE
BLOOD TRACKS THROUGH THE
INTIMA INTO THE MEDIA
-DISSECTION IS CLASSIFIED BY
THE EXTENT OF MEDIA
STRIPPING FROM THE ENTRY
TEAR TO THE DISTAL RE-ENTRY
POINT
-DISSECTION BEGINS WITH
INTIMAL TEAR AND IS
PROPAGATED BY THE INGRESS
OF BLOOD INTO THE MEDIA AND
SPIRALLING THROUGH THE
LENGHT OF THE AORTA
-MULTIPLE RE-ENTRY TEARS ARE
OFTEN PRESENT IN THE
DESCENDING AORTA
PATHOPHYSIOLOGY OF
THORACIC AORTIC
DISSECTION

10. -!!! IMPORTANT !!!:
-TO DISTINGUISH THE ENTRY TEAR
FROM THE EXTENT OF THE
DISSECTION AS SURGERY FOR TYPE A
DISSECTION AIMS TO EXCISE THE
ENTRY TEAR BUT OFTEN LEAVES
RESIDUAL SEPARATED LAYERS OF
THE AORTIC ARCH AND DESCENDING
AORTA
-AS THE ENTRY TEAR IS ELIMINATED
AND THE LAYERS ARE JOINED AT THE
DISTAL ASCENDING AORTA, NO
FURTHER BLOOD CAN ENTER THE
FALSE LUMEN UNLESS ADDITIONAL
ENTRY INTIMAL TEARS EXIST WITHIN
THE AORTA
CONTINUED…

11. -ASCENDING AORTA: 65% -
2 CM. APPROXIMATELY
ABOVE THE NON-CORONARY
SINUS;
-DESCENDING AORTA: 20% -
PROXIMALLY ON THE LEFT
ANTEROLATERAL WALL;
-AORTIC ARCH: 10% -
OPPOSITE THE INNOMINATE
ARTERY ON THE LESSER
CURVE
WHERE ARE ENTRY
TEARS USUALLY
LOCATED IN ATAD?

12. -A: AGE, ATHEROSCLEROSIS,
ANEURYSM;
-B: BICUSPID AORTIC VALVE
(FIBRILLIN DEFICIENCY), BLOOD
PRESSURE (HYPERTENSION);
-C: CONNECTIVE TISSUE DISORDERS
(MARFAN SYNDROME, EHLERS-
DANLOS SYNDROME);
-D: DEGENERATIVE (CYSTIC MEDIAL
DEGENERATION);
-E: TRAUMA, SURGERY, IATROGENIC,
PREGNANCY
WHAT ARE THE
PREDISPOSING
FACTORS FOR ATAD?

13. -PAIN: TEARING RETROSTERNAL CHEST PAIN RADIATING INTO THE
BACK OR NECK.
-SYMPTOMS OF ORGAN MALPERFUSION: MYOCARDIAL
ISCHAEMIA, STROKE, ABDOMINAL PAIN WITH MESENTERIC
ISCHAEMIA.
-DYSPNOEA: SECONDARY TO AORTIC REGURGITATION,
TAMPONADE OR LEFT-SIDED HAEMITHORAX.
-HYPOTENSION, HYPERTENSION OR BLOOD PRESSURE
DIFFERENTIAL BETWEEN THE LEFT AND RIGHT ARMS.
-AORTIC REGURGITATION MURMUR.
-ABSENT PERIPHERAL PULSES
WHAT ARE THE CLINICAL
FEATURES OF STANFORD
TYPE A ATAD?

14. -TRANSOESOPHAGEAL ECHOCARDIOGRAPHY:
- 98% SENSITIVITY
- PROVIDES CLEAR IMAGES AND QUANTIFIES THE
DEGREE OF AORTIC REGURGITATION
- BUT:
- RESULTS ARE OPERATOR-DEPENDENT;
- PASSING TOE PROBE MAY CAUSE ANXIETY AND
HYPERTENSION;
- BLIND SPOT IN DISTAL ASCENDING AORTA AND
PROXIMAL AORTIC ARCH
-CT WITH CONTRAST ENHANCEMENT:
- 95% SENSITIVITY
- QUICK
- COMMONLY AVAILABLE
- CAN OBTAIN IMAGES OF PLEURA, NECK, HEAD
VESSELS, PERICARDIUM
- BUT:
- THE PATIENT IS AT RISK OF CONTRAST NEPHROPATHY
-MRI IMAGING:
- 99% SENSITIVITY
- BEST IMAGES AND DETAILS VISUALISED
- BUT:
- NOT ALWAYS AVAILABLE
- TIME CONSUMING METHOD
- CONTRAINDICATED IN HAEMODYNAMICALLY
UNSTABLE PATIENTS WITH IMPENDING RUPTURE,
CARDIAC TAMPONADE
-AORTOGRAPHY:
- 80% SENSITIVITY
- RARELY USED
- HISTORICALLY THE GOLD STANDARD
- BUT:
- MAY PRECIPITATE AORTIC RUPTURE
WHAT ARE THE DIFFERENT
INVESTIGATIONS AVAILABLE FOR THE
DIAGNOSIS OF STANFORD TYPE A
ATAD?

15. TRANSOESOPHAGEAL ECHOCARDIOGRAPHY

16. CT WITH CONTRAST ENHANCEMENT

17. MRI IMAGING AORTOGRAPHY

18. -ARTERIAL LINES: PRE-
ARCH (RIGHT RADIAL
ARTERY) AND POST-ARCH
(FEMORAL OR LEFT RADIAL
ARTERY);
-URINARY CATHETER;
-CENTRAL VENOUS
ACCESS;
-NASOPHARYNGEAL
TEMPERATURE PROBE;
-CEREBRAL OXIMETRY (
NEAR INFRARED
SPECTROSCOPY, IF
AVAILABLE ) TO DETECT
CEREBRAL MALPERFUSION
MONITORING REQUIRED FOR
PATIENTS UNDERGOING SURGERY
FOR STANFORD TYPE A ATAD

19. - ENTRY TEAR: RESECT AND REPLACE THE SITE OF THE AORTIC ENTRY TEAR
- AORTIC ROOT: TO PREVENT CORONARY MALPERFUSION AND LATE AORTIC
ROOT COMPLICATIONS, SURGERY CAN EITHER:
- - REPAIR THE AORTIC SINUS SEGMENTS BY ADHESIVE RECONSTRUCTION TO
OBLITERATE THE FALSE LUMEN;
- - REPLACE THE AORTIC ROOT
- AORTIC VALVE: RESUSPENSION OR REPLACEMENT OF THE AORTIC VALVE
- AORTIC ARCH: HEMI-ARCH OR TOTAL ARCH REPLACEMENT DEPENDING ON
WHETHER THE ENTRY TEAR HAS EXTENDED INTO THE AORTIC ARCH
- DISTAL ANASTOMOTIC LINE: ADHESIVE RECONSTRUCTION AT THE
DISTAL ANASTOMOSIS TO OBLITERATE THE FALSE LUMEN AND RESTORE
FLOW THROUGH THE TRUE LUMEN
WHAT ARE THE
PRINCIPLES OF
STANFORD TYPE A ATAD?

20. -ASCENDING AORTA INTERPOSITION GRAFT
-ASCENDING AORTA INTERPOSITION GRAFT AND AORTIC
VALVE REPLACEMENT
-ASCENDING AORTA INTERPOSITION GRAFT AND
RESUSPENSION OF THE AORTIC VALVE
-AORTIC ROOT REPLACEMET ( BENTALL OR CABROL
OPERATIONS)
-VALVE-SPARING ROOT REPLACEMENT ( DAVID OR YACOUB
OPERATIONS)
-DISTAL REPAIR: HEMI-ARCH OR TOTAL ARCH REPLACEMENT
DIFFERENT SURGICAL
OPTIONS FOR ATAD
INCLUDE:

21. ASCENDING AORTA
INTERPOSITION GRAFT

23. AORTIC ROOT
REPLACEMENT -
BENTALL OPERATION

24. VALVED GRAFT
CONDUITS FOR BENTALL
OPERATION
VALSALVA CONDUITS WITH BIOPROSTHESIS AND MECHANICAL PROSTHETIC VALVE

25. ASCENDING AORTA AND
TOTAL ARCH
REPLACEMENT

26. UNDERLYING PRINCIPLE FOR
THESE PATIENTS IS TO
PREVENT LIFE-THREATENING
COMPLICATIONS OF ACUTE
TYPE A DISSECTION WHICH
INCLUDE:
INTRA-PERICARDIAL RUPTURE;
TAMPONADE;
MYOCARDIAL ISCHAEMIA;
AORTIC REGURGITATION

27. MORTALITY WITHOUT SURGERY APPROXIMATES

28. SURGICAL MORTALITY RANGES

29. 5-YEAR SURVIVAL OF HOSPITAL SURVIVORS AFTER SURGERY

30. - n21 consecutive ATAD cases ( 2 years: 07/18 -
07/20 )
- Early ( 1 month ) postoperative mortality: n9 -
42,86%
- Male: n10; Female: n11 / Age: 34-85 y.o.;
mean age: 60,85
- ASCENDING AORTA INTERPOSITION GRAFT:
n8 ( n2 deceased - 25% )
- ASCENDING AORTA + AVR: n1 (n0 deceased)
- ASCENDING AORTA + CABG: n1 (n0 deceased)
- BENTALL OPERATION: n1 (n0 deceased)
- BENTALL OPERATION + CABG: n4 (n4 deceased)
- ASCENDING AORTA + HEMI-ARCH
REPLACEMENT: n4 (n2 deceased)
- ASCENDING AORTA + TOTAL ARCH
REPLACENT: n2 (n1 deceased)
WHAT DOES REAL
EXPERIENCE SHOW IN
NUMBERS?
REDO CASES: N2

32. - MEDICAL MANAGEMENT WITH BLOOD PRESSURE CONTROL - LABETALOL (
alpha & beta BLOCKER) IS USED TO REDUCE THE FORCE OF:
- 1. VENTRICULAR CONTRACTION;
- 2. SHEAR STRESS;
- 3. ABSOLUTE BLOOD PRESSURE
- THE RATIONALE FOR NOT OPERATING ON ALL TYPE B ATAD IS:
- - MORTALITY WITH MEDICAL MANAGEMENT IS 10%
- - POSTOPERATIVE MORTALITY - 27%
- - OPERATIVE PARAPLEGIA RATE - 24%
- 5 YEAR SURVIVAL IS NOT IMPROVED WITH SURGERY
WHAT IS THE
MANAGEMENT OF
STANFORD TYPE B ATAD?

33. -RUPTURE OR IMPENDING RUPTURE OF THE
DESCENDING THORACIC AORTA ( LARGE
MEDIASTINAL HAEMATOMA, LARGE
HAEMOTHORAX )
-EXTENSION OF THE DISSECTION WITH
UNREMITTING PAIN
-EVIDENCE OF LIMB, VISCERAL OR SPINAL CORD
HYPOPERFUSION - METABOLIC ACIDOSIS, RAISED
LACTATE, OLIGURIA OR ANURIA, PARAESTHESIA
OR PARAPLEGIA IN THE LOWER LIMBS
INDICATIONS FOR INTERVENTION
(SURGICAL OR ENDOVASCULAR
STENT GRAFTING) ON ATAD:

34. -ACUTE & CHRONIC STANFORD TYPE B
DISSECTION
-TRAUMATIC AORTIC INJURY (TRANSECTION)
-DESCENDING AORTIC ANEURYSM
-COARCTATION OF THE AORTA
-AORTIC ARCH ANEURYSMS, IN CONJUNCTION
WITH BESPOKE BRANCHED ENDOGRAFTS, IN
SITU FENESTRATION OR DE-BRANCHING
SURGERY
WHAT ARE THE INDICATIONS FOR
ENDOVASCULAR STENT GRAFTING OF
THE THORACIC AORTA?

35. -REQUIREMENTS FOR OPTIMAL
RESULTS FOLLOWING
ENDOVASCULAR STENT GRAFT
INCLUDE:
-PROXIMAL AND DISTAL LANDING
ZONES >1,5 CM. OF NORMAL
AORTA;
-FEMORAL ARTERIES >7 MM.
DIAMETER TO ALLOW ACCESS
FOR THE STENT GRAFT;
-RELATIVELY STRAIGHT
THORACIC AORTA
WHAT ARE THE REQUIREMENTS OF
ENDOVASCULAR STENT GRAFT
DEPLOYMENT IN THORACIC AORTA?

36. STENT GRAFTS

37. -COMPLICATIONS INCLUDE:
-STENT COMPLICATION - ENDOLEAK, STENT
MIGRATION (10-15%);
-LOCAL VASCULAR COMPLICATION (5-10%);
-MORTALITY (5-10%);
-AORTIC TRAUMA - RUPTURE, DISSECTION,
FISTULA (5%);
-STROKE OR PARAPLEGIA (5%)
WHAT ARE THE COMPLICATIONS OF
ENDOVASCULAR STENT GRAFT
DEPLOYMENT IN THORACIC AORTA?

38. - ENDOLEAK: BLOOD FLOW BETWEEN THE
OUTSIDE OF THE STENT GRAFT AND THE DISEASED
VESSEL WALL.
- ENDOLEAK: COMPLICATION OF
ENDOVASCULAR STENT GRAFTING AND IS
CLASSIFIED ACCORDING TO THE SOURCE OF BLOOD:
-I: LEAK AT THE JUNCTION OF THE AORTA
AND THE STENT GRAFT DUE TO AN
INADEQUATE SEAL;
-II: BACK BLEEDING VESSELS WITHIN THE
ANEURYSMAL SAC;
-III: LEAK THROUGH A DEFECT IN THE STENT
GRAFT PROSTHESIS ( GRAFT FAILURE );
-IV: LEAK THROUGH THE PORES OF THE
STENT GRAFT FABRIC ( GRAFT POROSITY )
CLASSIFICATION OF ENDOLEAKS THAT
MAY OCCUR FOLLOWING
ENDOVASCULAR STENT GRAFTING

39. STANFORD B ATAD WITH
ARTERIA LUSORIA