Presentation on aortic dissection

1. Aortic Dissection

2. • Separation of aortic media from advantitia.
• True and False lumen
• Acute vs. Chronic

3. Predisposing factors
• Hypertension
• Connective tissue disorders
• Congenital
• Iatrogenic
• Pregnancy
• Drug related
• Syndromes

4. Classification
Stanford
• Type-A
( 70-75%)
• Type-B
(25-30%)
De Bakey
• I & II
• IIIa & IIIb

6. Epidemiology
• 50-70 Yrs
• < 40 Yrs
– Marfan
– BAV
– Prior aortic surgery

7. Natural history
• Highly lethal
• 70% die in 1st wk
• 90% at 3 month
• 10% chronic

8. Pathophysiology
Intimal tear
Progressive
separation of medial
layer
Antegrade/Retrograde
progression in spiral
fashion

9. Pathophysiology
• Medial degeneration
• Increased content of type-I &II collagen
• Activation of matrix metalloproteinase
• Compression by false lumen
• Intramural hematoma: Vasa vasorum rupture

10. Clinical features
Severe
chest
pain
Radiating to
back
Discrepency
between the
extremities in
pulse &B.P
Propagation
symptoms
Sharp and
tearing

11. • Hypotension may be due to:
– Impending rupture
– Intrapericardial rupture with temponade
– LVF due to AR
– MI due to compromise in coronary perfusion

12. Investigations
• Stanford diagnostic strategy-
– TEE
– CTA
– MRI: Not suitable for severely ill & unstable
patients

13. TEE CTA

14. X-Ray
• Widened mediastinum
• Abnormal aortic
contour

16. • ECG and serum markers are often normal

17. Treatment
Suspected aortic dissection
B.P control
I.V Esmolol
Stable
CECT
Ascending aortic dissection
Emergency Surgery
Descending aortic dissection
Complicated
Consider
EVAR
Uncomplicated
ICU
Management
Unstable
Intubation
TEE

18. Type A
• Primary tear-Continuous suture
• AR if present
• Annuloaortic ectasia-Root replacement with
replacement of coronary ostia (composite
valve graft)
• Hemiarch replacement
• Total arch replacement
• Strict long term B.P control

19. Chronic Aortic Dissection
• Indications of Surgery:
– Symptomatic patients
– Asymptomatic with Dia. Of AA > 55mm
– Asymptomatic with Marfan Dia. Of AA>50mm
– Rate of expansion > 1cm/yr

20. Type-B
• Medical management
• Surgical replacement of DTA:
– Aortic rupture or impending rupture
– Impaired distal organ perfusion
– Persistent pain
– Refractory arterial HTN
– Progression or expansion of dissection
– Sizable localized false aneurysm
– Marfan syndrome

21. • Stent grafting/Endoprosthesis-TEVAR
– Gore TAG
– Medtronic Talent
– Cook Zenith TX2
• Bare stent/flap fenestration

22. Indication of TEVAR
• >60 mm diameter or 2 times transverse
diameter of adjacent normal aortic segment
• Symptomatic regardless of size
• Growth rate of aneurysm to >3mm/yr

23. THANK YOU