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Aortic dissection


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Case presentation and brief review aortic dissection

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Aortic dissection

  1. 1. Aortic dissection
  2. 2. Case presentation50 yo man BIBA at 0230 with 3 hours of dull non-radiating central chest pain.En route, administered O2, 300mg Aspirin, 10mg Morphine and 10mg MetoclopramidePain free on arrival.
  3. 3. Previously wellNo positive risk factors for IHD or PENo regular medication or other drug useNo trauma or recent infections
  4. 4. No prior episodes of chest painVomited twice at home, and described as clammy and pale on arrival of ambulance, with BP 90/60 supine.
  5. 5. On arrivalPaleTemp 37 HR 60BP 60/40mmHg RR 14O2 sat 100% (3L/min)GCS 15/15Equal radial pulses4/6 Systolic murmurLungs clear to auscultation
  6. 6. ECG
  7. 7. Initial treatmentIV fluid 1L Normal saline statColour improved, BP to 90/60 mmHg,Pain freeEarly investigations:Trop T < 3 ng/L (N < 15)
  8. 8. CXR
  9. 9. Course2nd ECG normal and Trop T < 3 at 6 hours post onset of pain2nd litre of saline running, BP still 90/60mm/Hg, HR 60/min, with normal peripheral perfusionBP both arms the sameChest pain “2/10”Decision to order CT angiogram of chest
  10. 10. Intimal tear / flap ofdissection in aortic arch
  11. 11. 7.10AM Patient transferred to the OT for repair of the type A dissection and the aneurysmal dilatation of aortic root.
  12. 12. Aortic Dissection
  13. 13. Relatively uncommon (2.6-3.3/100 000 person- years)Initial event in aortic dissection is a tear in the aortic intima.Propagation of the dissection may be 1. Proximal (retrograde) 2. Distal (antegrade)
  14. 14. Complications Aortic valve injury with regurgitation Pericaridal tamponade End organ ischemia, examples include syncope, CVA, mesenteric or renal ischaemia.
  15. 15. Risk factors for aortic dissectionAdvancing ageMale sex 2:1 (Female – pregnancy)Systemic hypertensionPre-existing aortic aneurysmAtherosclerosis
  16. 16. Risk factors for under age 40Collagen vascular disordersVasculitisBicuspid aortic valveAortic coarctationTurners syndromeMarfan syndromePrior aortic valve surgeryInstrumentationTraumaHigh intensity weight lifting or other exerciseCocaine
  17. 17. ClassificationStanfordType A –ascending AortaType B – all other types / sites in aortaDeBakeyType I – Originates in ascending aorta, propagates at least to the aortic arch and often beyond it distally.Type II – Originates / confined to the ascending aorta.Type III – Originates in descending aorta, rarely extends proximally but will extend distally.
  18. 18. DiagnosisRoutine bloods – non diagnostic D-dimer < 500ng/ml unlikely to be dissectionHistory Anterior chest pain in ascending aortic dissection Severe sharp or tearing posterior chest or back pain when the dissection progresses distal to the subclavian artery
  19. 19. Pain can associated withSyncopeStrokeMIHeart failureEnd organ ischemia (splanchnic, renal, extremity or spinal cord ischaemia)Hypertension common with type BHypotension
  20. 20. Diagnosis of aortic dissection dependsupon demonstration of the dissection onimaging studies CXR CT MRI TEE / TTE
  21. 21.  CT
  22. 22. Immediate managementMaintain airway, good supportive careTreat hypotension / hypertension – aim for MAP 60-70 Beta blockers eg esmalol propranolol, labetalol Vasodilators Na nitroprusside Calcium channel blockers eg verapamil, diltiazem
  23. 23. ManagementType A – SurgicalType B – Surgical/medical