of the aorta, 2-3 times more common than rupture of the abdominal aorta. When left untreated, about 33% of patients die within the first 24 hours, and 50% die within 48 hours. The 2-week mortality rate approaches 75% in patients with undiagnosed ascending aortic dissection.
The establishment of the International Registry of Acute Aortic Dissection in 1996, which gathers information from 24 centers in 11 countries, has helped in the development of an understanding of the complexity of aortic dissection.
Dissections of the thoracic aorta have been classified anatomically by 2 different methods. The more commonly used system is the Stanford classification, which is based on involvement of the ascending aorta and simplifies the DeBakey classification.
Go to Aortic Dissection for complete information on this topic.
Stanford classification The Stanford classification divides dissections into 2 types, type A and type B. Type A involves the ascending aorta (DeBakey types I and II); type B does not (DeBakey type III).
This system helps to delineate treatment. Usually, type A dissections require surgery, while type B dissections may be managed medically under most conditions.
DeBakey classification The DeBakey classification divides dissections into 3 types, as follows:
Type I involves the ascending aorta, aortic arch, and descending aorta Type II is confined to the ascending aorta Type III is confined to the descending aorta distal to the left subclavian artery Type III dissections are further divided into IIIa and IIIb. Type IIIa refers to dissections that originate distal to the left subclavian artery but extend proximally and distally, mostly above the diaphragm. Prezentare general Disecie aortic este cea mai frecventa catastrofa de aorta , de 2-3 ori mai frecvente dect ruptura de aorta abdominala . Atunci cnd este lasata netratata , aproximativ 33 % dintre pacienti mor in primele 24 de ore , iar 50 % mor n termen de 48 de ore. Rata mortalitii de 2 sptmni, se apropie de 75 % la pacientii cu nediagnosticate disectie aortica ascendenta .
nfiinarea Registrului internaional de disectie aortica acuta in 1996 , care adun informaii de la 24 de centre in 11 de tari, a contribuit la dezvoltarea de o nelegere a complexitii de disectie aortica .
Disecii aleaortei toracice au fost clasificate anatomic prin 2 metode diferite . Sistemul mai frecvent utilizat esteclasificarea Stanford , care se bazeaz pe implicareaaortei ascendente i simplificclasificarea DeBakey .
Du-te la disectie aortic pentru informaii complete privind acest subiect .
clasificarea Stanford Clasificarea Stanford mparte disecii n 2 tipuri , de tip A i de tip B. Tipul A implic aorta ascendent ( tipuri DeBakey I i II ) , de tip B nu ( DeBakey tip III ) .
Acest sistem ajut la delimita tratament . De obicei , tip A disecii necesita o interventie chirurgicala , in timp ce disecii de tip B pot fi gestionate medical n cele mai multe condiii .
clasificarea DeBakey Clasificarea DeBakey mparte disecii n 3 tipuri , dup cum urmeaz :
Tipul I implic aorta ascendent , arcul aortic , i aorta descendenta Tip II este limitat laaorta ascendent Tip III se limiteaz laaortei descendente distal de artera subclavie stnga Tip III disecii sunt n continuare mprite n IIIa i IIIb . Tip IIIa se refer la disecii care provin distal de artera subclavie stnga , dar extinde proximal i distal , mai ales deasupra diafragmei .
Tip IIIb se refer la disecii care provin distal de
Type IIIb refers to dissections that originate distal to the left subclavian artery, extend only distally, and may extend below the diaphragm.
Thoracic aortic dissections should be distinguished from aneurysms (ie, localized abnormal dilation of the aorta) and transections, which are caused most commonly by high-energy trauma.
Prehospital Care Assure adequate breathing, maintain oxygenation, treat shock, and obtain useful historical information.
Establishing the diagnosis in the field is usually difficult or impossible, but certain salient features of aortic dissection may be observed. It is life threatening if not quickly recognized and treated.
Radio communication with the receiving hospital permits the medical control physician to direct care and select a capable destination hospital, while permitting the emergency department (ED) to mobilize appropriate resources.
In the rare event that the diagnosis can be made based on prehospital information, the physician directing prehospital care should request transport to a facility capable of operative treatment of an aortic dissection.
Emergency Department Care The mortality rate of patients with aortic dissection is 1-2% per hour for the first 24-48 hours. Initial therapy should begin when the diagnosis is suspected. This includes 2 large-bore intravenous lines (IVs), oxygen, respiratory monitoring, and monitoring of cardiac rhythm, blood pressure, and urine output.
Clinically, the patient must be assessed frequently for hemodynamic compromise, mental status changes, neurologic or peripheral vascular changes, and development or progression of carotid, brachial, and femoral bruits.
Aggressive management of heart rate and blood pressure should be initiated.
Beta blockers should be given initially to reduce artera subclavie stnga , extinde doar distal , i se poate extinde sub diafragm .
Disectii aortice toracice ar trebui s fie deosebit de anevrisme ( de exemplu , dilatarea anormal localizat a aortei ) i transections , care sunt cauzate cel mai frecvent de traumatisme de nalt energie .
ngrijirea prespitaliceasc Asigurarea respiraie adecvat , menine oxigenarea , trata oc , i de a obine informaii istorice utile .
Stabilirea diagnosticului n domeniul de obicei este dificil sau imposibil , dar anumite caracteristici importante ale disectie aortica pot fi observate . Acesta este n pericol viaa dac nu rapid recunoscute i tratate .
Comunicaii radio cu spitalul a primit permite medicului de control medical pentru ngrijirea direct i selectai un spital destinaie capabil , permind n acelai timp departamentul de urgenta ( ED ) de a mobiliza resursele adecvate .
n rarele cazuri care diagnosticul se poate face pe baza informaiilor prespital , medicul regie de ngrijire prespitaliceti trebuie s solicite de transport la o instalaie capabil de tratament operativ de o disectie aortic .
Departamentul de asistenta de urgenta Rata de mortalitate a pacienilor cu disectie aortica este 1-2 % pe ora in primele 24-48 de ore . Terapie iniial ar trebui s nceap atunci cnd se suspecteaz diagnosticul . Aceasta include 2 linii de mare cu teava intravenoase (IVS ) , oxigen , monitorizare respiratorie , i monitorizarea ritmului cardiac , a tensiunii arteriale , i diurezei .
Punct de vedere clinic , pacientul trebuie s fie evaluat frecvent pentru compromis hemodinamice , modificri ale statusului mental , modificri vasculare neurologice sau periferice , precum i dezvoltarea sau progresia bruits carotide , brahial , i femurale .
Ar trebui s fie iniiat de management agresiv al ritmului cardiac si a tensiunii arteriale .
Beta-blocantele trebuie acordat iniial pentru a the rate of change of blood pressure (dP/dt) and the shear forces on the aortic wall.
The target heart rate should be 60-80 beats per minute.
The target systolic blood pressure should be 100- 120 mm Hg.
End organ perfusion should be evaluated. Balancing the risks of dP/dt on the aortic wall versus the benefits of acceptable end organ perfusion may be a difficult clinical decision.
Retrograde cerebral perfusion may increase the protection of the central nervous system during the arrest period.
The mortality rate from aortic arch dissections is about 10-15%, with significant neurologic complications occurring in another 10% of patients. The mortality rate is influenced by the patient's clinical condition.
The American College of Radiology has established ACR Appropriateness Criteria for the diagnosis and treatment of suspected aortic dissection.[1]
Type A dissections Urgent surgical intervention is required in type A dissections.
The area of the aorta with the intimal tear usually is resected and replaced with a Dacron graft.
The operative mortality rate is usually less than 10%, and serious complications are rare with ascending aortic dissections.
The development of more impermeable grafts, such as woven Dacron, collagen-impregnated Hemashield (Meadox Medicals, Oakland, NJ), aortic grafts, and gel-coated Carbo-Seal Ascending Aortic Prothesis (Sulzer CarboMedics, Austin, Tex), has greatly enhanced the surgical repair of thoracic aortic dissections.
With the introduction of profound hypothermic circulatory arrest and retrograde cerebral perfusion, the morbidity and mortality rates associated with reduce rata de schimbare a tensiunii arteriale ( DP / dt) i forele de forfecare pe perete aortic .
Ritmul cardiac int ar trebui s fie 60-80 de batai pe minut .
Valoarea int a tensiunii arteriale sistolice ar trebui s fie de 100-120 mm Hg .
Perfuzia organelor final ar trebui s fie evaluat . Echilibrarea riscurile de dP / dt pe peretele aortic fa de beneficiile de perfuzie acceptabile de organe final poate fi o decizie clinic dificil .
Perfuziei cerebrale retrograd poate crete de protecie a sistemului nervos central n timpul perioadei de arest .
Rata mortalitii din arcul aortic disectii este de aproximativ 10-15 % , cu complicatii neurologice importante care apar ntr-un alt 10 % din pacienti . Rata de mortalitate este influenat de starea clinic a pacientului .
Colegiul American de Radiologie a stabilit ACR Criterii de adecvare pentru diagnosticul i tratamentul de disecie aortic suspectate . [ 1 ]
De tip A disecii Intervenie chirurgical de urgen este necesar tip A disecii .
Zona de aorta cu ruptura intimei , de obicei, este rezecat i nlocuit cu o grefa Dacron .
Rata de mortalitate operatorie este de obicei mai puin de 10 % , iar complicaii grave sunt rare, cu ascendent disectii aortice .
Dezvoltarea de grefe mai impermeabile , cum ar fi esute Dacron , Hemashield ( Medicals Meadox , Oakland , NJ) , grefe aortice , i gel - strat Carbo - Seal Ascendent Prothesis aortica ( CarboMedics Sulzer , Austin , Tex ) , colagen - impregnate -a mbuntit foarte mult repararea chirurgicale de disectii aortice toracice .
Odat cu introducerea de profund arestarea circulator hipotermic i a perfuziei cerebrale retrograde , ratele de morbiditate i mortalitate asociate cu aceasta operatie foarte invazive s-au this highly invasive surgery have decreased.
Dissections involving the arch are more complicated that those involving only the ascending aorta, because the innominate, carotid, and subclavian vessels branch from the arch. Deep hypothermic arrest usually is required. If the arrest time is less than 45 minutes, the incidence of central nervous system complications is less than 10%.
Aortic stent grafting is a challenging technique. It may prove feasible and has offered good results in a small series of patients. It may be a reasonable alternative in high-risk patients in the near future.
Type B dissections The definitive treatment for type B dissections is less clear.
Uncomplicated distal dissections may be treated medically to control blood pressure. Distal dissections treated medically have a mortality rate that is the same as or lower than the mortality rate in patients who are treated surgically.
Surgery is reserved for distal dissections that are leaking, ruptured, or compromising blood flow to a vital organ.
Acute distal dissections in patients with Marfan syndrome usually are treated surgically.
Inability to control hypertension with medication is also an indication for surgery in patients with a distal thoracic aortic dissection.
Patients with a distal dissection are usually hypertensive, emphysematous, or older.
Long-term medical therapy involves a beta- adrenergic blocker combined with other antihypertensive medications. Avoid antihypertensives (eg, hydralazine, minoxidil) that produce a hyperdynamic response that would increase dP/dt (ie, alter the duration of P or T waves).
Survivors of surgical therapy also should receive beta-adrenergic blockers.
diminuat .
Disecii implic arcului sunt mult mai complicate pe care cei care implic doar aorta ascendenta , deoarece brahiocefalic , carotid , i filiala subclavie nave de la arc . Arestarea profund hipotermic , de obicei, este necesar . Dac timpul de stop este mai mic de 45 de minute,incidena complicaiilor sistemului nervos central este mai mic de 10 % .
Stent aortice altoire este o tehnic dificil . Se poate dovedi fezabil i a oferit rezultate bune ntr -o serie mic de pacieni . Acesta poate fi o alternativa rezonabila la pacientii cu risc ridicat , n viitorul apropiat .
Tip B disecii Tratamentul definitiv de tip B disectii este mai puin clar .
Disecii distale necomplicate pot fi tratate medical pentru controlul tensiunii arteriale . Disecii distale tratat medical au o rat de mortalitate , care este la fel sau mai mic dect rata mortalitii la pacienii care sunt tratai chirurgical .
Chirurgia este rezervata pentru disecii distale care sunt scurgeri , rupt , sau de a compromite fluxul de sange la un organ vital .
Disecii distale acute la pacientii cu sindromul Marfan , de obicei, sunt tratate chirurgical .
Incapacitatea de a controla hipertensiunea arterial cu medicamente este , de asemenea, un indiciu pentru interventii chirurgicale la pacientii cu disectie distala toracice aortica .
Pacientii cu o disectie distala sunt de obicei hipertensivi , emphysematous , sau mai mari .
Tratament medical pe termen lung implic un blocant beta- adrenergic combinat cu alte medicamente antihipertensive . Evita antihipertensive (de exemplu , hidralazin , minoxidil ) care produc un rspuns hiperdinamice care ar crete dP / dt ( adic , modificareaduratei undelor P sau T ) .
Supravieuitorii de tratamentul chirurgical , de A series of patients with type B dissections demonstrated that aggressive use of distal perfusion, CSF drainage, and hypothermia with circulatory arrest improves early mortality and long-term survival rates.
Endovascular stenting remains an option for treatment of some type B dissections. Some studies recommend that patients with complicated acute type B dissections undergo endovascular stenting with the goal of covering the primary intimal tear.[2]
Definitive treatment Definitive treatment involves segmental resection of the dissection, with interposition of a synthetic graft.
When thoracic dissections are associated with aortic valvular disease, replace the defective valve.
With combined reconstructionvalve replacement, the operative mortality rate is approximately 5%, with a late mortality rate of less than 10%.
Operative repair of the transverse aortic arch is technically difficult, with an operative mortality rate of 10% despite induction of hypothermic cardiocirculatory arrest.
Repair of the descending aorta is associated with a higher incidence of paraplegia than repair of other types of dissections because of interruption of segmental blood supply to the spinal cord.
The operative mortality rate is approximately 5%.
In a study by Mimoun et al of patients with Marfan syndrome who had acute aortic dissection, the patients were found to have a better event-free survival when there were no dissected portions of the aorta remaining after surgery.[3]
Consultations Once a thoracic dissection is suspected, consult a thoracic surgeon. Because many patients with this disorder have concomitant medical illness, consult the patient's primary care provider to expedite preoperative preparation. Early consultation is encouraged when ordering further imaging studies if the patient requires rapid operative intervention. asemenea, ar trebui s primeasc beta - blocante adrenergice .
O serie de pacienti cu disectii de tip B, au demonstrat c utilizarea agresiv a perfuziei distale , drenajul LCR , i hipotermie cu arestarea circulator imbunatateste mortalitatea precoce si ratele de supravietuire pe termen lung .
Stentare endovasculare ramane o optiune pentru tratamentul unor disectii de tip B . Unele studii recomanda ca pacientii cu complicate disectii de tip B acute supuse stent endovasculare cu scopul de a acoperi ruptura intimei primar . [ 2 ]
tratament definitiv Tratamentul definitiv implic rezecia segmental de disectie , cu interpunerea de o grefa sintetic .
Cnd disecii toracice sunt asociate cu boala valvulara aortica , nlocuii supapa defect .
Cu nlocuire reconstrucia supape combinat ,rata mortalitii operativ este de aproximativ 5 % , cu o rat de mortalitate trzie a mai puin de 10 % .
Repararea operativ a arcului aortic transversal este punct de vedere tehnic dificil , cu o rat de mortalitate operatorie de 10 % , n ciuda inducerea de arestare cardiocirculatorii hipotermic .
Repararea aorta descendenta este asociat cu o incidenta mai mare de paraplegie dect repararea altor tipuri de disectii cauza de ntrerupere a alimentrii cu snge segmente de maduva spinarii .
Rata de mortalitate operatorie este de aproximativ 5 % .
ntr-un studiu de Mimoun et al pacientilor cu sindrom Marfan , care a avut disectie de aorta , pacientii s-au dovedit a avea o mai buna de supravietuire fara evenimente atunci cnd nu s-au disecat poriuni ale aortei rmase dup intervenia chirurgical . [ 3 ]
consultri Odat ce o disectie toracica este suspectat , consulta un chirurg toracic . Deoarece multi pacienti cu aceasta tulburare au boli concomitente medicale , consultai pacientului de ingrijire
Consult a radiologist prior to obtaining aortography.
Inpatient Care Patients with symptomatic dissection should undergo immediate repair, especially if it is leaking or expanding.
Symptomatic patients require admission to a center experienced in cardiopulmonary bypass and operative care.
Completely asymptomatic patients may have their repair performed electively but may require admission to expedite their evaluation or for preoperative stabilization of their condition.
Patients with chest pain should undergo serial echocardiograms (ECGs) and creatine kinase (CK) determinations if acute myocardial infarction (AMI) is indicated.
Outpatient Care Follow-up examinations with radiologic studies are recommended at 3-month intervals for the first year and every 6 months for the next 2 years.
After this, follow up annually.
Transfer Symptomatic patients require care at a facility equipped to perform cardiopulmonary bypass with aortic and/or valvular repair.
Contact the receiving physician as soon as possible to transfer patients before their condition deteriorates.
Early airway management is indicated in the presence of hemoptysis or stridor.
If coronary insufficiency is suspected, nitrates may be used, but therapy with thrombolytic agents and aspirin should be avoided.
Patients should be monitored and accompanied by personnel capable of resuscitation.
If a prolonged ground transport time is anticipated, consider air transport. primara de a accelera pregtire preoperatorie . Consultare devreme este ncurajat atunci cnd comanda studii suplimentare imagistica cazul n care pacientul necesit intervenie operativ rapid .
Consulte un radiolog nainte de obinerea aortografie .
staionar Pacientii cu disectie simptomatic ar trebui s fac reparaii imediate , mai ales dac acesta este scurgeri sau extinde .
Pacienii simptomatici nevoie de admitere la un centru de experien n by-pass cardiopulmonare i operative de ingrijire .
Complet asimptomatici pot avea repararea acestora, realizat prin alegere , dar poate solicita admiterea pentru a accelera evaluarea lor sau pentru stabilizarea preoperatorie de starea lor .
Pacienii cu durere in piept ar trebui s se supun ecocardiograme de serie ( ECG ) i creatinkinazei ( CK ) determinri , dac este indicat infarct miocardic acut ( IMA ) .
ambulatoriu Follow - up examene cu studii radiologice se recomand la intervale de 3 luni pentru primul an i la fiecare 6 luni pentru urmtorii 2 ani .
Dup aceasta , urmarire anual .
transfer Pacienii simptomatici necesita ingrijire la o instalaie echipate pentru a efectua by-pass cardiopulmonare cu aortic i / sau reparare valvulara .
Contactai medicul primete ct mai curnd posibil pentru a transfera pacientii inainte de starea lor se deterioreaza .
De gestionare a cailor aeriene precoce este indicat n prezena hemoptizie sau stridor .
Dac se suspecteaz insuficien coronarian , pot fi utilizate nitrai , dar terapia cu medicamente trombolitice i aspirin trebuie evitat .
Pacienii trebuie monitorizai i nsoite de personal capabil de resuscitare .
n cazul n care un timp prelungit de transport la sol se anticipeaz , ia n considerare transportul aerian .