Aortic Dissection and Aneurysms

Dr Syed Asmar Yazdani, MD

CTS

Abdominal Aortic Aneurysms

(AAA)
Risk factors

Elderly (>60)
Familial trend (18% with 1 relative)
Connective Tissue D/O (Marfans)
Other aneurysms
Atherosclerosis (HTN, Lipids, smoking, DM)

AAA
Pathogenesis

Intima infiltrated by atherosclerosis and thinned

media.
Possible intraluminal thrombus and adventitia
infiltrated by inflammatory cells

AAA
Average rate of growth 0.25-0.5 cm per
year.
Larger aneurysms extend more rapidly than
smaller ones. (LaPlace law)

AAA
Clinical Features

Syncope (10-12%)
Back and/or Abdominal Pain severe and abrupt,
ripping or tearing sensation (50%)
Shock intraperitoneal rupture, massive blood
loss
Sudden death

AAA
Physical Exam

Pain on palpation or not

Retroperitoneal hematoma
Cullen

sign (periumbilical ecchymosis)

Grey-Turner sign (flank ecchymosis)
Scrotal hematoma or inguinal mass (blood dissecting
to these areas)
Iliopsoas sign
Femoral nerve neuropathy

AAA
Found aneurysms refer to follow up
>5cm diameter increased chance of rupture
<5cm decreased chance of rupture
Symptomatic aneurysms of any size =
Emergency!!

AAA
Diagnosis

Includes differential diagnoses of syncope, abd

pain, CP, back pain and shock.
If with combo of two or more think aortic dz.

AAA
Radiologic Evaluation
Should not delay operative treatment!!

Plain abd film (calcified bulging)

US (bedside, up to 100% sensitive, not reliable
to detect rupture)
CT (with IV contrast only if stable)
MRI

AAA
ED Treatment

Urgent surgical consult

Make diagnosis & assist rapid transfer to OR
2 large bore IVs
Cardiac Monitor
O2
? Blood transfusion
IV fluid resuscitation controversial amount b/c too much can be
harmful

RADIOGRAPHIC STUDIES ONLY IF UNLIKELY TO

HAVE RUPTURED AAA!!!

AAA
of patients with ruptured AAA who
reach the OR die!

A Bit About Thoracic Aortic

Aneursym
Presenting symptoms include esophageal,
tracheal, bronchial, or even neurologic
disorders.
If it erodes to adjacent structures it is
immediately fatal!!

Aortic Dissection
Pathogenesis

Prominent cause of sudden death

Presents with severe abd., chest, and back pain
Violation of intima that allows blood to enter
media and dissect b/w intimal and adventitial
layers
Common site is ascending aorta at ligamentum
arteriosum

Aortic Dissection
Common presenting groups

>50 yoa with HTN

2/3 male
Marfans syndrome
Congenital heart disease
Pregnancy

Aortic Dissection
Stanford Classification

Type A -involves ascending aorta

Type B involves descending aorta

DeBakey Classification

Type I ascending, arch & descending aorta

Type II ascending only
Type III descending only

Aortic Dissection
Clinical Features

>85% abrupt, severe pain in chest or b/w scapula

50% ripping or tearing
Pain in anterior chest ascending aorta (70%)
Back pain (less common) descending aorta
(63%)
If dissection into carotid classic neuro symptoms

Aortic Dissection
Clinical Features

40% with neurologic sequelae (ex. paraplegia)

Nausea, vomiting, diaphoresis
Most have sense of impending doom!

Aortic Dissection
Physical Exam

Usually normal heart and lung exam

May have aortic insufficiency
<20% with decreased radial, femoral or carotid
pulse
HTN
Tachycardia
Hypotension

Aortic Dissection
Physical Exam

Pericardial tamponade (muffled heart tones,

JVD, pulsus paradoxus)
Hoarseness (compression of recurrent laryngeal
nerve)
Horners Syndrome (compression of superior
cervical sympathetic ganglion)

Aortic Dissection
Diagnosis

Ischemic end-organ manifestation such as MI,

pericardial dz, pulmonary d/o, stroke, SCI,
musculoskeletal dz of extremities,
intraabdominal ischemia.
Can change location with time as dissects.

Aortic Dissection
Thoracic Dissection

90% have abnormal CXR

Widened

mediastinum
Abnormal aortic contour
Pleural effusion
Deviation of trachea, mainstem bronchi, or esophagus
Intimal calcium visable & distant from edge (calcium
sign)

Aortic Dissection
Diagnosis

CT
83-100%

sensitive
87-100% specific
Use spiral CT with IV contrast
Will not give anatomic details of arterial branches or
aortic valve competence.
Modality of choice in unstable patient

Aortic Dissection
Diagnosis

Angiography
Gold standard
Shows all anatomy and involvement
94% specific
88% sensitive

TEE
97-100% sensitive
97-99% specific
Esophageal dz contraindication

Aortic Dissection
In contrast to ruptured AAA,
SUSPECTED DISSECTIONS MUST BE
CONFIRMED RADIOLOGICALLY
PRIOR TO SENDING TO OR!!!

Aortic Dissection
ED Treatment

Treat hypertension
-blocker

Esmolol 500g/kg IV bolus over 1 minute then 50-150 g/kg

minute
Metoprolol 5mg q2min x3 IV then 2-5mg/hr
Propranolol 20mg IV then 40mg, 8-mg q10min to 300mg
total
Calcium

channel blocker if -blocker contraindicated

Aortic Dissection
ED Treatment

Vasodilator
Nitroprusside

0.3 g/kg/min IV

Surgery
OR

for ascending aortic dissection

Descending aortic dissection worse surgical risks
controversial for repair

Any Questions????

Questions
1. A patient with a suspected aortic
dissection should be immediately tranferred
to OR without radiographic studies.
A. True
B. False

 2. Females are more likely than males to develop aortic

dissection.

A. True
B. False

3. Dissection of the ascending aorta only is DeBakey

classification

A.
B.
C.
D.
E.

Type I
Type II
Type III
Type A
Type B

 4. Patients with a ruptured AAA can present

with all of the following symptoms except

A.
B.
C.
D.
E.

Shock
Syncope
Sudden death
Nausea and vomiting
Headache

 5. Which of the following radiologic

modalities is considered the gold standard
for diagnosing an aortic dissection?

A.
B.
C.
D.
E.

CT
MRI
TEE
Angiography
CXR

Answers
1. B
2. B
3. B
4. E
5. D