PENYAKIT DAN TRAUMA AORTA

 the Global Burden Disease 2010 project the

overall global death rate aortic aneurysms and
AD increased from 2.49 per 100 000 to 2.78
per 100 000 with higher rates for men (1990
and 2010)
 AAA have declined over the last two decades.
The burden increases with age, higher rates for
men.
The aortic wall
 Tunica intima lined by the endothelium;

 Tunica media: elastic and collagen fibres with

the border zone of the lamina elastica interna
and -externa, as well as smooth muscle cells;
and
 Tunica adventitia containing mainly collagen,
vasa vasorum, and lymphatics
 pressure-responsive receptors located in the
ascending aorta and aortic arch.
aortic pressure HR and SVR,
aortic pressure HR and SVR
 Elasticity: Windkessel function
 rate of aortic expansion: 0.9 mm (men), 0.7
mm (women) each decade. related to a higher
collagen-to-elastin ratio (ageing), along with
increased stiffness and pulse pressure
 Personal cardiovascular risk factors, and
 family history of arterial diseases, especially
the presence of aneurysms and
 any history of AD or sudden death
a. Silent in many cases
b. Acute deep, aching or throbbing chest (‘feeling
of rupture’) or abdominal pain that can spread
to the back, buttocks, groin or legs(AD, AAS),
c. Cough, shortness of breath, or difficult or
painful swallowing (TAA).
d. Constant or intermittent abdominal pain or
discomfort, a pulsating feeling in the
abdomen, or feeling of fullness after minimal
food intake in large AAAs.
e. Stroke, transient ischaemic attack, or
claudication secondary to aortic
atherosclerosis.
f. Hoarseness due to left laryngeal nerve palsy
in rapidly progressing lesions.
 Prominent arterial pulsations or turbulent blood
flow causing murmurs
 Blood pressure and pulse should be compared
between arms
IMAGING

 X-Ray
 USG

 CT Scan

 PET/CT

 MRI

 Aortography

 Intravascular Ultrasound
ACUTE AORTIC SYNDROMES

 Emergency conditions
 eventually leads to a breakdown of the intima
and media
 tear or an ulcer allows blood to penetrate from the
aortic lumen into the media
 when a rupture of vasa vasorum causes a bleed
within the media
 IMH, PAU, or in separation of aortic wall layers
 Acute aortic dissection
 Intramural haematoma

 Penetrating aortic ulcer

 Aortic Pseudoaneurysm

 Contained ruptured of aortic aneurysm

 Traumatic aortic injury

1. ACUTE AORTIC DISSECTION

 Aortic dissection is defined as disruption of the

medial layer provoked by intramural bleeding
(True L and an False L)
 Acute AD (,14 d)
 sub-acute (15–90 d), and

 chronic aortic dissection (90 d)

CLINICAL PRESENTATION AND COMPLICATION
HIGHER PROBABILITY AAD
 D-dimers are immediately very high, the
suspicion of AD is increased. (highest Dx
during an hour from onset)
 Acute Type A AD has a mortality of 50%
within the first 48 hours if not operated
 perioperative mortality (25%) and
neurological complications (18%)
 surgery reduces 1-month mortality from 90%
to 30%.

 uncomplicated Type B AD receive medical

therapy to control pain, heart rate, and blood
pressure
2. INTRAMURAL HAEMATOMA
 haematoma develops in the media of the
aortic wall in the absence of an FL and
intimal tear.
 IMH is diagnosed in the presence of a
circular or crescent-shaped thickening of 0.5
mm of the aortic wall in the absence of
detectable blood flow
 ascending aorta (30%) and aortic arch (Type
A) (10), descending thoracic aorta (Type B)
(60–70%)
 CT and MRI are the leading techniques for
diagnosis and classification of intramural
haematoma
 imaging include to localize a primary (micro)
entry tear, which is very often present
 30–40% of Type A IMH evolved into AD, with
the greatest risk within the first 8 days after
onset of symptoms.
 Acute Type B IMH hasan in-hospital mortality
risk of 10%
 at 5 years survival reported in IMH series
ranged from 43–90%
3. PENETRATING AORTIC ULCER

 Penetrating aortic ulcer (PAU) is defined as

ulceration of an aortic atherosclerotic plaque
penetrating through the internal elastic lamina
into the media
 2–7% of all AAS

 Propagation lead to IMH, pseudoaneurysm, or

aortic rupture, or an acute AD
Common features in patients affected:
 older age, male gender, tobacco smoking,
HT, CAD, COPD, and concurrent abdominal
aneurysm

Symptoms
 may be similar to those of AD,

 more often in elderly patients and

 rarely manifest as signs of organ

malperfusion
 On unenhanced CT, PAU resembles an IMH.
 Contrast-enhanced CT is the technique of
choice for diagnosis of PAU

 Aim of treatment: prevent aortic rupture and

progression to acute AD.
 Intervention if recurrent and refractory pain,
rapidly growing aortic ulcer, associated
periaortic haematoma, or pleural effusion.
 Asymptomatic PAUs with D= 0.2mm or neck
0.1mm may be candidates for early intervention
4. AORTIC PSEUDOANEURYSM
 Aortic pseudoaneurysm (false aneurysm) is
defined as a dilation of the aorta due to
disruption of all wall layers, which is only
contained by the periaortic connective tissue
 Tension overmaximal Fatal
Rupture
1. commonly secondary to blunt thoracic trauma
2. Iatrogenic aetiologies
3. rare: mycotic aneurysms and penetrating ulcers

 interventional or open surgical interventions

are always indicated
5. (IMPENDING) RUPTURE OF THORACIC AORTIC
ANEURYSM
 acute pain in whom imaging detects aortic
aneurysm with preserved integrity of the aortic
wall
 Concurrent abdominal pain

 Acute respiratory failure: bleeding to L

hemithorax.
 haemoptysis from aortobronchial fistula

 haematemesis from an aorto-oesophageal fistula

 Overt free aortic rupture typically leads rapidly to

internal bleeding and death.
 As a general rule, the closer the location of
the aneurysm to the aortic valve, the greater
the risk of death.
 Fewer than half of all patients with rupture
arrive at hospital alive; mortality may be as
high as 54% at 6 hours and 76% at 24 hours
after the initial onset
 CT is indicated,
 using a protocol including a non-contrast phase
to detect IMH, followed by a contrast injection
to delineate the presence of contrast leaks
indicating rupture

 TAA are indications for urgent treatment

because of the risk of imminent internal
bleeding and death
6. TRAUMATIC AORTIC INJURY
 high-speed motor vehicle accidents or falling
from a great height (high suspicious: head
and side of body trauma)
 Up to 90% at the aortic isthmus
 Thoracic aortic injury 2nd most common
blunt trauma cause of death

 A classification scheme for TAI has been

proposed:
Type I (intimal tear), Type II (IMH), Type III
(pseudoaneurysm), and Type IV (rupture)
 Aggressive fluid administration should be
avoided because it may exacerbate bleeding,
coagulopathy, and hypertension;
 MAP should not exceed 80 mmHg

 Surgery
7. IATROGENIC AORTIC DISSECTION
 (i) catheter-based coronary procedures,
 (ii) cardiac surgery,

 (iii) as a complication of endovascular

treatment of aortic coarctation,
 (iv) aortic endografting,

 (v) peripheral interventions,

 (vi) intra-aortic balloon counterpulsation and,

more recently,
 (vii) during transcatheter aortic valve
implantation
AORTIC ANEURYSMS

 Aneurysm is the second most frequent disease

of the aorta after atherosclerosis
 aortic aneurysm may be associated with other
locations (illiac, femoral, or plopiteal)
 Increased risk CV event (caused by RF)

 27% AAA + TAA, women and elderly

1. THORACIC AORTIC ANEURYSMS

 Often Asymptomatic
 Less with clinical signs of compression,
chest pain, an aortic valve murmur
 In patients with Marfan syndrome, the TAA
growth is on average at 0.5–1 mm/year,
 In Loeys-Dietz syndrome (LDS) can grow
more than 10 mm/year, mean age of death
26 years
 Descending aorta grow faster (at 3
mm/year) than in ascending aorta (at 1
mm/year)
Evaluation
 Echo

 X-Ray

 CT scan

1. Size
2. Co-existing aorta disease (IMH, PAU,
aneurysmal branch vessel)
ABDOMINAL AORTIC ANEURYSM

 usually defined as a diameter ≥30 mm

 FR: Age, male gender, personal history of
atherosclerotic cardiovascular disease,
smoking and hypertension
 Dyslipidemia is considered as a weaker risk

 A family history of AAA is a powerful predictor of

prevalent
 Mostly silent.
 The most frequent mode of detection is
incidental
 Atypical abdominal or back pain may be
present
 may detect a pulsatile abdominal mass

 preceded by a less intense abdominal pain

for contained rupture
 Acute abdominal pain and shock if ruptured
 USG
 Aortography

 CT scan

 MRI
 Small abdominal aortic aneurysms (30-54
mm)
 Conservative : Beta Blocker, ACE inhibitor,
antiplatelet, statin.
Recommendation for asymptomatic AAA
GENETIC DISEASE OF AORTA

1. Turner syndrome
 Partial or complete monosomy of the X
chromosome (karyotype 45X0)
 A generalized dilation of major vessels is
observed, notably the aorta, the brachial, and
carotid arteries.
management
 imaging (echocardiogram and thoracic MRI) with
CV risk assessment.
FU:
 with TTE every 3–5 years for low risk,
 thoracic MRI every 3–5 years for moderate risk,
and
 referral to a cardiologist with 1–2-yearly thoracic
MRI for high-risk patients.
2. Marfan syndrome
 Heritable connective tissue disorder, AD

 mutations in the FBN1 gene that encodes

fibrillin-1, the major component of isolated
or elastin associated microfibrils
 Losartan is effective in reducing the rate of
dilation of the aortic root
3. Ehlers-Danlos syndrome Type IV or vascular
type
 Autosomal dominan

 The clinical features of EDSIV are thin,

translucent skin, extensive bruising,
 characteristic facial appearance (notably a
pinched and thin nose, thin lips, prominent
ears, hollow cheeks, and tightness of skin
over the face), and premature ageing of the
skin.
 The disease frequently involves the thoracic
and abdominal aorta, the renal, mesenteric,
iliac, and femoral arteries, as well as the
vertebral and carotid arteries (extra- and
intra-cranial).
 Arteries can dissect without previous dilation
and are thus unpredictable.
 in potentially fatal complications, since the
fragility of tissue, haemorrhagic tendency,
and poor wound healing confer an added
surgical risk
4. Loeys-Dietz syndrome
 Autosomal dominant

 Aortic aneurysm syndrome combining the

triad:
 arterial tortuosity and aneurysms throughout the
arterial tree,
 hypertelorism, and

 bifid uvula,

 And shared features Marfan syndrome

 recommendation of early operative at
ascending aortic diameters of ≥42 mm
COARCTATION OF THE AORTA

 a circumscript narrowing of the aorta

(discrete stenosis) or as a long, hypoplastic
aortic segment.
 Typically located at the area of ductus
arteriosus insertion,
 May ectopically (ascending, descending, or
abdominal aorta) in rare cases.
Clinical features:
 upper body systolic hypertension, lower
body hypotension, a blood pressure gradient
between the upper and lower extremities
(>20 mmHg indicates significant coarctation
of the aorta),
 radiofemoral pulse delay, and

 palpable collaterals
Echo:
 Site, structure, and extent of coarctation, EF,
and hypertrophy, and aortic and supra-aortic
vessel diameters
MRI
CT scan
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