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DISEASES OF THE AORTA

Dr. Allan B. Ruales
080709
Aorta
-

Normal = 3cm origin, 2.5cm

Aortic aneurysm
Atherosclerosis
Cystic medial necrosis
TB
Syphilitic infection
Mycotic infection
Rheumatic aortitis
Trauma
Aortic dissection
Cystic medial necrosis
Systemic hypertension
Atherosclerosis
Takyasus arteritis
Giant cell arteritis
*usually if with aneurysm, prone to dissect
Aortic occlusion
Atherosclerosis
Throboembolism
Aortitis
Syphilitic aortitis, rheumatic aortitis
Takyasus arteritis
Giant cell
AORTIC ANEURYSM
Pathologic dilatation of a segment of the aorta
True: involves 3 layers (intima, tuinica media,
adventitia)
Pseudoaneurysm: intima and medial layers
o Dilatation lined by adventitia
Gross appearance
o Fusiform: entire circumference
(diffusely dilated)
o Saccular: portion of the circumference
(outpouching of vessel wall)
MC cause: atherosclerosis
CYSTIC MEDIAN NECROSIS
Degeneration of collagen and elastic fibers in
the tunica media with loss of medial cells
replaced by mucoid material
Proximal aorta
Prevalent with Marfan and Ehlers-Danlos
syndrome
Familial clustering 20%
Syphilis
Uncommon
90% ascending aorta or arch
Tuberculous typically affect the thoracic aorta
from direct extension of infection from hilar LN
or contiguous abscesses
Mycotic

DISEASES OF THE AORTA

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Rare resulting from infection o an

atherosclerotic plaque
Usually saccular

Vasculitides
Arch and descending thoracic aorta
Takayasus and giant cell arteritis
Spondyloarthropathies
Ascending aorta
Behcets thoracic aneurysm
Trauma
Penetrating or non-penetrating
Descending thoracic beyond site of insertion of
ligamentum arteriosum
Congenital
Assoc with anomalies like bicuspid aortic valve
THORACIC AORTIC ANEURYSM
Clinical manifestation and natural hx depend
on location
Mc etiology: cystic medal necrosis
Arch and descending aorta
Ave growth rate: 0.1 to 0.4cm per year
Risk of rupture related to site and presence of
symptoms
Inc for ascending >6cm and descending >7cm
Symptoms are from compression of erosion of
adjacent tissue
Recurrent laryngeal nerve: hoarseness
May cause CHF as a consequence of AR
Compression of SVC = superior vena caval
syndrome
Xray: widening of mediastinal shadow and
displacement or compression of trachea or left
mainstem bronchus
2D echo: assess prox ascending and
descending thoracic aorta
CT and MRI: for thoracic aorta
o Asymptomatic patients with aneurysms
too small for surgery, performed 612months to monitor expansion
Aortography: length and involvement of branch
vessels
Treatment: long term beta blocker therapy
o Control HPN
o Operative repair: placement of
prosthetic graft, asymptomatic > 5cm
ABDOMINAL AORTIC ANEURYSM
More seen in males
Increase incidence with age
90% >4cm have atherosclerosis usually below
level of renal arteries
Risk of rupture increases with size
o >5cm 20-40%
o <5cm 1-2%
Commonly asymptomatic
Palpable, pulsatile and nontender mass
Incidental findings
Aneurismal pain: harbinger of rupture
representing a medical emergency

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Abdominal Xray: calcified outline

o 25% not calcified
Abdominal ultrasound: transverse and
longitudinal dimensions, mural thrombus
o Screen patients who are at risk
CT with contrast and MRI: more accurate for
location and size
Contrast aortography: can underestimate the
diameter
Treatment: prosthetic graft (any size,
expanding rapidly)
o Percutaneous endovascular stent
grafts: infrarenal aneurysm

AORTIC DISSECTION
Circumferential or transverse (less frequently)
tear of intima
Usually along right lateral wall of ascending
aorta (high hydraulic shear stress)
Next is descending thoracic aorta below
ligamentum arteriosum
Initiating event: primary intimal tear with 2o
dissection into the media
o Medial hemorrhage dissecting into and
disrupts intima
Classification
DeBakey I: intimal tear in asc aorta but also involving
des
DeBakey II: Dissecton limited to asc
DeBakey III: Intimal tear in des with distal propagation
Stanford for management
A: dissection of ascending (proximal)
B: limited to descending (distal)
Factors
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predisposing to Dissection
Systemic HPN 70% of patients
Cystic medial necrosis
Marfan syndrome
Ehlers-Danlos syndrome
Inflammation aortitis
Congenital aortic bicuspid valve
Normal women during 3rd trimester pregnancy

Clinical
-

manifestations
Peak: 60-70years
Men more affected
Sudden pain: very severe and tearing assoc
with diaphoresis front or back of chest
Syncope, dyspnea and weakness

Physical findings
Hypertension or hypotension
Loss of pulses
Pulmonary edema
AR
Neurologic findings due to obstruction to
carotid arteries
Bowel ischemia
Compression of adjacent structures
Hemopericardium and cardiac tamponade
type A lesion (retrograde dissection)
Xray: widened superior mediastinum

DISEASES OF THE AORTA

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Dx established: aortography or noninvasive

tests
Treatment: as soon as dx is considered
o IV nitrate to reduce shear stress
Surgery for type A or complicated type B
Medical therapy: for uncomplicated and stable
type B
Follow up 6-12 months CT or MRI
Good prognosis

VASCULAR DISEASES
Arterial disorders
PAD
Etiology: atherosclerosis
6th and 7th decade
High incidence: DM, smoker, HPN,
Pathology: segmental lesions causing occlusion
in large and medium-sized vessels
Femoral and popliteal arteries: 80-90%
Tibial and peroneal: 40-50%
Usually seen at branch points
Sites of increased turbulence
Altered sheared stress
Clinical manifestations:
o Asymptomatic
o Intermittent claudication MC
o Pain, ache, numbness
o Sense of fatigue relieved by rest
o Leriche syndrome: aorto iliac
o Critical limb ischemia in severe
occlusion: rest pain, feeling of cold or
numbness
o Bruit on narrowed arteries
o Ulcers gangrene
History and PE sufficient for diagnosis
Ankle:Branchial Index (ABI)
o >1.0 normal
o <1.0 in PAD
o <0.5 severe ischemia
o (systolic pressure)
Done when planning revascularization:
o MR Angiography
o Contrast angiography
Prognosis depends on coexisting CAD and
cerebral vascular disease (50% with
symptomatic PAD have significant CAD)
o With claudication: 70% 5-year and 50%
10-year survival rate
o Death sudden due to MI
o Worse if with DM or smokers
Treatment
o Asymptomatic: supportive measures
o Pharmacologic: clopidogrel, ASA,
Cilostazol
o Revascularization: non operative
intervention and surgical

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Thrombosis obliterans
Buergers disease
Inflammatory occlusive vascular disorder of
small and medium-sized arteries
Relationship to cigarette smoking
Triad:
o Claudicaiton
o Raynauds phenomenon
o Thrombophlebitis
PE
o Normal brachial and popliteal pulses
Arteriography
o Helpful in diagnosis
o Smooth tapering segmental lesions
Diagnosis: excisional biopsy and pathologic
exam of involved vessel
Treatment: no specific treatment
o Arterial bypass: larger vessels
o Amputation
o Local debridement with antibiotics
Acute Arterial Occlusion
Sudden cessation of blood flow to an extremity
Principal sources: embolism and thrombus in
situ
Sources of emboli: heart, aorta, large arteries
o Cardiac disorders: AF, AMI,
cardiomyopathy, prosthetic heart
valves, atrial myxoma
o Paradoxically from venous thrombus
entering via patent foramen ovale or
other septal defect
Thrombosis in situ
o Trauma on artery
o Arterial bypass graft
o Atherosclerotic vessel at site of plaque
or aneurysm
o Complication of arterial puncture and
placement of catheter
o Thoracic outlet compression
Clinical features depend on location, duration
and severity of obstruction
Severe pain, paresthesia, numbness, coldness
within one hour
Paralysis with severe ischemia
Diagnosis: clinical presentation is enough
o Arteroigraphy: location ad extent of
occlusion
Treatment
o IV heparin
o Intraarterial thrombolytic therapy
o Arterial bypass
o Endovascular or surgical
thromboembolectomy
RAYNAUDS PHENOMENON
Episodic digital ischemia, manifested by digital
blanching, cyanosis and rubor of fingers or toes
following cold exposure and subsequent
rewarming
Pathophy: cold-induced episodic digital
ischemia
Ischemia cyanosis rubor

DISEASES OF THE AORTA

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Two categories
Raynauds disease
o Idiopathic or primary variety
o Associated with angina
Secondary variety associated with other
diseases
Treatment
Reassurance
Avoid unnecessary cold exposure
Tobacco use is contraindicated
Drugs reserved for severe cases
Acrocyanosis
Arterial vasoconstriction and secondary dilation
of capillaries and venules resulting to
persistent cyanosis of hands
Livido reticularis
Mottled or net-like appearance of reddish to
blue discoloration
Pernio
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Erythematous lesions over legs

Pruritus
Burning sensation
Avoid cold exposure
Sympatholytic drugs

Eryhtromelalgia
Burning and erythema or extremities
Feet more affected than hands
Males more affected
Middle age
Precipitated by warm environment
Normal pulses
Expose to cool air or elevate
No specific treatment
Venous disorders
Venous thrombosis (thrombophlebitis)
Thrombus within a superficial or deep vein with
inflammatory response in the vessel wall
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Virchow Triad:
o Stasis
o Vascular damage
o Hypercoagulability

Inc risk for venous thrombosis

o Surgery

Thoracic, abdominal, GUT

procedures
o Neoplasms

Pancreas, lungs, ovaries, breast

o Trauma

Spines, pelvis, femur, spinal

cord injuries
o Immobilization: AMI, CHF, stroke
o Pregnancy

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o
o
o

Estrogen use (replacement or

contraception)
Hypercoagulable states: resistance to
activated protein C, deficiencies of
antithrombin III, DIC
Venulitis

Buerger

Behcets
Previous DVT

Deep Vein Thrombosis

Pulmonary embolism life threatening
Iliac, femoral, popliteal
Unilateral leg swelling
Phlegmasia cerulea dolens
o Deoxygenated hgb in stagnant veins
impart a cyanotic hue
Phlegmasia alba dolens
o Interstitial pressure exceeds capillary
perfusion pressure causing pallor
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Diagnosis: MC complaint is CALF pain

o Posterior calf tenderness
o Homans sign: inc resistance or pain on
dorsiflexion of foot)
o D-dimer test

Elevated

Not specific
o Duplex venous UTZ: high sensitivity for
proximal DVT
o MRI: similar accuracy with Duplex

Differentials
o Lymphedema
o Arterial occlusive disease

Treatment
o Prevent pulmo embolism
o Bed rest
o Give anticoagulants

Heparin - aPTT
Warfarin PT

Prophylaxis for high risk patients

o Heparin
o Warfarin
o External pneumatic compression

Superficial Vein Thrombosis

Does not result to PE
Greater or lesser saphenous veins and
tributaries
Treatment: heparin and warfarin
Varicose veins
Chronic venous insufficiency
lymphedema

QUIZ
1.
2.
3.

DISEASES OF THE AORTA

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Blue toe syndrome atheroembolism

Primary Raynauds Raynauds disease
String bead appearance fibromuscular
dysplasia
4. Buergers - thomboangitis obliterans
5. Raynauds phenomenon
6. Pseudoaneurysm involves all three layers
false
7. Saccular aneurysm involves the entire
circumference false
8. True
9. True
10. Abdominal aortic aneurysm commonly occurs
above the renal arteries false