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Aortic Aneurysm & Dissection

Presented by : Feryal AlKhateeb
Samah AlKhateeb

Anatomy

Histoloogy

Thoracic Aortic Aneurysm


Aortic aneurysm is defined as a permanent, localized dilatation
of the aorta to a diameter that is at least 50% greater
than is normal at that anatomic level.
The annual incidence of thoracic aortic aneurysms is
estimated to be 5.9 per 100,000 persons.
Aneurysms can be localized to a single aortic segment, or
they can involve multiple segments. In the most extreme
cases, the entire aorta is aneurysmal; this condition is
often called mega-aorta.

Aortic aneurysms can be either “true” or “false.”
 True aneurysms can take two forms: fusiform and
saccular.
1. Fusiform aneurysms are more common and can be
described as symmetrical dilatations of the aorta.
2. Saccular aneurysms are localized outpouchings of the
aorta.
 False aneurysms, also called pseudoaneurysms, are leaks in
the aortic wall that are contained by the outer layer of
the aorta and/or the periaortic tissue; they are caused by
disruption of the aortic wall and lead blood to collect in
pouches of fibrotic tissue.

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Ehlers-Danlos syndrome 4. Aneurysms-Osteoarthritis syndrome 6. Congenital bicuspid aortic valve 7. Familial aortic aneurysms 5. Marfan syndrome 2.Causes and Pathogenesis Nonspecific medial degeneration  Aortic dissection  Genetic disorders 1. Bovine aortic arch  Poststenotic dilatation  Infection  Aortitis  Takayasu arteritis  Giant cell arteritis  Rheumatoid aortitis  Trauma  . Loeys-Dietz syndrome 3.

acute cardiac tamponade and death. . . In many patients with thoracic aortic aneurysms. Distal embolization.Clinical Manifestation  1. 4. or left flank or abdomen (thoracoabdominal aorta). . . .widened pulse pressure. .anterior chest discomfort.diastolic murmer. Aortic valve regurgetation. And they are asymptomatic at time of diagnosis. or lower extremity branches.sudden. . . upper back or left chest (descending thoracic aorta).severe hemorrhagic shock. renal. .left vocal cord paralysis and hoarsness.interscapular back pain.middle back and epigastric pain. the aneurysm is discovered incidentally when imaging studies are performed for unrelated reasons. 2.occlusion and thrombosis of the visceral. Local compression and erosion. severe pain in the anterior chest (ascending aorta). 3.progressive heart failure. . . . Rupture.

Once a thoracic aortic aneurysm is detected on plain radiographs. additional studies are required to define the extent of aortic involvement.Diagnostic Evaluation  Plain radiography.convexity in the right superior mediastinum 2. . thus.loss of the retrosternal space (on lateral view) 3.a rim of calcification outlining the dilated aneurysmal aortic wall. 1. .(CXRs) may appear normal in patients with thoracic aortic disease and. . cannot exclude the diagnosis of aortic aneurysm.widening of the descending thoracic aortic shadow 4.

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 Echocardiography and Abdominal Ultrasonography. .

.provides information about an aneurysm’s location. extent. and relationship to major branch vessels. anatomic anomalies. . .CT is the most common—and arguably the most useful—imaging modality for evaluating thoracic aortic aneurysms. Computed Tomography.

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MRA imaging is suboptimal in patients with extensive aortic calcification. . Magnetic Resonance Angiography. .MRA environment is not appropriate for many critically ill patients. but have more limitations than CT. .It is the best method of diagnosing aneurysms. .

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the use of invasive aortography in patients with thoracic aortic disease is generally limited to those undergoing endovascular therapies or when other types of studies are contraindicated or have not provided satisfactory results. .A key limitation of aortography is that it : images only the lumen and may therefore underrepresent the size of large aneurysms that contain laminated thrombus. Invasive Aortography and Cardiac Catheterization. . Manipulation of intraluminal catheters can result in embolization of laminated thrombus or atheromatous debris. .

0 cm.strict control of hypertension. management begins with patient education. Once a thoracic Aortic aneurysm is detected.cessation of smoking. 4. Indecations for operation : Elective operation in asymptomatic patients when the diameter of an ascending aortic aneurysm is >5. Emergent intervention for patients who present with aneurysm rupture or superimposed acute dissection. .5 cm. The rate of dilatation is >0. .Treatment   1. or diameter of a descending thoracic aortic aneurysm is >6. 3.5 cm/y. 2. particularly if the patient is asymptomatic. patients who present with symptoms may need urgent operation .

The spectrum of operations ranges from simple graft replacement of the tubular portion of the ascending aorta to graft replacement of the entire proximal aorta.  Traditional open operations to repair proximal aortic aneurysms performed through a midsternal incision and require cardiopulmonary bypass. and reattachment of the coronary arteries and brachiocephalic branches. . including the aortic root.

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  Open repair vs. Stent graft repair of descending thoracic aortic aneurysms has become the accepted treatment option . endovascular repair.

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are the most devastating complications. microembolization. Complications specific to endovascular stenting include endoleaks. retrograde dissection. Myocardial infarction may occur with technical problems with coronary ostia implantation during root replacement for ascending aortic aneurysms and may require reoperation. Renal dysfunction. aortoesophageal fistula. Paraparesis and paraplegia. stent graft migration or thrombosis. stent fractures. Pulmonary dysfunction. either acute or delayed. iliac artery rupture. .Operative Complications        Bleeding is a potential complication for all aneurysm repairs. Stroke is a major cause of morbidity and mortality and typically results from embolization of atherosclerotic debris or clot.

echocardiography for ascending aneurysms) may be performed every 3-6 months during the first postoperative year and every 6 months thereafter. or descending aneurysms. CT or MRI for ascending.Long Term Monitoring  serial evaluations (ie. . arch.

Aortic Dissection By Samah AlKhateeb .

resulting in blood tracking into the aortic tissues splitting the medial layer and creating a false lumen. . the most common catastrophic event involving the aorta. is a progressive separation of the aortic wall layers that usually occurs after a tear forms in the intima and inner media.Pathology and Classification  Aortic dissection.

Blood flows freely downstream in normal aortic tissue. In classic aortic dissection. Penetrating aortic ulcers are deep atherosclerotic lesions that burrow into the aortic wall and allow blood to enter the media. In each of these conditions.Figure 22-17. the outer aortic wall is severely weakened and prone to rupture. Illustration of longitudinal sections of the aortic wall and lumen. the intima is intact. . blood entering the media through a tear creates a false channel in the wall. Intramural hematomas arise when hemorrhage from the vasa vasorum causes blood to collect within the media.

when the separation of layers occurs within the aortic root. inflamed. visceral. intercostal. renal. Finally. and iliac arteries. the aortic valve commissures can become unhinged. Second. which results in acute valvular regurgitation. including the coronary. the outer wall of the false lumen is extremely thin. First. which makes it prone to expansion or rupture in the face of ongoing hemodynamic stress. carotid. The extensive disruption of the aortic wall has severe anatomic consequences. the expanding false lumen can compress the true lumen and cause malperfusion syndrome by interfering with blood flow in the aorta or any of its branch vessels. . and fragile.

Aneurysm. The overused term dissecting aneurysm should be reserved for this specific situation. . in patients with degenerative aneurysms.Dissection vs.  Dissection and aneurysm are separate entities. dissection occurs in patients without aneurysms. The subsequent progressive dilatation of the weakened outer aortic wall results in an aneurysm. In most cases. although they often coexist and are mutual risk factors. On the other hand. the ongoing deterioration of the aortic wall can lead to a superimposed dissection.

Chronicity. Dissection is considered acute within the first 14 days after the initial tear. . after 14 days. dissections are categorized according to their anatomic location and extent. To guide treatment. the dissection is considered chronic. aortic dissections are classified according to their location and chronicity. Location.    For management purposes.Classification.

Dissection can be confined to the ascending aorta (left) or descending aorta (middle).Figure 22-19. Illustration of the classification schemes for aortic dissection based on which portions of the aorta are involved. or it can involve the entire aorta (right). .

 the specific causes remain unknown. Without appropriate modern medical or surgical treatment. most patients (approximately 90%) die within 3 months of dissection. any condition that weakens the aortic wall increases the risk of aortic dissection.Causes and Clinical History  Aortic dissection is a lethal condition. Ultimately. mostly from rupture. .

Smoking Hypertension Atherosclerosis Hypercholesterolemia       Connective tissue disorders. Bicuspid aortic valve.Risk Factors:  Common general cardiovascular risk factors. surgery. Cocaine and amphetamine abuse. Severe emotional stress or extreme physical exertion such as during weightlifting. or endovascular aortic repair. aortic injury during cardiac catheterization. Preexisting medial degenerative disease. Iatrogenic dissection. .

.  The location of the pain often indicates which aortic segments are involved. classically described as “tearing”. that migrates distally as the dissection progresses along the length of the aorta.Clinical Manifestations  The onset of dissection often is associated with sudden severe chest or back pain.

the mesenteric arteries (abdominal pain and bowel ischemia). loss or reduced pulses and limb ischemia). incontinance). The dissection can extend distally down the aorta to involve: the renal arteries (renal failure).Clinical Manifestations          The dissection may track proximally to involve: the head and neck vessels (symptoms and signs of a stroke or transient ischemic attack). the iliac arteries (leg pain. the spinal arteries (paraplegia. pallor. the coronary vessels (myocardial infarction). . the aortic root (aortic regurgitation).

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Transoesophageal echocardiography (TOE)   . Contrast CT shows a flap across the aortic lumen with distal aneurysmal change.ray shows widening of the mediastinum in two-thirds of patients and a small left pleural effusion.Investigations  Diagnosis is confirmed by:  Chest X. (it is probably the investigation of choice) Echocardiography may also demonstrate a flap and aortic regurgitation.

.Figure 1. Chest X-ray (postero-anterior projection) showing that the descending thoracic aorta is extremely dilated and tortuous.

In the chronic phase. Here. B. the membrane appears straighter and less mobile (arrow) because it has stabilized over time. A chronic DeBakey type III aortic dissection.Figure 22-21. This may lead to malperfusion of the heart. Computed tomographic scans showing that the aorta has been separated into two channels—the true (T) and false (F) lumens— in two patients with different phases of aortic dissection. . The dissecting membrane appears wavy (arrows) in the early phase of dissection. A. the true lumen of the proximal aorta can be seen to be extensively compressed. An acute DeBakey type I aortic dissection.

. Sagittal computed tomography images demonstrating the thoracic (A) and abdominal (B) portions of the involved dissecting aorta with arrows indicating the dissecting intimal flap.Figure 2.

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before further imaging.  In the emergency situation. blood pressure (which is usually high at presentation) should be brought under control to prevent extension of the dissection.Treatment  Once the diagnosis is made. treatment depends largely upon the type of dissection. .

. The surgery aims to interpose a prosthetic tube graft at the aortic root to prevent further dissection.Surgical options    Type A (or type I and II) Should be managed surgically because of the risk that the dissection may extend back across the aortic root resulting in tamponade. and to correct aortic incompetence.

Illustration of proximal aortic repair for acute ascending aortic dissection .

.Illustration of distal aortic repair of a chronic dissection.

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In cases where there is evidence of impending aortic rupture or non-perfusion of a visceral artery. and to re-establish blood flow through the collapsed true lumen. An aneurysm resulting from a chronic dissection may require treatment if it enlarges or produces pressure symptoms. Any organ. Hypertensive drugs are used. reducing systolic pressure to 100 –120 mmHg to prevent further extension of the dissection.       Type B (or type III) Usually treated conservatively. The stent is placed to cover the proximal entry into the false lumen. . endovascular placement of a covered stent (a stent – graft) is appropriate. limb or mesenteric ischemia resulting from the dissection is treated by revascularization.

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