Ascending Aortic

Aneurysm and dissection

Applied anatomy, Pathophysiology, and

Clinical Features
Aortic Root
Sinotubular Junction
Ascending Aorta
Aortic Arch
Aortic Arch
Arch Vessels Configuration
Relation with Trachea and
Esophagus
Relation with nerves
Classification
TYPES
 FACTORS

Smoking,

Hypertension,

Atherosclerosis,

Genetic disorders
Marfan syndrome and Ehlers-Danlos syndrome.

Inherited metabolic disorders

Syphilis

Bicuspid and unicuspid aortic valves

ETIOLOGY

Congenital or developmental
Marfans syndrome
Ehlers-Danlos syndrome

Degenerative

Inflammatory

Traumatic

Infection

Post surgery

Mechanical Post stenotic

False aneurysm
Clinical presentation
 Pain - site

Chest.

Back pain.

Abdomen pain.

Flank pain.
 Pain

Sudden onset.

Severe / worst ever.

Maximal at onset.

Quality sharp,
tearing, ripping.
 Dyspnea - Pulmonary edema

Acute aortic
insufficiency.

Coronary artery
compromise.
 Hypovolemic shock

 Clinical features

Isolated Ascending aortic aneurysm

are mostly asymptomatic while Arch
aneurysms are mostly symptomatic

Ascending aortic aneurysm patients

present with symptoms of Aortic
Regurgitation
PRESSURE SYMPTOMS

Signs of superior vena caval or airway
compression

Hoarseness -stretch injury of the left
RLN suggests distal arch or proximal
DTA

Dysphagia -more frequent with
congenital lesions

Dyspnea - when the pulmonary artery
or left bronchus is constricted.
Establishing diagnosis

Ascending aorta involved or not
(TypeA or Type B)

Site of proximal intimal tear (PIT).

Extent of dissection.

Diameter of aorta.

Involvement of coronary ostia, arch

vessels, visceral arteries.

Pericardial effusion.

Left ventricular function.

Valve function (esp. aortic valve

regurgitation)
 Chest Radiography

Low Sensitivity (67%) and Specificity.

Normal Chest X- Ray 12-20%

Suggestive findings:
1. Mediastinal widening.
2. Calcium sign intimal calcification displacement.
3. Widening of the aortic knob.
4. Tracheal deviation.
5. Pleural effusion
Mediastinal Widening
Calcium Sign
Pleural Effusion: Hemothorax
 Electrocardiogram

Normal ECG with Severe chest pain- ?? Dissection.

MI: 1 - 2% aortic dissections. (ST segment elevation)

Involvement of coronary artery (RCA > LCA).

Thrombolytic therapy 70% mortality.

Non-specific ST-T changes most common

40% of patients (associated LVH 30%).
Acute Coronary Syndrome - Type A
Dissection
 Patient characteristic

Type A dissection
Acute Coronary
Syndrome

Young
Old

Connective tissue
Hypertensive
disorder
Dyslipidemic

Angina pectoris
 Pain characteristic

Type A dissection
Acute Coronary
Syndrome

Sharp Excruciating.
Heaviness crushing.

Well localized.
Vague

Typical propagation.
Radiation to left
upper limb
 Aortic Dissection Acute Myocardial
Infarction
History Connective tissue disorder Angina pectoris.
Marfans Syndrome.

Pain: Character Sharp, excruciating. Heaviness, crushing

Pain: localization / Well localized Vague chest pain- radiating
radiation Typical propagation Left upper limb
pattern
Examination:
BP differential (arms) Present Absent
Pulse differential (limbs, Present Absent
carotids)
AR Wide pulse pressure Absent
Murmur
Pericardial Effusion Muffled heart sounds Absent
Malperfusion Pain / Paresthesia limbs Absent
Pain abdomen
 ECHO

Type A Dissection
Circumferential
Dissection
CT ANGIO
 CT ANGIO

Dissection: PIT
Indications of surgery in ascending aorta

Asymptomatic ascending aortic aneurysm >5.0 cm in

diameter.

Symptomatic aneurysms irrespective of size.

Asymptomatic ascending aortic aneurysm >4.5 cm in

patients with Marfan syndrome and BAV.

Acute dissection or rupture of ascending aortic aneurysm.

Pseudoaneurysm or traumatic aneurysm in ascending

aorta.

Ascending aortic aneurysm >4.5 cm in patients undergoing

aortic valve surgery.

Growth rate of >0.5 cm/y when ascending aorta is <5.0 cm

in diameter.
Hinge point
PATHOGENESIS
 PATHOGENESIS AORTIC DISSECTION

Elastic tissue or Smooth muscle degeneration

in aortic media.

Initial event- PIT

Blood flows within aortic wall

seperating layers of media.

Outer third of media.

Left posterolateral wall.

Antegrade / retrograde propagation.

Distal reentry multiple- sheared-off ostia of arterial branches

imperfect natural cure of the disease.
FACTORS AFFECTING PROGRESSION

Rate of increase of aortic systolic pressure

dP/dT.

Aortic diastolic elastic recoil pressure.

Mean arterial pressure.

Aortic wall integrity.

VARIANT FORMS
(PAU & IMH)
 PENETRATING ATHEROSCLEROTIC
ULCER

PAU: localized intimal lesion burrowing

into media leading to localized dissection.
 INTRAMURAL HEMATOMA

Spontaneous rupture of vasa vasorum within outer third of aortic media.

No intimal defect.

Mechanism- Spontaneously in predisposed individuals

Secondary to rupture of atheromatous plaque

Type B IMH higher propensity for aortic rupture / severe symptoms /

associated deep PAU
INTAAMURAL HEMATOMA CT SCAN IMAGE

TEE IMAGE SPECIMEN

 NATURAL HISTORY
IN ACUTE PRESENTATIONS
Is Essentially Natural History of Flap Progression and/or Rupture

AORTIC INSUFFICIENCY MESENTERIC MALPERFUSION

CORONARY INSUFFICIENCY RENAL MALPERFUSION

CEREBRAL MALPERFUSION RUPTURE

LIMB MALPERFUSION DEATH

AORTIC REGURGITATION

Dissection flap causing Cusp
Prolapse

Most commonly Non Coronary Cusp
 CORONARY ISCHEMIA
3 MECHANISMS

DISSECTION FLAP ENTERING CIRCUMFERENTIAL

OF OSTIUM CORONARY DETTACHMENT
 CORONARY ISCHEMIA

Incidence 6.1% - 11%

Right coronary is more
commonly involved

PRESENTATION

Frank Myocardial
Infarction

Inability come off bypass

Low CO on De-clamping

Death due to Massive MI

Mortality 20 33%

Coronary Revascularization is
DISSECTION FLAP SEEN ENTERING preferred to Local Repair
INTO THE CORONARY OSTIUM
 CEREBRAL MALPERFUSION

Incidence 3 - 13%

Right Common Carotid is
more commonly involved

PRESENTATION

Syncope

TIA

Hemiplegia Stroke

Coma

Post operative TIA Stroke

Mortality 30 - 45%

??? Endovascular intervention /
INVOLVEMENT OF ARCH VESSELS
Extraanotomic bypass within 3 Hrs
 LIMB ISCHEMIA

Incidence is about 10 - 12%

Upper Limb involvement is less
commonly evident clinically

Significant Lower Limb involvement

signifies massive dissection of aorta

Mortality as high as 70%

Endovascular Fenestration /
Surgical
Extra anotomic bypass may be
needed

Milder forms may improve with
SUCH PRESENTATIONS AS ABOVE
Central aortic surgical correction
ARE RARE
 RUPTURE

Hemopericardium

Flap in Aorta

Hemothorax

Rupture into the pericardium leading to

Cardiac Tamponade most common
Cause Of death
RUPTURE OF DISSECTION
INTO THE PLEURAL CAVITY
CAUSING LEFT HEMOTHORAX
 DEATH & SURVIVAL (T YPE A)

Uniformly fatal disease

Mortality in early hours 1 2% PER HOUR

Medical Management
alone is associated
with a mortality of
20% by 24 hours
30% by 48 hours
40% by day 7
50% by 1 month
THANK YOU