DISECTIILE DE AORTA

Conf. Dr. Horea Feier, UMF/IBCV Timisoara

 DEFINITIE
•= patrunderea sangelui in peretele aortic, de la nivelul unei
rupturi intimale (“poarta de intrare”), cu disectia longitudinala
a acestuia
 CONSECINTE

➡ Lumen fals
➡ Lumen real
➡ Poarta de iesire (±)
 POARTA DE INTRARE

• Localizarea portii de intrare :

• Aorta ascendenta (imediat deasupra jonctiunii ST) 60%

• Crosa aortei 10%

• Aorta descendenta (dupa emergenta a. subclavii stangi) 30%

 CLASIFICARE
• De Bakey I II III

✤ Stanford A B
 CLASIFICARE

• Europeana (ESCARDIO, 2007)

• Clasa I= Disectie clasica

• Clasa II= Hematom intramural

• Clasa III=Disectie localizata

• Clasa IV= Ulcer penetrant

• Clasa V= Disectie iatrogena/traumatica

WRITING GROUP MEMBERS et al. Circulation
2010;121:e266-e369
Computed Tomographic Scan of an Intramural Hematoma (Arrows) of the Ascending
Aorta.

Kouchoukos NT, Dougenis D. N Engl J Med 1997;336:1876-1889.

 Penetrating Atherosclerotic Ulcer.

Kouchoukos NT, Dougenis D. N Engl J Med 1997;336:1876-1889.

CT Scan Showing Localized Dissection of the Aortic Arch with an Intimal Tear (Arrows).

Pasic M et al. N Engl J Med 1999;341:1775-1775.

 SIMPTOMATOLOGIE CLINICA

• Durere (90%) ✓intensa, socogena (dg.dif. IMA=ECG)

• Tamponada (±) ✓hTA, soc, anurie, dispnee
• IAO acuta (±) ✓suflu diastolic, raluri crepitante, dispnee
• Malperfuzie (±) ✓AVC, sincopa,
✓ischemie acuta periferica, paraplegie,
oligurie
 ETIOLOGIE

✓Sindrom Marfan, Ehlers-Danlos, Noonan, Loeys-

Dietz
✓Osteogenesis imperfecta
• Congenitale
✓Coarctatie de aorta
✓Rinichi polichistic
✓Bicuspidie aortica/Maladie anuloectazianta

• Dobandite ✓Sarcina
✓HTA (efort fizic, stres emotional, alimentatie)
✓Droguri (cocaina, amfetamine, ecstasy)
✓Anevrisme degenerative
✓Aortite inflamatorii (sifilis, spondilita ankilopoetica)
✓Iatrogenie (cateterism cardiac/periferic, IABP, chirurgie cardiaca)
 DIAGNOSTIC
• Clinic: Durere toracica intensa, ECG+Enzime cardiace= OK
• Paraclinic: D-dimeri <500 ng/ml => NO dissection Shimony, A; The American journal of
cardiology 107 (8): 1227–34

• RX toracic (±)

✓Mediastin largit
✓Hemotorax stg (±)
✓Cardiomegalie/
Tamponada (±)
 DIAGNOSTIC
• Ecografia TT/TE

✓Diagnostic +
✓Tamponada
✓Regurgitarea aortica
✓Functia cardiaca
✓Valvulopatii asociate
✓Dependenta de examinator
 DIAGNOSTIC
• CT torace standard/angioCT 64/128/256
• non-dependenta de examinator

✓Diagnostic +
✓Lumen real+fals
✓Hemothorax, Tamponada
 DIAGNOSTIC
✤ CT torace standard/angioCT
✤ non-dependenta de examinator

✓Aorta asc+crosa+desc
✓Ischemii de organ/periferice
 DIAGNOSTIC

✤ RMN
✤ nu iradiaza

✤ non-dependenta de examinator

✤ costuri ++

✤ timp de realizare +

✤ Rezolutie >>>

✤ => Poarta de intrare!!!

 DIAGNOSTIC

✤ Cateterismul cardiac/Angiografie
+
✤ Coronare!
✤ Fenestratii/Stentari terapeutice!

-
✤ Iradianta
✤ Disectie iatrogena
 EVOLUTIE NATURALA

• Mortalitate imediata (ruptura/tamponada)

• 1% pe ora/primele 48h Tip A B

Medical 60 % 10 %

• La distanta: Chirurgical 25-30% 30 %

• Disectie cronica => Anevrism (ruptura)

• Trombozarea falsului lumen (rar)

 TRATAMENT MEDICAL
Survival curves due to acute type B aortic dissection for all patients and by management group
based on Kaplan-Meier analysis of 40-day mortality (P.I.=percutaneous intervention).

• Durere

• opiacee

• Hipotensoare

• β-blocante (dp/dt )

• nitrati-i.v, IEC, IRAA, bloc-Ca2+

Suzuki T et al. Circulation 2003;108:II-312-II-317
 Figure 2. Endovascular stent graft in type B dissection.

Nienaber C A et al. Circulation 2009;120:2519-2528

Copyright © American Heart Association

 TRATAMENT
INTERVENTIONAL?

• Studiu INSTEAD (2009)

• prospectiv, randomizat

• Stent-vs-Medical =
• Disectii Tip B necomplicate

Nienaber C A et al. Circulation 2009;120:2519-2528

 TRATAMENT
INTERVENTIONAL!!

• Disectii Tip B complicate

• TEVAR= Choice!

• =Malperfuzie, ruptura iminenta, HTA necontrolata, durere persistenta/recurenta

Szeto W. Y. et al.; Ann Thorac Surg 2008;86:87-94

 TRATAMENT CHIRURGICAL

• Deelectie in Disectia Tip A/Disectia Tip B complicata (absenta

TEVAR)

• Scop

• Rezectia portii de intrare !!!

• Detamponare

• Tratamentul IAO+leziunilor asociate (coronare, etc)

• Inlocuirea aortei disecate (>>>) + tromboza lumen fals

Kaplan–Meier Mortality Curve Stratified According to the Status of the False Lumen.

Tsai TT et al. N Engl J Med 2007;357:349-359.

Conceptual Model of Risk According to the Status of the False Lumen.

Tsai TT et al. N Engl J Med 2007;357:349-359.

 Frequency distribution of cerebral protection techniques.

Krüger T et al. Circulation 2011;124:434-443

Copyright © American Heart Association

 PROTECTIE CEREBRALA

Perfuzie Perfuzie
Hipotermie
CEC antegrada antegrada
profunda
unilaterala bilaterala

Mortalitate
11,4 % 19,4 % 13,9 % 15,9 %
imediata

Deficit
neurologic 9,1 % 11,5 % 10 % 11 %
permanent
A, Hypothermic circulatory arrest group (HCA) and bilateral (bACP) and unilateral (uACP) antegrade
cerebral perfusion groups.

Krüger T et al. Circulation 2011;124:434-443

Copyright © American Heart Association

 EXPERIENTA IBCV TIMISOARA

• N=85 Disectii acute de aorta (2000- Aprilie 2011)

• N=65, urgente (<24h) (76,47%)

• Ischemie periferica/organ N=12 (14,12%)

• Tamponada N=34 (40%)

 EXPERIENTA IBCV TIMISOARA

• Inlocuire simpla de aorta ascendenta, N=41

• Inlocuire
de aorta ascendenta+radacina de aorta (Bentall/
Tirone-David), N=39

• Inlocuire
de aorta ascendenta+ de arc aortic (Total arch
replacement), N=5
EXPERIENTA IBCV TIMISOARA
 EXPERIENTA IBCV TIMISOARA

• Mortalitate intraoperatorie, N=11 (12,94%)

• Mortalitate imediata (<30 zile), N=25 (29,41%)

• Analiza multivariata, CEC (p=0.043, OR=1.03/minut), Creatinina

la internare (p=0.018, OR=13.46)
 CAZ 1

• Pacient 38 de ani, HTA netratata, fumator, sportiv (M.I)

• Durere post exces alimentar !

CAZ 1
 CAZ 1

✓ Maladie
anuloectazianta

Operatie Bentall
(rezectie de radacina de aorta+aorta asc+valva
aortica+reimplantare art coronare)

Stop circulator sistemic =35 min

CAZ 1
 CAZ II
• Pacient64 de ani, HTA netratata+Anevrism de aorta.
Interventie chirurgicala refuzata

• Efort fizic => durere toracica+durere in mb. sup drept !!

•Deficit de puls (mb. sup drept)

•Parestezii
•Deficit TA 60/120 mm Hg
= Malperfuzie!!
CAZ II
CAZ II
CAZ II
CAZ II
 CAZ III
• Pacient 64 de ani, HTA netratata

• Efort fizic => durere toracica+sincopa, ECG=n => IBCV!!

✓ECHO TE => DISECTIE!!

 CAZ III

• Poarta de intrare= Crosa aortei!!

• => Inlocuire de aorta ascendenta+ arc

aortic
 CAZ III

Strauch J. T. et al.; Ann Thorac Surg 2004;77:581-590

=> Stop circulator sistemic=75 min

Copyright ©2004 The Society of Thoracic Surgeons

 CAZ III

• AngioCT de control la 3 luni post-op

 CAZ IV
26 ani, maladie anulo-ectazianta, malformatie arterio-
• Pacient
venoase mb. inf stang, rinichi unic congenital => HTA

• Durere brusc instalata, severa, ECG=n =>ETT=> Disectie!!

 CAZ IV
• Poarta de intrare= Crosa aortei!!
 CAZ IV
• IAO gradul IV, pacient tanar => operatia Tirone-David

Svensson L. G.; Ann Thorac Surg 2003;76:1751-1753

 CAZ IV
• IAO gradul IV, pacient tanar => operatia Tirone-David

Svensson L. G.; Ann Thorac Surg 2003;76:1751-1753

 CAZ IV
• Poarta de intrare= Crosa aortei!! => +Inlocuire totala de crosa!
REMODELARE DE RADCINA
DE AORTA+ INEL

E. Lansac, Annals of Cardiothoracic Surgery, 2013

REMODELARE DE RADCINA
DE AORTA+ INEL

E. Lansac, Annals of Cardiothoracic Surgery, 2013

REMODELARE DE RADCINA
DE AORTA+ INEL

E. Lansac, Annals of Cardiothoracic Surgery, 2013

REMODELARE DE RADCINA
DE AORTA+ INEL

E. Lansac, Annals of Cardiothoracic Surgery, 2013

REMODELARE DE RADCINA
DE AORTA+ INEL

E. Lansac, Annals of Cardiothoracic Surgery, 2013

 The number of operations for acute type A dissection and 30-day mortality per 6 years period.

Bekkers J A et al. Eur J Cardiothorac Surg 2013;43:389-396

© The Author 2012. Published by Oxford University Press on behalf of the European Association for
Cardio-Thoracic Surgery. All rights reserved.
 Observed cumulative survival after surgery for acute type A aortic dissection with 95% CI (dashed
lines) in all patients (A) and in 185 hospital survivors compared with a 58-year old Dutch male in the
general population and a 58-year old Dutch male after mechanical aortic valve replacement (B).

Bekkers J A et al. Eur J Cardiothorac Surg 2013;43:389-396

© The Author 2012. Published by Oxford University Press on behalf of the European Association for
Cardio-Thoracic Surgery. All rights reserved.
 Malperfuzie

Girdauskas E. et al.; J Thorac Cardiovasc Surg 2009;138:1363-1369

Copyright ©2009 The American Association for Thoracic Surgery

 Kaplan–Meier survival curves for patients with or without organ system malperfusion.

Pacini D et al. Eur J Cardiothorac Surg 2012;ejcts.ezs500

© The Author 2012. Published by Oxford University Press on behalf of the European Association for
Cardio-Thoracic Surgery. All rights reserved
Fenestratie interventionala

Fabre O. et al.; Ann Thorac Surg 2002;73:950-951

Copyright ©2002 The Society of Thoracic Surgeons

VA MULTUMESC!