welcome

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 By
Dr Jayadeep B P
II MD Repertory
GHMC,CALICUT
jayadeepbp@gmail.com

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 The aorta is the main
arterial trunk that delivers
oxygenated blood from the
left ventricle of the heart to
the tissues of the body.
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 It is divided for purposes of
description into the following parts:
 - ascending aorta
 -arch of the aorta
 -descending thoracic aorta &
 -abdominal aorta.

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Ascending Aorta
• The ascending aorta is the
first part of aorta
• 5 cm long and
• approximately 2.5 cm in
diameter
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 begins at the base of the left ventricle ,
level with the lower border of the third
left costal cartilage
 runs upward and forward to come to lie
behind the right half of the sternum at
the level of the sternal angle,
 where it becomes continuous with the
arch of the aorta
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 It lieswithin the fibrous pericardium
 enclosed with the pulmonary trunk in
a sheath of serous pericardium
 The ascending aorta is intrapericardial
& lies inferior to the transverse thoracic
plane
 it is considered as a content of the
middle mediastinum
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At its root it possesses three bulges,
the sinuses of the aorta(sinuses of
Valsalva)
 one posterior (non-coronary), one
left and one right
each one behind each aortic valve
cusp
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Relations

Anteriorly-to its lower part

 the infundibulum[the initial
segment of the pulmonary
trunk ] and
 the right auricle
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Superiorly
it is separated from the
sternum by
 pericardium
 right pleura
 anterior margin of the right lung
 loose areolar tissue and
 the remains of the thymus gland
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 Posteriorly
left atrium
right pulmonary artery and
principal bronchus.

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 Laterally-on right
 superior vena cava and
 right atrium
 Laterally-on left
 left atrium and,
 at a higher level, the pulmonary trunk.

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Aorticopulmonary bodies
 reminiscent of the carotid arterial chemoreceptors
and baroreceptors
 lie between the ascending aorta and the
pulmonary trunk.
 The inferior aorticopulmonary body is near the
heart and anterior to the aorta.
 The middle aorticopulmonary body is near the
right side of the ascending aorta.

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Branches

-Rright coronary artery arises

from the anterior aortic sinus
and
-Left coronary artery arises from
the left posterior aortic sinus.

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Arch of the Aorta

 It is the curved continuation of the

ascending aorta.
 It lies behind the manubrium sterni
 lies wholly in the superior
mediastinum.
 Its diameter at the origin is 28 mm, but
it is reduced to 20 mm at the end
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course
 begins posterior to the 2nd right
sternocostal joint at the level of the sternal
angle and arches upward, backward, and to
the left in front of the trachea
 its main direction is backward
 It then passes downward to the left of the
trachea and, at the level of the sternal angle,
becomes continuous with the descending
aorta
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The arch of the azygos vein
occupies a corresponding
position on the right side of the
trachea over the root of the right
lung, although its contents are
flowing in the opposite
direction.
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The ligamentum arteriosum,
the remnant of fetal ductus
arteriosus, passes from the root
of the left pulmonary artery to
the inferior surface of the arch
of the aorta
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 At the border with the thoracic aorta, a
small stricture (aortic isthmus),
followed by a dilatation, can be
recognized.
 In fetal life the isthmus lies between
the origin of the left subclavian artery
and the opening of the ductus
arteriosus.
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The shadow of the arch is easily
identified in chest x rays as 'aortic
knuckle'
The arch may also be visible in left
anterior oblique views enclosing a
pale space, 'the aortic window'
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Relations
Anteriorly
• left mediastinal pleura
It is crossed, in anteroposterior order by:
• the left phrenic nerve
• left lower cervical cardiac branch of the vagus
• left superior cervical cardiac branch of the sympathetic
and
• left vagus
• The left superior intercostal vein ascends obliquely
forwards on the arch

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 Posteriorly
trachea
deep cardiac plexus
the left recurrent laryngeal nerve
oesophagus
thoracic duct and
vertebral column
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Superiorly
brachiocephalic, left common
carotid and left subclavian arteries
arise from its convexity and
 are crossed anteriorly near their
origins by the left brachiocephalic
vein
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Inferiorly

pulmonary bifurcation
left principal bronchus
ligamentum arteriosum
superficial cardiac plexus and
left recurrent laryngeal nerve
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Branches
[1] The brachiocephalic artery
• the largest branch of the aortic arch
• [4-5 cm in length]
• is an innominate artery
• It arises from the convexity of the arch posterior
to the centre of the manubrium of sternum, and
• ascends posterolaterally to the right, at first
anterior to the trachea, then on its right
• Level with the upper border of the right
sternoclavicular joint, it divides into the right
common carotid and right subclavian arteries.

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[2] The left common carotid artery
• the second branch of the arch of the aorta
• is 20-25 mm long
• arises posterior to the manubrium, slightly posterior
and to the left of the brachiocephalic trunk.
• It ascends anterior to the left subclavian artery
• at first anterior to the trachea and then to its left
• It enters the neck by passing posterior to the left SC
joint

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[3] The left subclavian artery
• the third branch of the arch
• arises from the posterior part of the arch of the
aorta, just posterior to the left common carotid
artery.
• It ascends lateral to the trachea,oesophagus and
left common carotid artery through the superior
mediastinum
• has no branches in the mediastinum.
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 As it leaves the thorax and enters the root of
the neck, it passes posterior to the left SC
 It arches over the apex of the left lung lateral
to the medial border of scalenus anterior,
crosses behind this muscle and
 descends towards the outer border of the
first rib, where it becomes the axillary artery.

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Descending Thoracic Aorta
• The descending thoracic aorta lies
in the posterior mediastinum
• begins as a continuation of the arch
of the aorta on the left side of the
lower border of the body of the
fourth thoracic vertebra (i.e.,
opposite the sternal angle)
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 It runs downward on the left sides of the T5-
T12 vertebrae inclining forward and
medially to reach the anterior surface of the
vertebral column.
 As it descends, it approaches the median
plane and displaces the esophagus to the
right
[To a limited degree, the descending aorta
and oesophagus are mutually spiral]
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 At the level of the 12th thoracic vertebra, it
passes behind the diaphragm (through the
aortic hiatus) between the crura of the
diaphragm posterior to the median arcuate
ligament in the midline and becomes
continuous with the abdominal aorta.
 The thoracic aortic plexus an autonomic
nerve network, surrounds it.
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Relations
Anteriorly-from above down
 left pulmonary hilum
 the pericardium separating it from the left
atrium, oesophagus and diaphragm.
Posteriorly
 vertebral column and
 hemiazygos veins

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 Right lateral
azygos and thoracic duct and
below, the right pleura and lung
Left lateral
pleura and lung
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oesophagus, with its plexus
of nerves, is right lateral
above, but becomes anterior
in the lower thorax, and close
to the diaphragm it is left
anterolateral
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Branches

 visceral branches to the

 pericardium
 lungs
 bronchi and
 oesophagus &
 parietal branches to the thoracic wall

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 Pericardial branches-on posterior aspect of the
pericardium
 Bronchial arteries
 They vary in number, size and origin.
 usually only one right bronchial artery runs posteriorly on
the right bronchus
 left bronchial arteries, usually two; run posteriorly to the
left bronchus
 supplies pulmonary areolar tissue, bronchopulmonary
lymph nodes, pericardium and oesophagus

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 Mediastinal branches
• Numerous small vessels supply lymph nodes and
areolar tissue in the posterior mediastinum
Phrenic branches
• distributed posteriorly to the superior
diaphragmatic surface
Oesophageal arteries
• Unpaired,usually two, but as many as five

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Posterior intercostal arteries
• are given off to the lower nine intercostal spaces on each side
Subcostal arteries
• last paired branches of the thoracic aorta, in series with the posterior
intercostal arteries, and are below the twelfth ribs.
• Each enters the abdomen with the twelfth thoracic (subcostal) nerve at
the lower border of the twelfth rib, posterior to the kidney.
• anastomoses with the superior epigastric, lower posterior intercostal
and lumbar arteries
Aberrant artery
• A small artery sometimes leaves the thoracic aorta on its right
• vestige of the right dorsal aorta
• occasionally it is enlarged as the first part of a right subclavian artery.

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Abdominal aorta
 The aorta enters the abdomen through the
aortic opening of the diaphragm, anterior to
the inferior border of the twelfth thoracic
vertebra and the thoracolumbar
intervertebral disc.
 approximately 13 cm in length.

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It descends behind the peritoneum
on the anterior surface of the
bodies of the lumbar vertebrae
at the level of the fourth lumbar
vertebra, it divides into the two
common iliac arteries.

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 The level of the aortic bifurcation is 2 to 3
cm inferior and to the left of the umbilicus
at the level of the iliac crests
 The angle of aortic bifurcation varies widely,
particularly in the elderly.
 It has been suggested that the relationship
between aortic size and shape is a possible
causative factor in the development of
abdominal aortic aneurysm
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It diminishes rapidly in calibre
from above downward, because its
branches are large
diameter of the vessel at any given
height tends to increase slightly
with age.

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Relations

Anteriorly-from superior to inferior

• Celiac plexus and ganglion
• superior mesenteric artery
• Body of the pancreas and splenic vein
• Left renal vein
• proximal parts of the gonadal arteries
• Horizontal part of the duodenum.
• posterior parietal peritoneum
• Coils of the small intestine
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Posteriorly
• thoracolumbar intervertebral disc
• the upper four lumbar vertebrae
• intervening intervertebral discs
• anterior longitudinal ligament
• Lumbar arteries
• third and fourth (and sometimes second) left
lumbar veins to reach the inferior vena cava.
• Below the second lumbar vertebra, it is closely
applied to the left side of the inferior vena cava.
• Level with the second lumbar vertebra, it is related
to the duodenojejunal flexure and the left
sympathetic trunk, the fourth part of the duodenum
and the inferior mesenteric vessels
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Laterally
On the left
on the right
 azygos vein  left crus of the diaphragm
 chyle cistern  left celiac ganglion
 thoracic duct
 right crus of the diaphragm
and
 right celiac ganglion

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Branches

• Most arteries supplying the posterior abdominal wall

arise from the abdominal aorta
• they are described as anterior, lateral and dorsal.
• anterior and lateral branches are distributed to the
viscera
• dorsal branches supply the body wall, vertebral
column, vertebral canal and its contents.
• The aorta terminates by dividing into the right and left
common iliac arteries.

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 Anterior group
 Three anterior visceral branches:
 -celiac artery
 -superior mesenteric artery
 -inferior mesenteric artery

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1.Coeliac trunk (coeliac axis)
• first anterior branch and arises just below the aortic
hiatus at the level of T12/L1 vertebral bodies.
• 1.5-2 cm long
• passes almost horizontally forwards and slightly above
the pancreas
• It divides into the left gastric, common hepatic and
splenic arteries

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2.Superior mesenteric artery
• originates from the aorta 1 cm below the
coeliac trunk, at the level of the L1-2
intervertebral disc.
• It lies posterior to the splenic vein and the
body of the pancreas
• It runs inferiorly and anteriorly, anterior to
the uncinate process of the pancreas and the
third part of the duodenum
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3.Inferior mesenteric artery
 usually smaller in calibre than the superior
mesenteric artery
 It arises from the anterior or left
anterolateral aspect of the aorta at about the
level of the third lumbar vertebra, 3 or 4 cm
above the aortic bifurcation and posterior to
the horizontal part of the duodenum.
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Lateral group
Three lateral visceral branches
 suprarenal artery
 renal artery and
 testicular or ovarian artery

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1.Suprarenal artery
 Its the middle suprarenal artery arises from the
lateral aspect of the abdominal aorta, level with
the superior mesenteric artery.
 It ascends slightly, and runs over the crura of the
diaphragm to the suprarenal glands
 anastomoses with the suprarenal branches of the
phrenic and renal arteries.

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2.Renal artery
• two of the largest branches of the abdominal
aorta
• arise laterally from the vessel just below the
origin of the superior mesenteric artery
• The right is longer and usually arises slightly
higher than the left. It passes posterior to the
inferior vena cava, right renal vein, head of the
pancreas and second part of the duodenum
• The left renal artery arises a little lower down and
passes behind the left renal vein, the body of the
pancreas and the splenic vein

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3.Gonadal arteries
 two long, slender vessels that arise
from the aorta a little inferior to the
renal arteries
 Each passes inferolaterally under the
parietal peritoneum on psoas major

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Dorsal group
 inferior phrenic artery and
four lumbar arteries

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inferior phrenic arteries
 Supplies diaphragm and to the capsule
of liver,spleen.
 Each inferior phrenic artery has two or
three small suprarenal branches and
medial and lateral branches

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Lumbar arteries
• usually four on each side.
• arise from the posterolateral aspect of the aorta,
opposite the lumbar vertebrae
• they passes into the muscles of the posterior
abdominal wall
• anastomoses with one another and the lower posterior
intercostal, subcostal, iliolumbar, deep circumflex iliac
and inferior epigastric arteries.
• Each lumbar artery has a dorsal branch, which supply
the dorsal muscles of the back
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 Terminal branches
• the two common iliac arteries and
• the median sacral artery
Common Iliac Arteries
• The right and left common iliac arteries are the terminal branches
of the aorta.
• They arise at the level of the 4th lumbar vertebra and
• run downward and laterally along the medial border of the psoas
muscle
• Each artery ends in front of the sacroiliac joint by dividing into
the external and internal iliac arteries.
• At the bifurcation, the common iliac artery on each side is crossed
anteriorly by the ureter
• The internal iliac artery enters the pelvis
• The external iliac artery follows the iliopsoas muscle
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Median sacral artery

 small,unpaired branch
 arises from the posterior aspect of the aorta a little
above its bifurcation.
 Although markedly smaller, it could also be considered
a midline continuation of the aorta
 sends branches into the anterior sacral foramina

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APPLIED ASPECTS

Generally three types of condition

may affect the aorta:
-Aneurysm
-dissection and
-aortitis

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AORTIC ANEURYSM
• An aortic aneurysm is an abnormal dilatation of the
aortic wall.
• both atheromatous and aneurysmal arterial diseases
has similar risk factors (e.g. smoking and
hypertension) and often coexist
• generally termed as 'non-specific' aneurysmal disease
• tends to run in families, and genetic factors are
undoubtedly important.

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 most common site is infrarenal abdominal
aorta.
 The suprarenal abdominal aorta and a
variable length of the descending thoracic
aorta may be affected in 10-20% of patients
 but the ascending aorta is usually spared
 commonly seen with Marfan's syndrome,
homocystinuria and Ehlers-Danlos
syndrome
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Thoracic aneurysms
• may produce chest pain similar to cardiac
pain, associated with expansion of the
aneurysm.
• If they extend proximally they may cause
aortic valve regurgitation.
• They can also cause symptoms by
compressing the trachea, main bronchus
or superior vena cava
• Occasionally, they may erode into the
adjacent structures, causing
haemorrhage, tamponade and death
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Abdominal aneurysms[AAAs]
• Incidentally seen on physical examination,
plain chest x ray, and most commonly on
USG
• Even large AAAs can be difficult to feel, so
many remain undetected until they
rupture
• commonly presented with pain in the
central abdomen, back, loin, iliac fossa or
groin
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 Men are affected three times more
commonly than women.
 The median age at presentation is 65 years
for elective and 75 years for emergency cases
 present in 5% of men aged over 60 years
 80% are confined to the infrarenal segment

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Thromboembolic complications
• Thrombus within the aneurysm sac may be a source of emboli to
the lower limbs
• Less commonly, the aorta may undergo thrombotic occlusion
compression
• Surrounding structures such as the duodenum (obstruction and
vomiting) and the inferior vena cava (oedema and deep vein
thrombosis)
Rupture
• Into the retroperitoneum, the peritoneal cavity or surrounding
structures
• most commonly the inferior vena cava, leading to an aortocaval
fistula

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diagnosis
• plain abdominal X-ray.
• Ultrasound is the best way ;an approximate size may
be obtained, and the technique can be used to follow
up patients with asymptomatic aneurysms that are not
yet large enough to warrant surgical repair.
• CT will provide much more accurate information
about the size and extent of the aneurysm
• Arteriography is usually only indicated if there are
concerns about associated lower limb, renal and/or
visceral occlusive disease.
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Management
• Until an asymptomatic AAA has reached a maximum of 5.5
cm in diameter, the risks of surgery generally outweigh the
risks of rupture.
• All symptomatic AAAs should be considered for repair
• Distal embolisation is a strong indication for repair,
regardless of size, because otherwise limb loss is common.
• Most patients with a ruptured AAA do not survive to reach
hospital, but if they do and surgery is thought to be
appropriate, there must be no delay in getting them to the
operating theatre to clamp the aorta
• Open AAA repair is the established treatment of choice in
both the elective and the emergency setting, and entails
replacing the aneurysmal segment with a prosthetic
(usually Dacron) graft.
• Some AAAs may be treated with a covered stent placed via
a femoral arteriotomy under radiological guidance.
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AORTIC DISSECTION
• occurs as a result of degeneration of the medial aspect
of the aortic wall as a result of ageing, persistent
hypertension or in fibrillin diseases such as Marfan's
disease.
• An intimal tear may occur, producing a split into the
medial wall, which creates a false lumen
• Aortic dissection is classified into type A and type B
involving or sparing the ascending aorta respectively.
• Type A dissections account for two-thirds of cases and
frequently also extend into the descending aorta

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PREDISPOSING FACTORS
 Hypertension (80% of cases)
 Aortic atherosclerosis
 Non-specific aortic aneurysm
 coarctation of aorta
 Collagen disorders (e.g. Marfan's syndrome, Ehlers-Danlos
syndrome)
 Fibromuscular dysplasia
 Previous aortic surgery (e.g. aortic valve replacement)
 Pregnancy (usually third trimester)
 Trauma
 Iatrogenic (e.g. cardiac catheterisation, intra-aortic balloon
pumping
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Clinical features

• severe retrosternal or intrascapular 'tearing' chest

pain.
• Onset of pain- typically very abrupt and collapse is
common
• If there is aortic regurgitation the aortic valve may
need to be repaired or even replaced.
• There may be asymmetry of the brachial, carotid or
femoral pulses, and the signs of aortic reflux may be
present in type A dissections

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complications
 Occlusion of aortic branches may cause a
variety of complications including
myocardial infarction (coronary), paraplegia
(spinal), mesenteric infarction with an acute
abdomen (coeliac and superior mesenteric),
renal failure (renal) and acute limb (usually
leg) ischaemia..
 Extension into the pericardium causes
cardiac tamponade and circulatory collapse
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Diagnosis
• chest X-ray - shows broadening of the upper mediastinum
and distortion of the aortic 'knuckle‘.
• A left-sided pleural effusion is common.
• ECG may show left ventricular hypertrophy in patients with
hypertension, or rarely, changes of acute MI
• Doppler echocardiography may show aortic regurgitation, a
dilated aortic root and, occasionally, the flap of the
dissection.
• Transoesophageal echocardiography is particularly helpful
• CT and MRI are both highly specific

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managemant
 Surgical repair is essential for ascending aortic or aortic arch dissection
 Assessment and treatment are urgent because the early mortality of
acute dissection is approximately 1% per hour.
 Initial management comprises pain control and antihypertensive
treatment
 Type A dissections require emergency surgical repair. Surgery involves
replacing the ascending aorta with a Dacron graft.
 Type B aneurysms can be treated medically unless there is actual or
impending external rupture, or vital organ (gut, kidneys) or limb
ischaemia.
 Percutaneous or minimal access endoluminal repair is possible in some
cases and involves either 'fenestrating' (perforating) the intimal flap so
that blood can return from the false to the true lumen (so
decompressing the former), or implanting a stent graft placed from the
femoral artery

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AORTITIS
 Syphilis is a rare cause of aortitis that characteristically
produces saccular aneurysms of the ascending aorta
containing calcification.
 Other cause are-
 Takayasu's disease,
 Reiter's syndrome,
 giant cell arteritis and
 ankylosing spondylitis

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COARCTATION OF AORTA
• most often occurs as a stenosis just opposite the site of
insertion of the ductus arteriosus and
• can be preductal & post ductal
• is called simple when it occurs as an isolated abnormality
with or without presence of PDA.
• Complex coarctation refers to the association of
coarctation of aorta with other cardiac abnormalities such
as VSD, valvar aortic stenosis, or bicuspid aortic valve.
• more common in males and accounts for approximately
two per cent of patients with CHD in India

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PATHOPHYSIOLOGY
• The obstruction results in systemic
hypertension in the upper segment with
normal pressure in the lower segment.
• To overcome the obstruction, branches of
the subclavian arteries and the intercostal
arteries increase in size and anastomose
with the vessels from the lower segment.
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Clinical features

 may result in systolic hypertension, shock and

congestive cardiac failure in the first month of
life.
 In older children, symptoms consist of
intermittent claudication, exertional dyspnoea
and weakness in the legs.
 Characteristic findings of Turner’s syndrome may
be evident in some females

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On physical examination

 -femoral arterial pulsations are weak and delayed

compared to the radial pulsations.
 The blood pressure in the arms is elevated and is
normal or unrecordable in the inferior extremities.
 Palpable collaterals are present along both borders of
the scapula and mid thoracic intercostal spaces on
both sides along the lower borders of the ribs.

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The heart size remains normal with
a forcible left ventricular impulse.
A systolic thrill may be palpable in
the suprasternal notch.
The carotid pulsations are
prominent.
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auscultation
 - The first heart sound is accentuated
 . The second heart sound is usually normally
split with an accentuated aortic component.
 A loud constant ejection click is best heard
at the apex but is well conducted all over the
precordium.
 With severe systemic hypertension a left
atrial fourth sound may be audible.

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An ejection murmur
Continuous murmurs, though rare
 An aortic ejection systolic murmur
or a decrescendo diastolic murmur
of aortic regurgitation may be
heard because of the bicuspid
aortic valve
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Investigations

• Electrocardiogram shows left ventricular hypertrophy

• Chest X-ray shows -left ventricular configuration and prominent
ascending aorta and aortic knuckle.
• Rib notching appears by the age of ten years
• Barium swallow shows indentation of the oesophagus by the
dilated arch of the aorta and post stenotic dilation of the
proximal descending aorta, resulting in the "figure of 3" sign
• Suprasternal two-dimensional echocardiogram can demonstrate
the coarctation clearly
• doppler evaluation
• MRI
• Cardiac catheterisation
• Selective angiogram for associated anomalies like hypoplasia of
the arch and patent ductus arteriosus.
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Aortic rupture in trauma

• Aortic rupture resulting from blunt trauma is a life threatening injury.

• It commonly occurs in road traffic accidents and has a poor survival
rate of 20%.
• There is usually a transverse tear in the wall of the aorta, which may
involve the intima through to the media of the aorta.
• The pressure within the systemic circulation may itself cause the
formation of a false aneurysm.
• Rupture of the isthmus region of the descending aorta is more
common,.
• Other sites include the ascending aorta proximal to the origin of the
brachiocephalic artery, the aortic arch and the abdominal aorta.
• -Rupture is likely to be the result of a number of factors, including
torsion and shear and stretching forces, and is possibly compounded by
hydrostatic pressure.

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Aortic Valve Stenosis

• Aortic valve stenosis is the most frequent valve

abnormality.
• In the 20th century, rheumatic fever was a common
cause but now accounts for < 10% of cases of aortic
stenosis.
• The great majority of aortic stenoses is a result of
degenerative calcification
• age group -6th decade of life or later.
• Aortic stenosis causes extra work for the heart,
resulting in left ventricular hypertrophy
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Aortic Valve Insufficiency

Insufficiency of the
aortic valve results
in aortic
regurgitation
(backrush of blood
into the left
ventricle),
 producing a heart
murmur and a
collapsing pulse
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Thank
uuuuuuuuu
all

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