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SHORT REVIEW
08.09.2015
• Aortic dissection is defined as separation of the layers
within the aortic wall. Tears in the intimal layer result
in the propagation of dissection (proximally or
distally) secondary to blood entering the intima-media
space.
• Initiating event
-primary rupture of the intima.
-haemorrhage within the media.
INCIDENCE
• Turner syndrome.
Aortic dissection or rupture, often occurring with
coarctation, is an increasingly recognized cause of
death in women with Turner syndrome.
• Coronary artery bypass graft surgery (CABG).
Ascending aortic dissection is a rare complication of
CABG, perhaps more often, with minimally invasive
off-pump CABG .
• Crack cocaine
TYPES OF AORTIC DISSECTION
Classification
• Radiation
• Hypertension
• Distal (type B) dissection
• Marfan syndrome
• Atherosclerosis, prior aortic aneurysm, iatrogenic
dissection, or intramural hematoma,
Initial study :
CT in 61 percent,
TEE in 33 percent,
Aortography in only 4 percent, and
MRI in only 2 percent .
• Important to rapidly identify acute dissections involving
the ascending aorta.
• Other findings
widening of the aortic contour,
displaced calcification,
aortic kinking, and
opacification of the aorticopulmonary window
Aortography
Site of dissection
Relationship between dissection and major branches
Communication site between the true and false lumen
Coronary angiography and evaluation for AR
Generally been replaced by non invasive testing
Sensitivity of 88 % and a specificity of 94 %
Positive and negative predictive values were 96 and 84 %
• False negative Aortography
Disadvantages of standard CT
Intimal flap is seen in less than 75 percent of cases and
that the site of entry is rarely identified .
Potentially nephrotoxic iodinated contrast is required,
No capability to assess for AR
The accuracy substantially improved with spiral (helical) CT
and perhaps with multidetector (multislice)
CT (Spiral CT may be more accurate than MRI or TEE in the
detection of aortic arch vessel involvement .
Potential limitation is a spiral CT artifact that can simulate
an aortic dissection flap in patients if performed without
ECG gating
Patient with an
ascending type
A aortic
dissection
showing the
intimal flap.
Patient with a
type A aortic
dissection
involving the
ascending and
descending
aorta
• MRI
Color Doppler permits clear identification of flow within and between the
true and false lumens .
The presence of flow does not absolutely distinguish the true lumen from
the false lumen.
The true lumen has an endothelial lining and is contiguous with the aortic
valve.
Thrombosis in the false lumen, pericardial effusion, concomitant
AR, and proximal coronary arteries can be readily visualized.
The 135º long axis view from TEE can define the severity and
mechanism of aortic regurgitation that complicates acute type A
dissections .
• Thoracic MRI, thoracic CT, and multiplane TEE are the preferred
methods, if available.
• GENERAL PRINCIPLES
• Confined to the descending aorta are treated medically unless the patient
demonstrates progressive dissection with end-organ ischemia or
continued hemorrhage into the pleural or retroperitoneal space.
• Inotropic agents should be avoided since they will increase aortic wall
shear stress and worsen the dissection.
• In a series of 384 patients with type B dissections from the IRAD, 73 percent
were managed medically. In-hospital mortality for these patients was 10
percent .
The first six factors were the most important predictors of in-hospital
mortality in the IRAD review
• Survival after repair
• However, the morbidity rate was 21 percent (small bowel and renal
infarction and lower extremity gangrene) and 30-day mortality was 16
percent.
Procedure success 98 %
Major complications 11.1 %
Neurologic complications, the most serious, in 2.9 percent,
mostly peri-procedural stroke and paraplegia (1.9 and 0.8
percent, respectively)
The major complication rate higher with acute compared
with chronic dissections (21.7 versus 9.1 percent)
Minor complications - 2.5 percent.
The rate of complications compared favourably with
previously reported surgical series.
• Type A dissections
• Possible alternative to surgery in patients with
type A dissections with ischemic complications.
• Limited experience .In one series, the false lumen
was completely obliterated in 14 of 15 patients
within three months .
• Further study is required to determine the role for
this approach in such patients.
• A hybrid approach to the repair of type A aortic dissection,
sometimes referred to as the “frozen elephant trunk
repair,” uses an open approach to surgically repair the
ascending aorta while using a stent-graft to manage the
descending aorta.
• Fenestration and other stents
• Medical therapy
• Life-long therapy with an oral beta blocker to reduce
systemic blood pressure and the rate of rise in systolic
pressure, both of which will minimize aortic wall stress
• Target blood pressure of less than 120/80 mmHg .
• Avoidance of strenuous physical activity is also
recommended as another method to minimize aortic
shear stress.
• Serial imaging — Baseline thoracic MRI or chest CT scan
prior to discharge with follow-up examinations at 3, 6, and
12 months, even if the patient remains asymptomatic .
Subsequent screening studies are then performed every one
to two years if there is no evidence of progression.
• Approaches include:
• (1) development of dedicated stent-graft prostheses with
fenestrations or branches for direct side branch access, and
• (2) modification of readily available interventional techniques
to establish extra-anatomic side branch perfusion (e.g.
‘Chimney’, ‘Sandwich’ technique etc.).
Outcome parameters
• The closure rate of the primary entry tear and
thrombosis of the false lumen of the stented
segment of the thoracic aorta is high in most series,
but needs to be reported in the long term .
Endoleaks
• The majority of endoleaks can be avoided by careful selection
particularly with regard to important morphological details such
as the length of the landing zone, use of multiple stents, length of
overlapping segments as well as severe angulation and massive
aortic calcification (porcelain aorta)
PENDING QUESTIONS
• Abstract
• Background: Uncomplicated type B dissections have been traditionally managed
with antihypertensive therapy. In the endovascular era, this dictum has been
revisited. This review pooled the available studies to compare the outcomes of
best medical therapy (BMT) to thoracic endovascular aortic repair (TEVAR) for
uncomplicated type B dissections.
• Methods: A literature search was performed to identify studies on uncomplicated
type B dissections managed with BMT with and without TEVAR. The primary
outcome measures were mortality rates at 30 days and at 2 years following
intervention.
• Results: A total of 6 studies included 123 patients who underwent TEVAR/BMT,
and 566 patients who had BMT alone. The mortality rates at 30 days (6.5%
TEVAR/BMT vs 4.8% BMT, P = .21) and at 2 years (9.7% vs 11.9%, P = .32) were
similar. Renal failure was greater in TEVAR/BMT (15.4% vs 2.1%, P < .01). Rates of
surgical reintervention/intervention were similar (17.6% vs 20.1%, P = .31).
• Conclusion: The TEVAR with BMT does not provide survival benefit compared to
BMT alone, 2 years following uncomplicated type B aortic dissection.
Anatomy
• The aorta is composed of the intima, media, and adventitia. The intima,
the innermost layer, is thin, delicate, lined by endothelium, and easily
traumatized.
• The media is responsible for imparting strength to the aorta and consists
of laminated but intertwining sheets of elastic tissue. The arrangement of
these sheets in a spiral provides the aorta with its maximum allowable
tensile strength. The aortic media contains very little smooth muscle and
collagen between the elastic layers and thus has increased distensibility,
elasticity, and tensile strength. This contrasts with peripheral arteries,
which, in comparison, have more smooth muscle and collagen between
the elastic layers.
• The outermost layer of the aorta is adventitia. This largely consists of
collagen. The vasa vasorum, which supplies blood to the outer half of the
aortic wall, lies within the adventitia. The nervi vascularis, bundles of
nerve fibers found in the aortic adventitia, are involved in the production
of pain, which occurs with acute stretching of the aortic wall from a
dissection.[11] .The aorta does not have a serosal layer.
• The aorta plays an integral role in the forward circulation of
the blood in diastole. During left ventricular contraction,
the aorta is distended by blood flowing from the left
ventricle, and kinetic energy from the ventricle is
transformed into potential energy stored in the aortic wall.
During recoil of the aortic wall, this potential energy is
converted to kinetic energy, propelling the blood within the
aorta to the peripheral vasculature.
• The volume of blood ejected into the aorta, the compliance
of the aorta, and resistance to blood flow are responsible
for the systolic pressures within the aorta. Resistance is
mainly due to the tone of the peripheral vessels, although
the inertia exerted by the column of blood during
ventricular systole also plays a small part.
• The aorta has thoracic and abdominal regions. The thoracic aorta is
divided into the ascending, arch, and descending segments; the
abdominal aorta is divided into suprarenal and infrarenal segments.
The ascending aorta is the anterior tubular portion of the thoracic
aorta from the aortic root proximally to the innominate artery
distally. The ascending aorta is 5 cm long and is made up of the
aortic root and an upper tubular segment.
• The aortic root consists of the aortic valve, sinuses of Valsalva, and
left and right coronary arteries. It extends from the aortic valve to
the sinotubular junction and supports the base of the aortic
leaflets. The aortic root allows the 3 sinuses of Valsalva to bulge
outward, facilitating the full excursion of the leaflets in systole. The
left and right coronary arteries arise from these sinuses.
• The upper tubular segment of the ascending aorta starts at
the sinotubular junction and ends at the beginning of the
aortic arch. The ascending aorta lies slightly to the right of
the midline, with its proximal portion in the pericardial
cavity. Structures around the aorta include the pulmonary
artery anteriorly; the left atrium, right pulmonary artery,
and right mainstem bronchus posteriorly; and the right
atrium and superior vena cava to the right.
• The arch of the aorta curves upward between the
ascending aorta and descending aorta. The brachiocephalic
arteries originate from the aortic arch. Arteries that arise
from the aortic arch carry blood to the brain via the left
common carotid, innominate, and left subclavian arteries.
• The initial part of the aortic arch lies slightly left and in front of the
trachea; the arch ends posteriorly to the left of the trachea and
esophagus. Inferior to the arch is the pulmonary artery bifurcation,
the right pulmonary artery, and the left lung. The recurrent
laryngeal nerve passes beneath the distal arch, and the phrenic and
vagus nerves lie to the left. The junction between the aortic arch
and the descending aorta is called the aortic isthmus. The isthmus is
a common site for coarctations and trauma.
• The descending aorta extends from the area distal to the left
subclavian artery to the 12th intercostal space. Initially, the
descending aorta lies in the posterior mediastinum to the left of the
course of the vertebral column. It passes in front of the vertebral
column in its descent and ends behind the esophagus before
passing through the diaphragm at the level of the 12th thoracic
vertebra.
• The abdominal aorta extends from the descending aorta at the level
of the 12th thoracic vertebra to the level of bifurcation at the fourth
lumbar vertebra. The splanchnic arteries branch from the
abdominal aorta. The thoracoabdominal aorta is the combination of
the descending thoracic and abdominal aorta.
• With increasing age, the elasticity and distensibility of the aorta
decline, thus inducing the increase in pulse pressure observed in
elderly individuals. The progression of this process is exacerbated
by hypertension, coronary artery disease, or hypercholesterolemia.
• Histologically, the loss of distensibility is marked by fragmentation
of elastin and the resultant increase in collagen and, thus, a higher
collagen-to-elastin ratio. This, along with impairment in flow in the
vasa vasorum, may be responsible for the age-related changes.
These factors cumulatively lead to increased left ventricular systolic
pressure and wall tension with associated increases in end-diastolic
pressure and volume.