Diseases of Aorta

Thoracic aorta dissection

 Thoracic aorta dissection occurs

as blood flow is redirected from
the aorta (true lumen) through
an intimal tear into the media of
the aortic wall (false lumen).
Risk factor
 Hypertension
 Connective tissue disorders 
(Marfan, Turner's)
 Aortitis
 Iatrogenic
 Atherosclerosis
 Thoracic aortic aneurysm
 Bicuspid aortic valve
Risk factor

 Trauma
 Coarctation of aorta
 Hypervolemia (pregnancy)
 Congenital aortic stenosis
 Polycystic kidney disease
 Pheochromocytoma
 Risk factor
 Approximately 20% of aortic aneurysms and
dissections are related to hereditary connective
tissue disorders

 Marfan syndrome is the most common disorders,

occurring in the worldwide population at a
frequency of 1 in 5000

 Marfan syndrome, with aortic aneurysm and

dissection as the major cause of morbidity and
mortality
INTRODUCTION
 Prevalence:
– Male to female = 2:1
 Peak incidence:
– 6th & 7th decades
 Mortality rate: (Untreated)
– >25% within the first 24 h
– >50% within the first week
– >75% within one month
– >90% within one year
Clinical Presentation
 Chest pain is present in about two thirds of patients
and back pain invariably accompanies dissections
that begin distal to the aortic arch

 Pain may migrate as the dissection progresses

distally

 Patients with ascending aortic dissections may have

associated aortic valve insufficiency with dyspnea

 Related to aortic branch occlusion can cause

cerebral infarction, myocardial infarction, abdominal
malperfusion, limb ischemia, and paraplegia
SIGNS AND SYMPTOMS

 40% of patients die immediately

 The diagnosis requires a high level of

suspicion

 As many as 30% of patients are first

thought to have another diagnosis
SIGNS AND SYMPTOMS
 Pain is generally located in the mid-
sternum
 Painless dissection has been described and
usually occurs in the setting of an existing
aneurysm
 Signs or symptoms related to mal-
perfusion of the brain, limbs, or visceral
organs
Surgical Classifications
DeBAKEY SYSTEM
Type I:
– Begins in the ascending aorta, extends beyond the
ascending aorta and arch
Type II:
– Begins in the ascending aorta, confined to the ascending
aorta
Type IIIa:
– Originates in the descending thoracic aorta and is limited to
the thoracic aorta
Type IIIb:
– Originates in the descending thoracic aorta and extend
below the diaphragm
 Indications for surgery
 Debakey I or II
- immediate surgery

 contraindications:
– advanced age
– incurable disease
– paraplegia, extensive brain damage
Indications for surgery

Debakey III
 No complications, medical treatment

 Complications: persistent pain, hemothorax,

limb ischemia, acute renal failure, paraparesis
Surgery/ Stenting
STANFORD CLASSIFICATION
 The DeBakey system has been
replaced by the Stanford system
 Type A:
– involving the ascending aorta with the initial tear
located in the ascending, transverse, or
descending region
 Type B:
– confined to the descending aorta with the initial
tear located distal to the left subclavian artery
DIAGNOSTIC STUDIES
 Chest x-ray

 CT angiography (CTA) acquires axial images

during the arterial phase following a bolus
of intravenous (IV) contrast medium. CTA
can distinguish the difference between the
false and true lumen in aortic dissection

 TEE
widened mediastinum, rightward tracheal displacement, irregular
aortic contour with loss of the aortic knob, an indistinct
aortopulmonary window, and a left pleural effusion.
Surgery for Dissection of Aorta

Indications
 Since Type A carries 50% mortality in 48h

Surgery is indicated immediately

 Dg is established preferably with CT/MRI
demonstrating the entire Aorta
 TTE and TEE (preferably under general
anesthesia) caries equal sensitivity and
specificity
Clinical Presentation
Aortic aneurysm

 An aortic aneurysm is defined as a

localized or diffuse aortic dilation that
exceeds 50% of the normal aortic
diameter
Factors associated with aneurysm
formation
 Advanced age
 Hypertension
 Smoking
 Arteriosclerosis
 Aortic dissection.
Classification of descending
thoracic aortic aneurysm
Clinical Presentation

 In most patients an aortic aneurysm is

discovered incidentally without specific
symptoms, because the slow growth
of aneurysms is typically silent.
Clinical Presentation

 Back pain is a frequent complaint

 Large aortic aneurysms can put pressure
on adjacent structures
Clinical Presentation
 Dyspnea
 pulmonary hypertension
 Dysphagia
 Hoarseness
 Hemoptysis
 Weight loss
 Intestinal angina
 Arterial hypertension
Indications for surgery
 Patients who are diagnosed with aneurysms
greater than 5 cm or larger or with rapid
aneurysm enlargement are considered for
surgical repair

 A sudden change in the characteristics or

the severity of the pain is significant and
should alert clinicians to the possibility of
rapid aneurysm expansion, leakage, or
rupture
Indications for surgery
 More than 90% of deaths in Marfan patients
are related to complications of aneurysms or
dissections of the thoracic aorta.

 Marfan patients are often considered for

surgery at an earlier stage of aneurysm
development due to faster rates of
aneurysm growth and rupture at smaller
diameters.
Prognosis
 Untreated, 75% to 80% of thoracic aortic
aneurysms will eventually rupture

 Five-year untreated survival ranges between

10% and 20%

 Although women develop thoracic aortic

aneurysms 10 to 15 years later than men,
rupture occurs more frequently in women
Prognosis
 Age has also been associated with increased
risk of rupture.

 Aneurysm size significantly influences the

rate of rupture

 When an ascending aortic aneurysm reaches a

diameter of 6 cm, the risk of rupture is 31%

 For the descending thoracic aorta the critical

size is around 7 cm with a 43% risk of
rupture
Prognosis