Acute Aortic Syndromes Flashcards
When are acute aortic syndromes more common?
Circadian variation - early morning and winter due to times of increased BP
Name the risk factors for acute aortic syndromes
Increasing age
Male sex
Diabetes
Pre-existing aortic disease
Connective tissue disorders
Bicuspid aortic valve
Hypertension
Iatrogenic
Trauma
Previous aortic surgery
Family history
What are acute aortic syndromes?
Aortic dissection
Intramural haematoma
Penetrating aortic ulcer
Describe aortic dissection
Tear in the intima of the aorta that allows blood to form a pathological cleavage plane between itself and the adventitia by disrupting the media
What is the name for the channels created in aortic dissection?
False and true lumens
Describe the blood flow in the lumens
Pressure higher in the false lumen as outflow is a small re-entry tear leading to compression of the true lumen
What are the two types of vessel malperfusion?
Dynamic - mobile dissection flap intermittently shuttering the ostia of vessels
Static - fixed flap
What is intramural haematoma?
Clotted blood in the intramural space without an obvious intimal tear
What causes IMH?
Rupture of medial vasa vasora leading to tear in the aortic lumen
What disease associated with IMH?
Hypertension
What causes penetrating aortic ulcer?
Focal ulceration of an atherosclerotic plaque into the media
What part of the vessel is affected in PAU?
Intima
How do aortic syndromes present?
Severe chest pain with radiation to neck/back
BP abnormality depending on type
Collapse/death/neuro deficit/limb ischaemia
How is aortic dissection classified?
DeBakey System (type A proximal type B - distal)
I - ascending to descending aorta
II - ascending aorta only
III - beyond origin of LSA
What are the findings in a complicated dissection?
Impending or frank rupture
Malperfusion
Persistent pain
Refractory hypertension
How are aortic syndromes investigated?
Bloods
CXR
ECG
Transoesophageal echo
CTA
MRA
What type of aortic dissection is more common?
Type A
Who must type A dissections be referred to?
Cardiothoracic surgery
What is the surgery for type A dissection?
Seal entry point to decompress false lumen - usually with aortic root replacement and bypass
What is the surgery for type A dissection?
Seal entry point to decompress false lumen - usually with aortic root replacement and bypass
What is the medical management of an uncomplicated type B?
HR <60
SBP 100-120 mmHg
Urine output 0.5ml/kg/hour
1st line - Beta blocker (labetalol)
2nd line - CCB (nicardipine)
Add on - hydralazine
What indicates a complicated TBAD?
Visceral/limb ischaemia
Entry tear >10mm
Inner curve entry tear
Aortic diameter >4cm
Persistent pain/HTN
False lumen >22mm
False lumen thrombosis
Define complicated Type B dissection
- rapid aortic expansion
- aortic rupture
- hypotension/shock
- ischaemia
- paraplegia
- para-aortic haematoma
- recurrent/refractory pain
- refractory hypertension
How is Type B dissection treated?
TEVAR
How often is uncomplicated type B managed?
Annually
How are patients with type B dissection treated?
Beta blocker for BP
CCB reduce mortality
When is intervention required in type B dissection?
aorta >55mm
false lumen >40mm
Where do most IMH occur?
Descending thoracic aorta
How is IMH generally managed?
Surveillance
>55mm or >5mm/year expansion - TEVAR
Beta blocker
What are the indications for intervention in IMH?
Refractory chest pain
Increase in haematoma size
Aortic rupture
Pleural effusion
When should repair be considered in PAU?
diameter >20mm or depth >10mm
