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oral boards > AHA: TAA incl hereditary aortopathy & BAV + TEVAR > Flashcards

AHA: TAA incl hereditary aortopathy & BAV + TEVAR Flashcards

1
Q

ongoing/subsequent imaging monitoring in BAV with aortic sinuses (root) or asc Ao diameter ≥4.0cm

A

lifelong TTE/CMR/CTA
interval by rate of progression & fam hx
(2a)

“1. In patients with BAV and a diameter of the aortic sinuses or ascending aorta of ≥4.0 cm, lifelong serial evaluation of the size and morphology of the aortic sinuses and ascending aorta by echocardiography, CMR, or CT angiography is reasonable, with the examination interval determined by the degree and rate of progression of aortic dilation and by family history.” (2a)

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2
Q

ongoing/subsequent imaging monitoring in BAV s/p AVR with aortic sinuses (root) or asc Ao diameter ≥4.0cm

A

lifelong serial imaging
(2a)

“2. In patients with a BAV who have undergone AVR, continued lifelong serial interval imaging of the aorta is reasonable if the diameter of the aortic sinuses or ascending aorta is ≥4.0 cm.” (2a)

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3
Q

aortic root or asc Ao threshold to replace in BAV

A

\≥5.5cm (1)
\≥5cm with RF(s) for dissxn @ COE (2a) OR pt low-risk @ COE (2b)
\≥4.5cm with concomitant SAVR @ COE (2a)
A:h≥10 @ COE (2a)

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4
Q

Do the indications/size threshold to rx/replace aneurysm differ for aortic root v asc Ao in BAV/HTAD/Marfan’s/Loeys-Dietz/Turner?

A

NO

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5
Q

Do the indications to replace root v asc Ao for aneurysm differ for sporadic?

A

NO

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6
Q

How does the mgmt of the asc Ao in setting of root aneurysm differ in Marfan’s compared to other situations (sporadic or other HTAD/syndromes)?

A

replace the asc Ao WITH the rootkom
even if not aneurysmal / regardless of size

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7
Q

indication(s) to replace aortic root or asc Ao in BAV

A
  • >5.5cm (1)
    regardless of sx status
  • asx + 5.0-5.5cm + dissxn RF @ CVC (2a)
  • asx + 5.0-5.5cm + low-risk @ CVC (2b)
  • SAVR + ≥4.5cm @ CVC (2a)
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8
Q

Is it OK to spare the valve in a normally-functioning AV when replacing the aortic root or asc Ao in BAV?

A

YES (@ CVC)
(2b)

“4. In patients with a BAV who meet criteria for replacement of the aortic sinuses, valvesparing surgery may be considered if the surgery is performed at a Comprehensive Valve Center.” (2b)

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9
Q

initial mgmt of uncomplicated type B (desc) aortic dissxn

A

medical tx (1) i.e. anti-impulse tx:
1. IV β-blockade (esmolol) to HR 60-80 (AHA) / HR<60 (SESATS: ∝￬AEs)
2. vasodilators to SBP<120 (AHA)

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10
Q

initial mgmt of ANY acute thoracic aortic dissxn OR injury

A

anti-impulse tx:
1. IV β-blockade (1) (esmolol) > non-dihydropyridine Ca-channel blocker (2a) to HR 60-80
2. ± vasodilators to SBP<120 (1)
a-line in ICU (1)
pain control (1)

except in hypoTN/hypovolemic shock trauma pts (obviously)

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11
Q

A:h (Ao cross-sectional area : pt height) ratio threshold for aneurysm rx

A

≥10 cm2/m
in: sporadic, BAV, Marfan’s

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12
Q

Ao landing zones

A

all vessel landmarks are to the distal end of their origin in the chest & to the prox end of origin in the abdomen

  • thoracic
  • zone 0 = STJ to innominate artery
  • zone 1 = to L carotid
  • zone 2 = to L subclv
  • zone 3 = to T4 / 2cm distal to L subclv
  • zone 4 = to T6 / mid-desc Ao
  • zone 5 = to celiac (prox origin)
  • abdominal
  • zone 6 = celiac to SMA (prox origin)
  • zone 7 = SMA to renals (prox origin)
  • zone 8 = renals
  • zone 9 = infrarenal to Ao bifurc
  • zone 10 = CIAs to EIA (prox origin)
  • zone 11 = EIAs

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

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13
Q

Ao zone 0

A

asc Ao incl innominate:
STJ through distal origin of innominate artery

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

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14
Q

Ao zone 1

A

L carotid:
end of innominate artery through distal origin of L carotid

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

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15
Q

Ao zone 2

A

L subclavian:
end of L carotid through distal origin of L subclv

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

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16
Q

Ao zone 3

A

1st 2cm desc Ao:
end of L subclv + 2cm distal / through T4

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

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17
Q

Ao zone 4

A

mid-desc Ao:
T4 through T6

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

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18
Q

Ao zone 5

A

low/distal desc Ao:
T6 to prox origin of celiac

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

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19
Q

Ao zone 6

A

celiac axis:
celiac to prox origin of SMA

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

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20
Q

Ao zone 7

A

SMA:
SMA to prox origin of renals

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

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21
Q

Ao zone 8

A

renals:
renals

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

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22
Q

Ao zone 9

A

infarenal Ao:
end of renals to Ao bifurc

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

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23
Q

Ao zone 10

A

CIAs:
Ao bifurc to prox origin of EIAs

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

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24
Q

Ao zone 11

A

EIAs:
from prox origin of EIAs

AHA aortopathy guideline
Figure 3. Classification of Aortic Anatomic Segments by 11 Landing Zones
https://drive.google.com/file/d/124b35WMwk_1Q_esHhFJmcXHtZHFIVwIU/view

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25
Q

aortic root anatomic definition

A

sinuses of Valsalva
= annulus to STJ

AHA aortopathy guideline
Figure 1. The Anatomy of the Aorta and Its Main Branches
https://drive.google.com/file/d/122sAH6tRvA8iINUGIZ0GfEyB_wlm8LkH/view

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26
Q

asc Ao anatomic definition

A

STJ to prox origin of innominate

AHA aortopathy guideline
Figure 1. The Anatomy of the Aorta and Its Main Branches
https://drive.google.com/file/d/122sAH6tRvA8iINUGIZ0GfEyB_wlm8LkH/view

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27
Q

aortic arch anatomic definition

A

innominate through L subclv artery (prox origin to distal origin)

AHA aortopathy guideline
Figure 1. The Anatomy of the Aorta and Its Main Branches
https://drive.google.com/file/d/122sAH6tRvA8iINUGIZ0GfEyB_wlm8LkH/view

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28
Q

desc thoracic Ao anatomic definition

A

end of subclv to diaphragmatic hiatus

AHA aortopathy guideline
Figure 1. The Anatomy of the Aorta and Its Main Branches
https://drive.google.com/file/d/122sAH6tRvA8iINUGIZ0GfEyB_wlm8LkH/view

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29
Q

classifications of Ao dissxn acuity/chronicity:
hyperacute

(by SVS/STS 2020 Reporting Standards)

A

<24h

from sx onset

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30
Q

classifications of Ao dissxn acuity/chronicity:
acute

(by SVS/STS 2020 Reporting Standards)

A

2w (1-14d)

from sx onset

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31
Q

classifications of Ao dissxn acuity/chronicity:
subacute

(by SVS/STS 2020 Reporting Standards)

A

3mo (15-90d)

from sx onset

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32
Q

classifications of Ao dissxn acuity/chronicity:
chronic

(by SVS/STS 2020 Reporting Standards)

A

> 3mo (>90d)

from sx onset

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33
Q

DeBakey aortic dissxn classification

A

Type I = asc tear + desc
Type II = asc tear only
Type IIIa = desc tear thoracic only
Type IIIb = desc thoracic tear + abd

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34
Q

Stanford aortic dissxn classification

A

type A = involving asc (± desc)
type B = involving desc only
regardless of site of entry tear

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35
Q

recommended measurement of thoracic Ao diameters

A

inner-edge to inner-edge

unless wall abnormalities e.g. atherosclerosis, discrete wall thickening: outer-edge to outer-edge

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36
Q

recommended measurement of aortic root diameter

A

maximum sinus to sinus

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37
Q

aortic root or asc Ao threshold to replace in non-syndromic HTAD

A

≥5.0cm (1)
≥4.5cm with RFs OR concomitant <3 surg @ COE (2a)

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38
Q

risk factors (“high-risk features”) for aortic dissxn in BAV

A
  • FH of dissxn @ <5.0cm
  • rapid Ao growth (≥0.3cm/y)
  • Ao CoA
  • “root phenotype”
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39
Q

risk factors (“high-risk features”) for aortic dissxn in non-syndromic HTAD

A
  • FH of dissxn @ <5.0cm
  • FH unexplained sudden death <50yo
  • rapid Ao growth (≥0.5cm/1y x1y OR ≥0.3cm/y x2y)
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40
Q

risk factors (“high-risk features”) for aortic rupture in desc TAA

A
  • rapid Ao growth (≥0.5cm/1y)
  • +sx
  • genetic aortopathy
  • saccular aneurysm
  • ♀
  • infxs/mycotic aneurysm
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41
Q

risk factors (“high-risk features”) for aortic rupture in TAAA (thoracoabd Ao aneurysm)

A
  • rapid Ao growth (≥0.5cm/1y)
  • +sx
  • significant ∆ in appearance/morphology
  • saccular aneurysm
  • PAU
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42
Q

risk factors (“high-risk features”) for aortic dissxn in non-syndromic HTAD

A
  • FH of dissxn @ <5.0cm
  • FH unexplained sudden death <50yo
  • rapid Ao growth (≥0.5cm/1y x1y OR ≥0.3cm/y x2y)
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43
Q

risk factors (“high-risk features”) for aortic dissxn in Marfan syndrome

A
  • FH of dissxn
  • rapid Ao growth (>0.3cm/y)
  • diffuse aortic root & asc Ao dilation
  • marked vertebral artery tortuosity
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44
Q

risk factors (“high-risk features”) for aortic dissxn in Loeys-Dietz syndrome

A
  • FH of dissxn (esp @ young age or small Ao diameter)
  • rapid Ao growth (>0.3cm/y)
  • severe extra-aortic features
  • certain pathogenic variants
  • women with TGFBR2 & small body size
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45
Q

risk factors (“high-risk features”) for aortic dissxn in Turner syndrome

A
  • Ao CoA
  • Ao dilation
  • BAV
  • HTN
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46
Q

imaging surveillance of Marfan syndrome (starting @ dx)

A

TTE @ dx + 6mo to assess growth rate 🠆 Q1Y (1)

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47
Q

postoperative imaging surveillance for Marfan syndrome s/p aortic root replacement

A

MRI > CTA Q1Y x2y 🠆 Q2Y
(for distal TAD)

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48
Q

medical mgmt of Marfan syndrome

A

β-blocker and(2a)/or(1) ARB @ max-tolerated doses

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49
Q

medical mgmt of Loeys-Dietz syndrome

A

β-blocker and/or ARB @ max-tolerated doses (2a)

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50
Q

aortic root threshold to replace BOTH root & asc Ao in Marfan syndrome

A

replace root AND asc Ao together
≥5.0cm (1)
≥4.5cm with RFs @ COE (2a)
A:h≥10 @ COE (2a)

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51
Q

aortic arch/desc Ao threshold to replace in Marfan syndrome

A

≥5.0cm (2a)

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52
Q

initial imaging w/u of Turner syndrome

A

TTE + cMRI @ dx to assess for BAV, root/asc dil, CoA, other congen heart defects (1)
🠆 if no dilation or RFs TTE or MRI Q10Y (1)
if ASI>2.3 aortic imaging (NOS) Q1Y (1)

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53
Q

initial imaging w/u of Loeys-Dietz syndrome

A

TTE @ dx + 6mo to assess growth rate 🠆 Q1Y (1)
MRI or CTA head to pelvis @ dx (1) + Q2Y (2a)

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54
Q

aortic root or asc Ao threshold to replace BOTH root & asc Ao in Loeys-Dietz syndrome

A

replace root AND asc Ao together
TGFB3: ≥5.0cm
else: ≥4.5cm
TGFBR1/2 with RFs: ≥4.0cm

else = SMAD3, TGFB2, TGFBR1/2 without RFs

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55
Q

aortic arch/desc Ao threshold to replace in Loeys-Dietz syndrome

A

TGFBR1/2 or SMAD3:
≥4.5cm (2b)

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56
Q

aortic root or asc Ao threshold to replace in Ehlers-Danlos syndrome

A

UNKNOWN
“shared decision-making” @ COE

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57
Q

ASI (aortic size index)

A

max Ao diameter (cm) / BSA (m2)
(used for Turner syndrome ≥15yo: rx ASI≥2.5)

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58
Q

AHI (aortic height index)

A

max Ao diameter (cm) / height (m)
(used for sporadic TAA: rx AHI≥3.21 @ COE)

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59
Q

aortic root or asc Ao threshold to replace in Turner syndrome

A

ASI≥2.5 with RFs (2a)
ASI≥2.5 (2b) (without RFs)

(aortic size index = max Ao diam / BSA)
can replace root or asc Ao alone, or can do both together

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60
Q

goal BP for medical mgmt of sporadic TAA

A

SBP<130
DBP<80
⇒ ￬MACE (1)

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61
Q

aortic root or asc Ao threshold to replace in sporadic TAA

A

aortic root OR asc Ao:
+sx (1)
≥5.5cm (1)
rapid Ao growth (≥0.5cm/1y x1y OR ≥0.3cm/y x2y) (1)
≥5.0cm @ COE (2a)
A:h≥10 if h>1σ above/below μ @ COE (2a)
ASI≥3.08 OR AHI≥3.21 @ COE (2b)

asc Ao only:
≥5.0cm + concomitant SAVR (2a) OR other concomitant <3 surg (2b)
≥4.5cm + concomitant SAVR @ COE (2a)

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62
Q

aortic arch threshold to replace in sporadic TAA

A

+sx (1)
≥5.5cm + low-risk (2a)
hemiarch with aTAA rx extending into prox arch (2a)
elephant trunk with aortic arch aneurysm rx extending into prox desc Ao (2b)

hybrid or endovascular if high-risk for open surgery (2b)

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63
Q

desc Ao threshold to replace in sporadic TAA

A

≥5.5cm (1)
<5.5cm with RFs (2b)

≥6.0+cm if high-risk for surgery (2b)

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64
Q

Ao threshold to replace in h/o repaired dissxn or IMH with residual chronic TAD

A

≥5.5cm (1)

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65
Q

pt risk factors for ￪cxs with open desc TAA rx

A

age ≥75yo > 65-75yo
CKD3 or ESRD/HD
COPD with FEV1≤50%
h/o stroke

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66
Q

pt risk factors for ￪cxs with endovascular desc TAA rx

A

fxnal status (dependence)
thoracoabd extent
“pulm dz”
need for EIA access (instead of CFA)
zone 1/2 landing

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67
Q

recommendation for TEVAR v open rx of desc TAA with Marfan, Loeys-Dietz, Ehlers-Danlos syndromes

A

NONE
AHA does not specify
so do open

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68
Q

general/big-picture recommendation for TEVAR v open rx of desc Ao TAA/type B dissxn

A

TEVAR (1)
EXCEPT in genetic aortopathy EXCEPT in acute type B dissxn

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69
Q

recommendation for TEVAR v open rx of TAAA (thoracoabd Ao aneurysm) with Marfan, Loeys-Dietz, Ehlers-Danlos syndromes

A

open rx (1)

TEVAR with fenestrated or branched stent grafts @ COE (2b)

70
Q

recommendation for TEVAR v open rx of ruptured desc TAA

A

TEVAR ⇒ ￬periop M&M (1)
can cover L subclv and/or celiac (2b)

71
Q

recommendation for TEVAR v open rx of ruptured type B dissxn

72
Q

recommendation for TEVAR v open rx of non-ruptured but complicated type B dissxn

A

TEVAR (2a)

73
Q

recommendation for TEVAR v open rx of uncomplicated type B dissxn with RFs

A

may consider TEVAR (2b)

74
Q

risk factors (“high-risk features”) in uncomplicated type B aortic dissxn

A
  • imaging
  • Ao diameter >4cm
  • false lumen >2cm
  • entry tear >1cm
  • entry tear @ lesser curve
  • ￪∆ Ao diam >0.5cm on serial imaging
  • bloody pleural effusion
  • radiographic-only malperfusion
  • clinical
  • refrx HTN on max doses of >3 med classes
  • refrx pain >12h
  • need for readmission
75
Q

risk factors (“high-risk features”) in PAU

A
  • diameter ≥2cm
  • depth ≥1cm
  • “significant” ￪ diam or depth
  • a/w saccular aneurysm
  • ￪pleural effusion (“increasing”)
76
Q

complicated type B IMH (features)

A
  • malperfusion
  • periaortic hematoma
  • percardial effusion with tamponade
  • persistent/refrx/recurrent pain
  • rupture
77
Q

risk factors (“high-risk features”) in uncomplicated type B IMH

A

- dissxn
- ￪Ao diam
- ￪hematoma thickness
- Ao diameter >5cm
- hematoma ≥1.3cm
- focal intimal disruption i.e. acute phase development of PAU in desc Ao
- ￪ or recurrent pleural effusion

78
Q

risk factors (“high-risk features”) in uncomplicated type A IMH

A

- dissxn
- ￪Ao diam
- ￪hematoma thickness
- Ao diameter >5cm
- hematoma ≥1.0cm
- focal intimal disruption i.e. acute phase development of PAU in asc Ao or arch
- pericardial effusion @ adm

79
Q

recommendation for TEVAR v open rx of ruptured TAAA (thoracoabd Ao aneurysm)

A

open rx (1)

TEVAR if pt stable @ COE (2b)

80
Q

Ao threshold to replace in TAAA (thoracoabdominal Ao aneurysm)

A

≥6.0cm (1)
≥5.5cm @ COE (2a)
<5.5cm with RFs (2a)

81
Q

recommendation for SCI (spinal cord injury) ppx in open TAAA (thoracoabd) rx

A

spinal (CSF) drain ⇒ ￬temp and/or perm SCI (1)

82
Q

recommendation for SCI (spinal cord injury) ppx in open OR endovasc TAAA (thoracoabd) rx

A

if delayed (≤2w postop) SC dysfxn, “timely measures to optimize SC perfusion & ￬intrathecal pressure” (1), i.e.:
- cardioversion of tachyarrhythmias
- spinal (CSF) drain (if not already)
- MAP>100
- transfuse to Hb>10
- volume resusc
- supplemental O2

SC perfusion pressure = MAP - SC fluid pressure

83
Q

incidence of immediate/early spinal cord dysfxn after TAAA (thoracoabd) rx

A

~3%?
2-15% depending on extent etc (AHA)

84
Q

incidence of delayed (up to 2w postop) spinal cord dysfxn after TAAA (thoracoabd) rx

85
Q

AHA recommendation for imaging surveillance after TEVAR TAA rx

A

CT @ 1mo + 1y 🠆 Q1Y (1)
or MRI (2a)

86
Q

AHA recommendation for imaging surveillance after open surgery TAA rx

A

CT or MRI @ 1y 🠆 Q5Y (2a)
if no residual aortopathy
if residual, Q1Y (2a)

87
Q

mgmt of type B aortic dissxn with rupture tamponade

A

TEVAR ± false lumen embo

AHA aortopathy guideline
Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options
https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

88
Q

mgmt of type B aortic dissxn with mesenteric or renal malperfusion

A

endovascular fenestration OR TEVAR

AHA aortopathy guideline
Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options
https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

89
Q

mgmt of type B aortic dissxn with limb malperfusion (lower extremity ischemia)

A

TEVAR

AHA aortopathy guideline
Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options
https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

90
Q

mgmt of type B aortic dissxn with mesenteric or renal malperfusion with persistent ischemia s/p endovascular fenestration

A

target vessel stenting

AHA aortopathy guideline
Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options
https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

91
Q

mgmt of type B aortic dissxn with mesenteric or renal malperfusion with persistent ischemia s/p TEVAR

A

target vessel stenting OR extra-anatomic bypass

AHA aortopathy guideline
Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options
https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

92
Q

mgmt of type B aortic dissxn with limb malperfusion (lower extremity ischemia) with persistent ischemia s/p TEVAR

A

extra-anatomic bypass

AHA aortopathy guideline
Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options
https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

93
Q

mgmt of type A aortic dissxn with rupture tamponade

A

emergency surgery

AHA aortopathy guideline
Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options
https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

94
Q

mgmt of type A aortic dissxn with stroke

A

emergency surgery

AHA aortopathy guideline
Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options
https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

95
Q

mgmt of type A aortic dissxn with mesenteric or renal malperfusion

A

emergency aTAA/arch rx surgery ± antegrade TEVAR OR
endovascular fenestration 🠆 surgery

AHA aortopathy guideline
Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options
https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

96
Q

mgmt of type A aortic dissxn with limb malperfusion (lower extremity ischemia)

A

emergency aTAA/arch rx surgery + antegrade TEVAR

AHA aortopathy guideline
Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options
https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

97
Q

mgmt of type A aortic dissxn with mesenteric or renal malperfusion with persistent ischemia s/p emergency aTAA/arch rx surgery + antegrade TEVAR

A

target vessel stenting

AHA aortopathy guideline
Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options
https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

98
Q

mgmt of type A aortic dissxn with limb malperfusion (lower extremity ischemia) with persistent ischemia s/p emergency aTAA/arch rx surgery + antegrade TEVAR

A

target vessel stenting

AHA aortopathy guideline
Figure 21. Acute Aortic Dissection: Malperfusion Treatment Options
https://drive.google.com/file/d/124fKWI1TxURk4qN7pfrv76O9hGDla3li/view

99
Q

How should you manage the aortic valve in the setting of acute type A aortic dissxn partially involving the root but with a healthy AV?

A

aortic valve re-suspension preferred (1)

100
Q

How should you manage the aortic valve & root in the setting of acute type A aortic dissxn destroying the root or with root aneurysm or genetic aortopathy but with a healthy AV?

A

valved conduit Bentall preferred (1)
over valve-sparing root @ COE (2b)

101
Q

recommendation for mgmt of dissxn flap extending through the arch into desc Ao in the setting of acute type A aortic dissxn

A

may consider antegrade TEVAR ⇒ ￬malperfusion & late distal Ao cxs (2b)

102
Q

recommendations for cannulation strategy in acute type A aortic dissxn

A

axillary > femoral ⇒ ￬stroke & retrograde malperfusion (2a)
OR
direct Ao or innominate with imaging guidance reasonable alternative (2a)

103
Q

complications of acute type B aortic dissxn

A
  • rupture
  • branch artery occlusion & malperfusion (complete or patial occlusion of a major branch regardless of clinical e/o ischemia)
  • dissxn extension prox or distal
  • Ao enlargement (progressive of true and/or false lumens) during acute phase
  • intractable pain
  • uncontrolled/-able? HTN
104
Q

complications of IMH

A
  • malperfusion
  • periaortic hematoma
  • pericardial effusion with tamponade
  • persistent/refrx/recurrent pain
  • rupture
105
Q

mgmt of complicated type A OR B IMH

A

same as dissxn
“urgent” rx (1)

106
Q

mgmt of type A IMH (± complicated)

A

same as dissxn
“prompt” open rx (1)

medical mgmt in selected high-risk pts withOUT RFs (2b)

107
Q

mgmt of uncomplicated type B IMH

A

same as dissxn
medical tx (1)

108
Q

mgmt of uncomplicated type B IMH with RFs

A

basically same as dissxn
rx may be reasonable (2b)

109
Q

recommendation for TEVAR v open rx of complicated type B IMH

A

basically same as dissxn
TEVAR OR open rx
TEVAR if zones 2-5/favorable anatomy (2a)
open rx if unfavorable anatomy for TEVAR (2a)

110
Q

mgmt of PAU with rupture

A

basically same as dissxn
“urgent” rx (1)

111
Q

mgmt of asc (“type A”) PAU with IMH

A

basically same as dissxn
“urgent” rx (1)

112
Q

mgmt of arch/desc (“type B”) PAU with IMH

A

“urgent” rx (2a)

113
Q

mgmt of isolated PAU (no rupture, IMH, cx)

A

+sx ∝ radiologic findings ⇒ rx (1)
asx with RFs ⇒ may consider elective rx (2b)

114
Q

recommendation for TEVAR v open rx of asc/prox arch (zones 1-2) PAU

A

open rx (1)

115
Q

recommendation for TEVAR v open rx of dist arch (zones 2-3)/desc PAU

A

open rx OR TEVAR (2a)

116
Q

blunt traumatic thoracic aortic injury (BTTAI) grades

A
  1. intimal tear ± flap
  2. IMH
  3. contained rupture (pseudoaneurysm)
  4. free rupture

AHA aortopathy guidelines
Figure 23. Classification System for BTTAIs
https://drive.google.com/file/d/12B26qVr-fs4PAEGltkc_bcjSgJ-ENk4N/view

117
Q

initial mgmt of blunt traumatic thoracic aortic injury (BTTAI) grade 1 (intimal tear)

A

non-op with f/u imaging (1)

AHA aortopathy guidelines
Figure 23. Classification System for BTTAIs
https://drive.google.com/file/d/12B26qVr-fs4PAEGltkc_bcjSgJ-ENk4N/view

118
Q

initial mgmt of blunt traumatic thoracic aortic injury (BTTAI) grade 2 (IMH)

A

non-op with f/u imaging (2b)
OR rx (“intervention”) with RFs (2a)

AHA aortopathy guidelines
Figure 23. Classification System for BTTAIs
https://drive.google.com/file/d/12B26qVr-fs4PAEGltkc_bcjSgJ-ENk4N/view

119
Q

initial mgmt of blunt traumatic thoracic aortic injury (BTTAI) grade 3-4 (contained - free rupture)

A

rx (“intervention”) (1)

AHA aortopathy guidelines
Figure 23. Classification System for BTTAIs
https://drive.google.com/file/d/12B26qVr-fs4PAEGltkc_bcjSgJ-ENk4N/view

120
Q

risk factors (“high-risk features”) in blunt traumatic thoracic aortic injury (BTTAI)

A
  • posterior mediastinal hematoma >1cm
  • mediastinal hematoma causing mass effect
  • lesion : normal Ao diameter ratio >1.4
  • Ao pseudo-coarctation
  • lg L HTX
  • asc Ao/arch/great vessel involvement
  • arch hematoma
121
Q

recommendation for TEVAR v open rx of blunt traumatic thoracic aortic injury (BTTAI)

122
Q

imaging surveillance for BTTAI s/p medical tx only, aortic dissxn + IMH s/p medical mgmt OR TEVAR or open rx

A

CT > MRI @ 1mo, 6mo, 12mo 🠆 Q1Y (1)

123
Q

imaging surveillance for PAU s/p medical mgmt only

A

CT @ 1mo 🠆 Q6mo x2y 🠆 Q1Y (2a)

124
Q

MY postoperative imaging surveillance for any endovascular aortic procedure

A

before discharge +
@ 1mo, 3-6mo, 12mo
🠆 Q1Y

125
Q

all Ao root/asc size thresholds to replace

A
  • ≥5.0cm (with RFs/concom) in benign (sporadic, BAV)
  • ≥4.5cm with excuses (e.g. SAVR @ COE) in benign
    + (with RFs/concom) in nsHTAD, Marfan
    + in OK Loeys-Dietz
  • ≥4.0cm in bad Loeys-Dietz
  • ASI≥2.5 in Turner

sporadic: ≥4.5-5.0cm
BAV: >4.5-5.0cm
nsHTAD: ≥4.5cm
Marfan: >4.5cm
Loeys-Dietz TGFB2/3: ≥4.5cm
Loeys-Dietz TGFBR1/2,SMAD3: ≥4.0cm (2b)
Turner: ASI≥2.5

126
Q

indication(s) for C-sxn (over vaginal delivery) with aortopathy

A

h/o chronic dissxn (1)
root and/or asc ≥4.5cm (2a)
nsHTAD root and/or asc ≥4.0cm (2b)

127
Q

Ao size threshold to replace pre-partum

A

≥5.0cm in benign (sporadic, BAV)
≥4.5cm in else (nsHTAD, Marfan, Loeys-Dietz)
≥4.0cm with RFs
(Turner: ASI≥2.5)

sporadic: ≥5.0cm (1)
BAV: ≥5.0cm (1)
nsHTAD: ≥4.5cm (1) OR ≥4.0cm with RFs
Marfan: ≥4.5cm (1) OR ≥4.0cm with RFs (2b)
Loeys-Dietz TGFB2/3: ≥4.5cm
Loeys-Dietz TGFBR1/2,SMAD3: ≥4.0cm (2b)
Turner: ASI≥2.5

128
Q

mgmt of acute type A aortic dissxn in 1st or 2nd trimester

A

urgent surgery with fetal monitoring (1)

129
Q

mgmt of acute type A aortic dissxn in 3rd trimester

A

urgent C-sxn 🠆 surgery (1)

130
Q

mgmt of acute type B aortic dissxn in pregnancy

A

same as usual
medical tx for un-cx / TEVAR or surgery for cx
(1)

131
Q

mgmt of significant Ao CoA (either native or recurrent) + HTN

A

endovascular stent or open rx (1)

132
Q

additional screening imaging after dx of Ao CoA (adult)

A

CTA/MRI head for intracranial aneurysm (2b)

133
Q

recommended BP measurement in Ao CoA

A

all 4 extremities
(BUE + 1 LE)

134
Q

definition of/criteria for “significant” Ao CoA

A
  1. UE HTN (at rest or with pathologic exercise response)
  2. LVH
  3. 1 of:
    - UE:LE gradient >20mmHg
    - peak-to-peak gradient across Coa by cath >20mmHg
    - mean gradient across CoA by ECHO Doppler >20mmHg
135
Q

indication(s) for rx of Kommerell’s diverticulum

A

diverticulum orifice >3cm and/or divertic + adjacent desc Ao >5cm
(2b)

“In patients with Kommerell’s diverticulum, depending on patient anatomy and comorbidities, repair may be reasonable when the diverticulum orifice is >3.0 cm, the combined diameter of the diverticulum and adjacent descending aorta is >5.0 cm, or both.” (2b)
https://drive.google.com/file/d/12C8xFk6pvyp3vCO8PYPCz2Afl9C1YaXr/view

136
Q

rule of thumb for minimum size of access vessels based on sheath/delivery system size

A

sheath size ÷ 3
(e.g. 24Fr TEVAR sheath ÷ 3 = 8mm access needed)

137
Q

standard TEVAR/interventional wire length

A

180cm (or 260cm for exchange)

138
Q

typical wire for initial access in TEVAR

A

Benston Starter (straight floppy tip)
0.035” x 180cm

139
Q

catheter exchange
wire length in TEVAR

A

260-300cm
(also usu stiffer)

140
Q

typical wire for TEVAR device delivery/deployment

A

Amplatz Super Stiff
(straight flex tip 6cm)
0.035” x 260cm

141
Q

next step wire for TEVAR delivery/deployment if typical wire does not pass

A

Lunderquist Extra Stiff (even stiffer than Amplatz)
(straight flex tip 4cm)
0.035” x 260cm

142
Q

alternative to typical wire for initial access in TEVAR (e.g. if tortuous, stenotic)

A

Glidewire
(hydrophilic-coated)
0.035” x 180cm
-- others are non-hydrophilic-coated usu with tetrafluoroethylene (TFE)

“The hydrophilic-coated Glidewire manufactured by Terumo Medical Corporation features a nitinol mandrel with a polyurethane outer coating instead of a metal coil. The polyurethane material contains tungsten for radiopacity, and this surface is further coated with a hydrophilic polymer; most manufacturers now offer similarly constructed wires. This wire is well-known for its ability to track in tortuous areas and stenoses. However, care must be taken when using this or any hydrophilic-coated wire, as there is greater risk of dissection or perforation due to the little resistance offered by these wires when advanced through vessels (“best friend and greatest enemy!”).”

143
Q

conventional definition of arterial aneurysm (any location)

A

diameter ≥1.5x nl

144
Q

normal diameter of root/Ao (at sinuses of Valsalva)

145
Q

normal diameter of STJ

146
Q

AHA definition of “enlarged” for root/Ao

147
Q

normal diameter of asc Ao

148
Q

normal diameter of aortic arch

149
Q

normal diameter of desc Ao

150
Q

normal diameter of abd Ao

151
Q

sheath size for TEVAR

A

20-24Fr ⇒ ≥8mm iliacs (fems?)

152
Q

max available TEVAR stent graft prox diameter

A

44mm
(⇒ usu max Ao size can stent 36-38mm)
tapered stent grafts avail

153
Q

available TEVAR stent graft lenghts

154
Q

overlap length for TEVAR stent grafts

155
Q

cannulae/cannulation strategy for TEVAR

A

L CFA micropuncture ￫ dilate/upsize to sheath then TEVAR delivery system
+ R CFA 5Fr sheath for pigtail (aortogram)

156
Q

TEVAR stent graft sizing for acute dissxn

A

0-10% oversize

157
Q

TEVAR stent graft sizing for aneurysm (non-acute)

A

20% oversize

158
Q

1st choice TEVAR stent graft for acute dissxn

A
  • covered
  • 8-10cm (shortest: just cover entry tear)
  • 0-10% oversized diameter (up to 44mm max)
159
Q

indication(s) for spinal drain in TEVAR (or open desc Ao rx)

A

YES, also:
- >15-20cm covered
- prior aortic stents or procedures
- covering L subclv
- postop sxs of LE ischemia

160
Q

spinal drain mgmt

A
  • drain to CSF pressure (CSFP) <10mmHg
  • Q1H, passive drainage, 5mL at a time (then check CSFP before more drainage)
  • max drainage: 20mL/h
  • d/c @ 24-48h for TEVAR / 72h for open (asx)
161
Q

TEVAR procedure steps

A
  1. CVC, BUE a-lines, neuro monitoring (SSEP=somatosensory evoked potential), spinal drain, Foley
  2. US-guided cannulation of bilat CFA (non-TEVAR side 5Fr sheath for pigtail / TEVAR side wire then stent)
  3. heparin (100u/kg)
  4. pigtail side soft wire up to arch ￫ pigtail
  5. ACT≥250
  6. arch aortogram in LAO ￫ fine-tune fluoro position/check landing zones
  7. L soft wire (Bentson) up to arch ￫ exchange catheter ￫ super stiff wire (Amplatz)
  8. IVUS + TEE to check true lumen
  9. upsize/insert TEVAR deployment device
  10. pull back pigtail
  11. ￬MAP to 60 / ￬SBP to 80 (HR<90)
  12. completion aortogram (∅ balloon)
  13. close & ￪MAP >80 (for spinal cord protection)
162
Q

spinal cord protection maneuvers (ppx)

A
  • spinal drain to CSFP ~10 (8-12)
  • MAP>80 (80-100) / SBP≥140
  • CI≥2.5
  • Hb≥8
  • O2 to sat>95%
  • Q1H NCs
163
Q

spinal cord rescue maneuvers (sx)

A
  • spinal drain if not already
  • lay flat
  • drain to CSFP≤5
  • MAP>100
  • Hb>10
  • O2 to sat>95% (100%???)
  • neuro c/s
  • L subclv-carotid bypass if covered
164
Q

TAAA (thoracoabdominal aortic aneurysms) extent classification

A
  1. I = suprarenal desc Ao = below L subclv to above renals
  2. II = entire desc Ao = below L subclv to aortic bifurc
  3. III = lower desc Ao = below 6th (“T6”) intercostal space to bifurc
  4. IV = entire abd Ao = below T12 to bifurc
  5. V = middle desc Ao = below T6 to above renals
165
Q

2 options for alternative access for CFAs<8mm for TEVAR

A
  • L lower paramedian retroperitoneal access to sew 8-10mm graft onto L EIA
  • 10mm endoconduit (covered stent) of entire L EIA
166
Q

potential cx(s) of covering/jailing L subclavian artery with TEVAR

A
  • posterior circulation stroke
  • LUE ischemia
167
Q

mgmt of type 2 endoleak from L subclavian artery on TEVAR post-placement aortogram

A

call vascular/IR colleagues and coil/embolize it (can do at interval)

168
Q

What type of endoleak(s) is/are mandatory to address on the table?

A
  • type 1 (prox/dist)
  • type 3 (porosity)
169
Q

types of endoleak

A
  1. a/b = prox/dist
  2. side-branch back-filling
  3. overlap between components
  4. porosity
  5. endotension (“magic”)
170
Q

minimum ACT for TEVAR

oral boards (15 decks)

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