Aorta

Question 1

What is the Crawford Classification?

Answer 1

Type I  LSCA to diaphragm 
Type II LSCA to bifurcation
Type III T6 to to bifurcation
Type IV T6 to renals
Type V T6 to above renals

Question 1

Things to ask when imaging aorta?

Answer 1

Location of abnormal
Max diameter
If genetic syndrome, av sinus, STJ, asc aorta diam
Filling defects
Presence if IMH, PAU, calcification
Extension into branches end organ injury
Presence of rupture hematoma
Previous imaging

Question 2

What are the indications for surgical treatment for ascending aorta?

Answer 2

Class I
Asympto aneurysm, asc, root, IMH, PAU, mycoric pseudo >5.5 cm
Asympto growth rate >o.5 cm per year
Asympto plus cv sx >4.5 cm
Sympto
Modified David if possible for marfans LD, EHD

Question 3

What is risk for asc/thoracic repair?

Answer 3

MI 1-5%
Infection 1-5%
Stroke. 1-2%
Reop 1-6%
Resp failure 5-15%
Paralysis 2-4% increase in extent II

Question 4

What are causes of TAAA?

Answer 4

Degenerative 82%
Dissection 17%
CTD

Question 5

What are the Indications for desc aneurysm/TAAA?

Answer 5

Class I
If chronic dissection >5.5cm
If defen/traumatic >5.5cm or saccular or pseudo EVAR recommend
If EVAR not commended and TAAA then 6.0 cm

Question 6

What inflamm dz are associated with TAA and dissection?

Answer 6

Takayasau. T cell mediated para arteritis
Giant cell arteritis- elastic vessel vasculitis
Behcet
Ank spon
Infective

Question 7

What bacteria are common in infected aorta?

Answer 7

S. Aureus, salmonella most common
Pneumococcus and E. coli most common gram negative
Treponema pallidum
Candida/aspergillus

Question 8

Before stenting defending what do you need to confirm before covering LSCA?

What conditions increas risk of paraplegia when stenting?

Answer 8

Contra r subclavian and verts are patent
Verts communicate via basilar artery

Previous AAA 10% vs 2%

Question 9

What is the endoderm classification?

Answer 9

Type I leak at attachment site
Ia proximal, Ib distal, Ic iliac occluder

Type II branch vessel, IIa single vessel, IIb 2 or more

Type III defect in great
IIIa junction of component, IIIb wint graft defect

Type IV. Graft porosity

Type V
Continued expansion without demonstrating leak endotension

Question 10

Which endoleak is most common?
Which endoleak considered unresolved? What percentage are these?
How to deal with type II?
Does type IV require tx?

Answer 10

II 80%
I 10%
Can resolve spon or add occluder
NO

Question 11

What are indications for definitive management for acute aortic disease?

Answer 11

Asc urgent repair
Desc
Medical management unless complicated

Question 12

What is medical management of acute aortic disease?

Answer 12

Class I
IV BB HR 60 SBP<120
If BB CI then CCB
If SBP >120 with adequate HR use second vasod or ACEi

Question 13

In what condition should BB and AoD be administered cautiously?

Answer 13

AI with AoD

Will block compensatory tachy

Question 14

What is natural he of type A dissection?
Surgical mortality?
Survival?

Answer 14

50% die immediately then 1% per hour
10%
50-70% alive at 5years

Question 15

What is natural history of type B?

What is mortality of treated?

Answer 15

50% mort untreated

9% hospital mortality

Question 16

What are indications for arch replacement?

Answer 16

Class IIa
Entire arch if dissected or leaking
Low operative risk and asympto >5.5cm
Growth rate >0.5 cm per year

Question 17

What is operative mortality for arch aneurysm?
Stroke rate?
Ten year survival?

Answer 17

Mort 9%
Stroke 7%
60-70%

Question 18

How do you treat arch/thoracic atheroma embolic dz?

What is natural hx?

Answer 18

IIa
Warfarin or anti PLT in stroke patients with atheroma >4mm
1/3 progress
10% regress

Question 19

What are bindi cations for BP management for thoracic aneurysmal dz?
And cholesterol?

Answer 19

Class I
BP <140/90 or 130/80 if diabetic/CRD
BB to all marfans

IIa
BB to decrease SBP as low as tolerated

IIb
LDL <70 mg/dl for atherosclerosis dz, aneurysm CAD or high risk for CAD

Question 20

What mutations are associated with 
Marfans
Loeys dietz
Ehlers danlos type IV
Turners
Familial thoracic aneurysm

Answer 20

FBN1. Fibrillin, increase penetrate with variable penetration
TGBFR1, TGBFR2, autosomal dom
COL3AI, type III collagen, autosomal dom
45X
ACTS2 14%, TGBFR2 4%, MYH11 1%

Question 21

What are surgical I medications for marfans, loeys dietz and ED for asc and root?

Answer 21

Marfans
>5.0 cm unless fam hx rupture <5.0 cm, growth rate >0.5cm year, signif AI

LD
>= 4.2cm by TEE internal, 4.4-4.6 by ct MRI external,
ED UV not recommended for prophylaxis

Question 22

What are main clinical findings in marfans?

Answer 22

Ocular skeletal cardiovascular

Question 23

At what size can offer elective repair for root in marfans before conception?
If becomes pregnant what to do ?
When is guest risk?

Answer 23

4.5cm
Abort
Third trimester for dissection rupture

Question 24

What is natural hx of TRA?
How to tx?
Mortality with tx?

Answer 24

20% MVA at autopsy
10-15% of them arrive to hospital alive
2% survive
Stent 1.5% mortality

Question 25

What are features of TRA on CXR?

Answer 25

Widened mediastinum 8-8.5cm
Deviation of the esophagus
Trachea >1-2cm to the right of spinous process

Question 26

When is thoracotomy indicate in penetrating mediastinal wound?

Answer 26

> 1500-2000ml blood loss within first four hours
200-300ml per hour for 4-5 hours
Chest greater then half full despite chest tube
Positive arteriography for vessel injury

Question 27

What % of blunt trauma have pericardial tear?

What are common injuries to heart with blunt trauma?

Answer 27

37%

Tear RA at junction of IVC/SVC, VS, ASD (Rare), AI

Question 28

What percent of trauma have myocardial contusion?
What are the most frequent sites?
Comps of contusion?
TX of contusion?

Answer 28

90%
Ant right ventricular wall then and intervention septum and LV apex
Arrhytmia and myocardial contractility
10-20%
EKG 12-24 hours, serial troponins, TTE, monitored bed