Aorta Flashcards
What is the Crawford Classification?
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
Things to ask when imaging aorta?
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
What are the indications for surgical treatment for ascending aorta?
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
What is risk for asc/thoracic repair?
MI 1-5% Infection 1-5% Stroke. 1-2% Reop 1-6% Resp failure 5-15% Paralysis 2-4% increase in extent II
What are causes of TAAA?
Degenerative 82%
Dissection 17%
CTD
What are the Indications for desc aneurysm/TAAA?
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
What inflamm dz are associated with TAA and dissection?
Takayasau. T cell mediated para arteritis
Giant cell arteritis- elastic vessel vasculitis
Behcet
Ank spon
Infective
What bacteria are common in infected aorta?
S. Aureus, salmonella most common
Pneumococcus and E. coli most common gram negative
Treponema pallidum
Candida/aspergillus
Before stenting defending what do you need to confirm before covering LSCA?
What conditions increas risk of paraplegia when stenting?
Contra r subclavian and verts are patent
Verts communicate via basilar artery
Previous AAA 10% vs 2%
What is the endoderm classification?
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
Which endoleak is most common?
Which endoleak considered unresolved? What percentage are these?
How to deal with type II?
Does type IV require tx?
II 80%
I 10%
Can resolve spon or add occluder
NO
What are indications for definitive management for acute aortic disease?
Asc urgent repair
Desc
Medical management unless complicated
What is medical management of acute aortic disease?
Class I
IV BB HR 60 SBP<120
If BB CI then CCB
If SBP >120 with adequate HR use second vasod or ACEi
In what condition should BB and AoD be administered cautiously?
AI with AoD
Will block compensatory tachy
What is natural he of type A dissection?
Surgical mortality?
Survival?
50% die immediately then 1% per hour
10%
50-70% alive at 5years
What is natural history of type B?
What is mortality of treated?
50% mort untreated
9% hospital mortality
What are indications for arch replacement?
Class IIa
Entire arch if dissected or leaking
Low operative risk and asympto >5.5cm
Growth rate >0.5 cm per year
What is operative mortality for arch aneurysm?
Stroke rate?
Ten year survival?
Mort 9%
Stroke 7%
60-70%
How do you treat arch/thoracic atheroma embolic dz?
What is natural hx?
IIa
Warfarin or anti PLT in stroke patients with atheroma >4mm
1/3 progress
10% regress
What are bindi cations for BP management for thoracic aneurysmal dz?
And cholesterol?
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
What mutations are associated with Marfans Loeys dietz Ehlers danlos type IV Turners Familial thoracic aneurysm
FBN1. Fibrillin, increase penetrate with variable penetration TGBFR1, TGBFR2, autosomal dom COL3AI, type III collagen, autosomal dom 45X ACTS2 14%, TGBFR2 4%, MYH11 1%
What are surgical I medications for marfans, loeys dietz and ED for asc and root?
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
What are main clinical findings in marfans?
Ocular skeletal cardiovascular
At what size can offer elective repair for root in marfans before conception?
If becomes pregnant what to do ?
When is guest risk?
4.5cm
Abort
Third trimester for dissection rupture
What is natural hx of TRA?
How to tx?
Mortality with tx?
20% MVA at autopsy
10-15% of them arrive to hospital alive
2% survive
Stent 1.5% mortality
What are features of TRA on CXR?
Widened mediastinum 8-8.5cm
Deviation of the esophagus
Trachea >1-2cm to the right of spinous process
When is thoracotomy indicate in penetrating mediastinal wound?
> 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
What % of blunt trauma have pericardial tear?
What are common injuries to heart with blunt trauma?
37%
Tear RA at junction of IVC/SVC, VS, ASD (Rare), AI
What percent of trauma have myocardial contusion?
What are the most frequent sites?
Comps of contusion?
TX of contusion?
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
