Aortic disease

Question 1

What is the tunica intima ?

Answer 1

Layer of endothelial cells
Subendothelial layer- collagen and elastic fibres
Separated from tunica media internal elastic membrane

Question 2

What is the tunica media ?

Answer 2

Smooth muscle cells

Secrete elastin in the form of sheets or lamellae

Question 3

What is the tunica adventitia ?

Answer 3

Thin collective tissue layer
Collagen fibres and elastic fibres (not lamellae)
The collagen in the adventitia prevents elastic fibres from stretching beyond their limits during systole

Question 4

What is the risk factors for atheroscleorsis ?

Answer 4

Hypertension
Hypercholesterolaemia
Smoking
Diabetes
Family history 
Male > female

Question 5

What is the pathophysiology of atheroscleorsis ?

Answer 5

MI
Stroke
Peripheral vascular disease
Aneurysm

Question 6

What is an aneurysm ?

Answer 6

A localised enlargement of an artery caused by a weakening of the vessel wall

Question 7

What is a true aneurysm ?

Answer 7

Weakness and dilation of wall

Involves all 3 layers

Question 8

What are true aneurysms associated with ?

Answer 8

Hypertension
Smoking
Atherosclerosis
Bicuspid aortic valve 
Collagen abnormalities (marfans)
Infection 
Trauma

Question 9

What is a false anuerysm ?

Answer 9

Rupture of wall of aorta with the haematoma either contained by the thin adventitia layer or by the surrounding soft tissue

Question 10

What is the aetiology of a false aneurysm ?

Answer 10

Trauma
Iatrogenic
Inflammation

Question 11

What are the signs and symptoms of thoracic anuerysm ?

Answer 11

Asymptomatic
Based on location
SOB
Dysphagia and hoarseness
Back pain 
Symptoms of dissection- sharp chest pain radiating to back 
Pulsatile mass

Question 12

What is the investigations of anuerysm ?

Answer 12

CXR- widened mediastinum
ECHO- assess aortic root valve size and aortic valve 
CT angiogram aorta- diagnostic 
MRI aorta- diagnostic and follow up 
TOE and invasive aortogram

Question 13

What is an aortic dissection ?

Answer 13

Tear in the inner wall of aorta

Blood forces walls apart

Question 14

What type of aortic dissection is a medical emergency ?

Answer 14

Acute

Question 15

What are the aetiological factors of dissection ?

Answer 15

Hypertension
Atherosclerosis 
Marfans syndrome 
Bicuspid aortic valve 
Trauma

Question 16

What is the Stanford classification of aortic dissection ?

Answer 16

Type A- all dissections involving the ascending aorta, regardless of site of origin
Type B- all dissections not involving ascending aorta

Question 17

What is the symptoms of an aortic dissection ?

Answer 17

Chest pain- severe, sharp, radiating to back (inter-scapular)
Collapse (tamponade, acute AR, external rupture)
Stroke

Question 18

What is the examination findings of an aortic dissection ?

Answer 18

Reduced or absent peripheral pulses
Hypertension o hypotension
BP mismatch between sides
Soft early diastolic murmur
Pulmonary oedema
Signs of CVA

Question 19

What are the investigations of aortic dissection ?

Answer 19

ECG- might show ST elevation/ ischaemia indicating coronary involvement 
CXR- widened mediastinum
Transthoracic ECHO- assess aortic root 
CT angiogram aorta- confirms diagnosis 
~50% mortality pre-hospital

Question 20

What is the treatment for type A dissection ?

Answer 20

BP control:
	 - Beta-blocker
	 - IVI nitrate 
	 - Ca channel blocker 
         - IVI sodium nitroprusside 
Emergency surgery

Question 21

What is the treatment of Type B dissection ?

Answer 21

BP control:
	 - Beta-blocker
	 - IVI nitrate 
	 - Ca channel blocker 
         - IVI sodium nitroprusside 
Emergency surgery

Question 22

What is the presentation of Takayasu’s arteritis ?

Answer 22

Inflammation
Granulomatous vasculitis
F>M
Aorta and main branches
Stenosis, thrombosis, aneurysm, renal artery stenosis, neurological
Steroids and immunosuppressive
Surgery and percutaneous intervention may be needed

Question 23

What is syphilis ?

Answer 23

STD
Treponema pallidum
Antibiotics prevents late stage

Question 24

What is the presentation of bicuspid aortic valve ?

Answer 24

Most common congenital abnormality 
1-2% prevalance 
Prone to aortic valve stenosis +/- regurgitation 
Associated with coarctation
Abnormal aorta 
Prone to aneurysm/ dissection 
Monitor with ECHO/MRI

Question 25

What is coarctation of aorta ?

Answer 25

Narrowing close to where ductus arteriosus inserts (ligamentum arteriosum)

Question 26

What are the 3 types of coarctation ?

Answer 26

Pre-ductal 5%- can be life-threatening if severe narrowing
Ductal
Post-ductal- most common in adults- hypertension in upper extremities

Question 27

What are the signs of coarctation ?

Answer 27

Cold legs
Poor leg pulses
If before left subclavian- radial-radial right radial-femoral delay
If after left subclavian- no radial-radial delay
Right and left radio-femoral delay

Question 28

What are the symptoms of coarctation ?

Answer 28

Heart failure
Failure to thrive
Hypertension
CV complications

Question 29

What is the treatment of coarctation ?

Answer 29

Percutaneous or surgical correction