Aortic Disease Flashcards by Annie Caldwell

Parts of the aorta

Ascending aorta
Aortic arch
Descending aorta

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What level does the aorta transverse the diaphragm?

T12

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What can be seen on a CT in the aortic valve?

Aortic annulus
Sinus Valsalva
Sino tubular junction

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What is the sinus Valsalva?

Widest part of aortic route

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When does atherosclerosis start?

Early child

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Risk factors for atherosclerosis

HTN
Hypercholesteraemia
Smoking
DM
FH
Male

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What can atherosclerosis lead to?

Stroke
MI
Anuerysm

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What is an aneurysm?

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

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Types of aneurysms

Saccular
Fusiform
False
Dissecting

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What are the true aneurysms?

Saccular

Fusiform

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What is a true aneurysm?

Weakness and dilation of the wall

Involves all 3 layers

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Associations of true aneurysm

HTN
Atherosclerosis
Smoking
Collagen abnormalities (marfans, cystic medial necrosis)
Trauma
Infection (mycotic/syphilis)

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What is the difference between true and false aneurysms?

The layers involved

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What is a false aneurysm?

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

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Causes of false aneurysm

Inflammation (e.g. endocarditis with septic emboli)
Trauma
Iatrogenic

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What would be felt with a false aneurysm?

Thrill
Bruit
Pulsatile mass

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What is a dissecting aneurysm?

Dissection / tear in first or second layer but there is still a layer left. The artery is teared and blood is going into the sac of one layer

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Classification of aortic aneurysm by site

Ascending
Aortic arch
Descending
Abdominal

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Which aneurysm site can be very dangerous and why?

Arch

3 main vessels come off here

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Presentation of thoracic aneurysms

Asymptomatic 
Based on location of aneurysm
- SOB 
- HF
- dysphagia and hoarseness (ascending aorta, chronic)
- Sharp chest pain radiating to back 
- pulsatile mass
- hypotension

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What is aortic dissection?

Tear in the inner wall of the aorta

Blood forces the walls apart

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Types of aortic dissection

Acute (medical/surgical emergency)

Chronic

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Classification systems of aortic dissection

DeBakey

Stanford

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What is in the Debakey classification of aortic dissection?

Type I - Originates ascending aorta, propagates at least to the aortic arch and often beyond it distally
Type II - Originates in and is confined to the ascending aorta
Type III - Originates in the descending aorta and extends distally down the aorta or rarely retrograde into the aortic arch and ascending aorta

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What are the Stanford classifications of aortic dissection?

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

Causes of dissection

HTN Atherosclerosis Trauma Marfans syndrome

Histology of aortic dissection

Cystic medial necrosis False lumen can progress in an antegrade (down into distal aorta) or retrograde direction (back into ascending aorta) May occlude branches (e.g. mesenteric, carotid, renal, spinal) Rupture - back into the lumen or externally into the pericardium (tamponade) or mediastinum If in the root then can affect coronary arteries and so can dissect these - MI symptoms

What may dilation of ascending aorta cause?

Presentation of aortic dissection

Tearing, severe chest pain radiating to back Collapse - tamponade, acute AR, external rupture

What should you beware of in aortic dissection?

Inferior ST elevation

Mortality of aortic dissection

50%

Signs on examination for aortic dissection

``` Reduced or absent peripheral pulses (BP mismatch between sides) Hypo/HTN Soft early diastolic murmur (AR) Pulmonary oedema CXR showing widened mediastinum ECHO ```

Diagnosis of aortic dissection is confirmed by what?

CT | ECHO

Treatment for aortic dissection

Type A ; surgery | Type B; Meticulous BP control (BP systolic <100 using IV GTN), sodium nitroprusside (not unless have to) + BB

What is takayasus Arteritis?

Inflammatory disease - granulomatous vasculitis

Who gets takayasus arteritis?

F > M | Asians

Pathology of takayasus arteritis

Aorta and main brances | Stenosis, thrombosis, aneurysms, renal artery stenosis, neurological symptoms

Treatment of takayasus arteritis

Steriods | Surgery

What causes syphilis?

Treponema pallidum

Without Tx of syphilis, 1/3rd of people develop 1 of 3 types of tertiary syphilis, which are....

Late neuro syphilis Gummatous syphilis Cardiac syphilis

What is a bicuspid aortic valve?

Fusion of two of the cusps and so functionally becomes two cusps instead of 3

What is the most common congenital abnormality?

Bicuspid aortic valve

What are bicuspid aortic valves prone to?

Stenosis +/- regurgitation

Bicuspid aortic valves effect on the abdominal aorta

Reduced tensile strength Prone to - aneurysm - dissection

Monitoring of bicuspid aortic valve

ECHO | MRI

What is coarctation of aorta?

Narrowing of aorta

What are the 3 shunts before birth?

Ductus arteriosus Foramen ovale Ductus venosus

3 types of coarctation of aorta

Pre ductal Ductal Post ductal

What are the locations of coarctation of aorta in relation to?

Where the ductus arteriosus inserts (ligamentum arteriosum)

What is the most common coarctation in adults?

Post ductal

Presentation of post ductal coarctation

HTN in upper extremities Weak pulses in lower limbs Rib notching (collateral circulation) Asymptomatic in children

Presentation of coarctation of aorta

``` Cold legs Poor leg pulses If before left subclavian - radial radial and RIGHT radial femoral delay If after left subclavian - no radial radial delay but right and left radio femoral delay Severe infancy HF FTT HTN ```

Investigations of coarctation of aorta

CXR | CMRI

What genetics are associated with marfans?

Fibrillin 1 gene

What is marfans?

A genetic condition which causes connective tissue weakness

Effects of marfans

``` Aortic/mitral valve prolapse/regurg Skeletal system Eyes - cataracts - upwards lens dislocation Vascular - aneurysm Lungs - pneumontorax Aneurysm Dissection ```

What is Leriche syndrome?

Atheromatous disease involving the iliac vessels which compromises the blood flow to the pelvic viscera

Triad of presenting symptoms in males with Leriche syndrome

1. Claudication of buttocks and thighs 2. Atrophy of musculature of the legs 3. Impotence (due to paralysis of L1 nerve)

Features of Takayasu arterities

Systemic features of vasculitis e.g. malaise, headache Unequal blood pressure in the upper limbs Carotid bruit Intermittent claudication Aortic regurg (20%)

Assosiations of takayasus arteritis

Renal artery stenosis

Management of takayasus

Steriods

Over what size of aortic aneurysm must the DVLA be notified?

> 6cm

Over what size of aortic aneurysm will you be banned from driving at?

> 6.5 cm

Management of Type A + B aortic dissection and the pneumonic to remember

Type A - ASS - Surgery and systolic management Type B - BOOBS - Bed rest and beta blockers

What is coarctation of the aorta associated with?

Bicuspid aortic valve

What are the diagnostic indications of carotid sinus hypersensitivity?

After carotid sinus massage, either; - Cardioinhibitory (ventricular pause > 3 seconds) - Vasodepressive (Fall in SBP > 50mmHg)

How does the carotid sinus massage work to diagnose carotid sinus hypersensitivity?

Gently massaging carotid artery for 5 seconds This stimulates the baroreceptors and the parasympathetic nervous system This increases the vagal tone and affects the SA and AV node Leading to a decrease in BP and HR If the baroreceptor is hypersensitive, this response is exaggerated

What is present in 70% of adults with coarctation of the aorta?

Notching of the inferior border of the ribs