Aortic Disease Flashcards
Parts of the aorta
Ascending aorta
Aortic arch
Descending aorta
What level does the aorta transverse the diaphragm?
T12
What can be seen on a CT in the aortic valve?
Aortic annulus
Sinus Valsalva
Sino tubular junction
What is the sinus Valsalva?
Widest part of aortic route
When does atherosclerosis start?
Early child
Risk factors for atherosclerosis
HTN Hypercholesteraemia Smoking DM FH Male
What can atherosclerosis lead to?
Stroke
MI
Anuerysm
What is an aneurysm?
A localised enlargement of an artery caused by weakening of the vessel wall
Types of aneurysms
Saccular
Fusiform
False
Dissecting
What are the true aneurysms?
Saccular
Fusiform
What is a true aneurysm?
Weakness and dilation of the wall
Involves all 3 layers
Associations of true aneurysm
HTN Atherosclerosis Smoking Collagen abnormalities (marfans, cystic medial necrosis) Trauma Infection (mycotic/syphilis)
What is the difference between true and false aneurysms?
The layers involved
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
Causes of false aneurysm
Inflammation (e.g. endocarditis with septic emboli)
Trauma
Iatrogenic
What would be felt with a false aneurysm?
Thrill
Bruit
Pulsatile mass
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
Classification of aortic aneurysm by site
Ascending
Aortic arch
Descending
Abdominal
Which aneurysm site can be very dangerous and why?
Arch
3 main vessels come off here
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
What is aortic dissection?
Tear in the inner wall of the aorta
Blood forces the walls apart
Types of aortic dissection
Acute (medical/surgical emergency)
Chronic
Classification systems of aortic dissection
DeBakey
Stanford
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
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?
AR
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
- Claudication of buttocks and thighs
- Atrophy of musculature of the legs
- 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
