Aortic disease

Question 1

Sinuses of valsalva

Answer 1

3 pouches that sit above the aortic valve in a garlic bulb shape. the left and right contain the left and right coronary ostiums. The sinotubular junction is right above them.

Question 2

Basic Histology of the aorta

Answer 2

Tunica intima
Layer of endothelial cells
Subendothelial layer – collagen and elastic fibres
Separated from tunica media internal elastic membrane.

Tunica media
smooth muscle cells
secrete elastin in the form of sheets, or lamellae

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

Question 3

Classification of Aneurysms By Type

Answer 3

Saccular - bulges on onse side

Fusiform - bulges on both sides

False aneurysm - only an aneurysm in one layer of tunica

dissecting aneurysm - blood is going into gap between layers

Question 4

True Aneurysm and associations

Answer 4

Weakness & dilation of wall
Involves all 3 layers
Associated with
	Hypertension
	Atherosclerosis
	Smoking
	Collagen abnormalities 	(Marfan’s, cystic medial necrosis)
	Trauma
	Infection 	(mycotic/syphillis)

Question 5

False Aneurysm and associations

Answer 5

Rupture of wall of aorta with the haematoma either contained by the thin adventitial layer or by the surrounding soft tissue
.Inflammation ( eg endocarditis with septic emboli)
Trauma
Iatrogenic

Thrill
Bruit
Pulsatile mass

Ischaemia
Rupture

Question 6

Classification of aortic aneurysm by site

Answer 6

ascending, arch, descending, abdominal

Question 7

Signs and Symptoms of Thoracic Aneurysms

Answer 7

Asymptomatic
Based on the location of the aneurysm.
shortness of breath or even heart failure (AR)
dysphagia and hoarseness (ascending aorta, chronic)
Sharp chest pain radiating to back –between shoulder blades –Possible dissection!
Pulsatile mass
Hypotension

Question 8

Aortic Dissection

Answer 8

Tear in the inner wall of aorta
Blood forces walls apart
Acute –medical/surgical emergency
Chronic
false lumen can progress in an antegrade or retrograde direction
May occlude branches (eg mesenteric, carotid, renal, spinal)
Rupture - back into the lumen or externally in to pericardium (tamponade) or mediastinum
Dilation of ascending aorta may cause acute aortic regurgitation

Question 9

Stanford classification

Answer 9

Type A- involves ascending aorta

Type B- does not involve ascending aorta

Question 10

DeBakey classification

Answer 10

Type I- originates in ascending aorta, propagates at least to arch, often beyond it distally

Type II- originates in and is confined to ascending aorta

Type III- originates in descending aorta and extends distally down aorta or rarely retrograde into the arch and ascending aorta

Question 11

Aetiological factors of dissection

Answer 11

Hypertension
Atherosclerosis
Trauma
Marfan’s syndrome

Question 12

Histology of dissection

Answer 12

cystic medial necrosis

Question 13

Symptoms and Signs of Aortic Dissection

Answer 13

Tearing, severe chest pain (radiating to back)
Collapse (tamponade, acute AR, external rupture)
Beware inferior ST elevation
~50% mortality pre-hospital

Reduced or absent peripheral pulses (BP mismatch between sides)
Hypotension/ hypertension
Soft early diastolic murmur (AR)
Pulmonary oedema
Chest x-ray usually shows a widened mediastinum
Diagnosis can be confirmed by echocardiogram or CT scanning

Question 14

Treatment of dissection

Answer 14

Type A-Surgery
Type B -Meticulous blood pressure control
-Sodium nitroprusside plus beta blocker

Question 15

Infection and Inflammation of aorta

Answer 15

Infection: Syphyllis
Inflammation: Takayasu’s Arteritis

Question 16

Takayasu’s Arteritis

Answer 16

Granulomatous vasculitis
Females>Males
Aorta & main branches
Stenosis, thrombosis, aneurysms, renal artery stenosis, neurological sx
Steroids
Surgery

Question 17

Syphilis

Answer 17

STD
Treponema pallidum
Antibiotics prevent late stages.

Primary - chancre ( bulge on penis)
Secondary - rash
Tertiary - Without treatment – 1/3rd develop 1 of 3 types
Late neuro-syphillis
Gummatous syphillis
Cardiac syphillis

Cardiac syphillis (10-30yrs post infection)
Syphilitic aortitis – aneurysm
Aortic regurgitation

Question 18

Congenital aortic aneurysm causes

Answer 18

Bicuspid Aortic Valve

Marfan’s Syndrome

Coarctation

Question 19

Bicuspid Aortic Valve

Answer 19

Most common congenital abnormality
1-2% prevalence
Prone to stenosis +/- regurgitation

Associated with coarctation
Abnormal aorta (reduced tensile strength)
Prone to aneurysm/ dissection
Monitor with echo/ MRI

Question 20

Coarctation

Answer 20

Aortic narrowing close to where
Ductus arteriosus inserts
(ligamentum arteriosum)
3 types:
Pre-ductal (5% turner’s) can be life-threatening if severe narrowing (B)
Ductal (A)
Post-ductal (C) –most common in adults – hypertension in upper extremities, weak pulses in lower limbs
Associated with rib-notching (collateral circulation)

Question 21

Signs of Coarctation

Answer 21

Cold legs
Poor leg pulses
If before left subclavian artery:
Radial – radial and RIGHT radial-femoral delay
If after left subclavian artery:
No radial- radial delay
Right and left radio-femoral delay

Question 22

Symptoms of coarctation

Answer 22

Infancy (severe)
Heart failure
Failure to thrive

Later life
Hypertension

Question 23

Marfan’s Syndrome

Answer 23

Aneurysm
Dissection
Fibrillin 1 gene
Connective tissue weakness
Aortic/ Mitral valve prolapse – regurgitation
Skeletal system
Eyes (cataract, lens dislocation)
Vascular – aneurysm, dissection
Lungs (pneumothorax)