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219 Conditions > Aortic Dissection > Flashcards

Aortic Dissection Flashcards

1
Q

What is an aortic dissection?

A
  • when a separation has occurred in the aortic wall, causing blood flow into a new false channel
  • sometimes discrete intimal tear
  • acute AD if <14 days old
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2
Q

Risk Factors for aortic dissection

A
  • atherosclerotic aneurysmal disease
  • Marfan syndrome
  • Ehlers-Danlos syndrome
  • bicuspid aortic valve
  • annulo-aortic ectasia
  • coarctation
  • smoking
  • Fx of aortic aneurysm/dissection
  • hypertension

Weak RFs

  • age
  • giant cell arteritis
  • overlap connective-tissue disorders
  • surgical/catheter manipulation
  • cocaine/amphetamine use
  • heavy lifting
  • pregnancy
  • non-diabetic
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3
Q

Classification of aortic dissections

A

Stanford:

  • Type A: dissection involves the ascending aorta with or without involvement of the arch and descending aorta
  • Type B: dissection doesn’t involve the ascending aorta. Mainly involves only the descending thoracic and/or abdominal aorta

Onset:

  • hyperacute <24hrs
  • acute <14 days
  • subacute 15-90 days
  • chronic >90 days

DeBakey:

  • Type 1: Tear originates in the ascending aorta and involves it and arch, some of the descending
  • Type 2: Dissection confined to the ascending aorta
  • Type 3: Tear originates distal to the left subclavian artery and extends through the thoracic aorta or extends beyond the visceral segment
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4
Q

Case History of aortic dissection

A

1) A 59-year-old man presents to the accident and emergency department with a sudden onset of excruciating chest pain, which he describes as tearing. He has a history of hypertension. On physical examination, his heart rate is 95 beats per minute. Blood pressure is 195/90 mmHg in the right arm and 160/80 mmHg in the left arm. Pulses are absent in the right leg and diminished in the left.

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5
Q

Presentations

A
  • acute chest/back/interscapular/abdo pain
  • abrupt onset
  • severe
  • ripping or tearing
  • symptoms of stroke or visceral or acute limb ischaemia may be present
  • haemodynamically shock
  • 10% without pain
  • heart failure signs, cardiac tamponade, left pleural effusion

Perfusion deficit

  • pulse deficit/difference
  • systolic bp difference in arms
  • paraesthesia
  • Paraplegia

Auscultation- diastolic decrescendo murmur

Fetaures of Marfans syndrome: tall stature, arachnodactyly, pectus excavatum, hypermobile joints, high-arched palate, narrow face

Features of Ehlers-Danlos syndrome: Type IV, translucent skin, easy bruising, hypermobility of small joints, premature skin ageing (acrogeria)

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6
Q

Treatment of aortic dissection

A
  • ECG- ST segment depression
  • x-ray
  • blood tests- d-dimer (ruling out AD)
  • CT
  • TTE - transthoracic echocardiography
  • Magnetic resonance angiogram
  • Intravascular USS- type B dissection
  • high sensitivity troponin
  • renal function tests- elevated urine, creatinine
  • LFTs- AST, ALT
  • lactate- bowel ischaemia/metabolic acidosis- elevated
  • FBC- anaemia
  • G & S- surgery prep
  • blood gas- metabolic acidosis -procalcitonin- differeniate b/w SIRS and sepsis
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7
Q

Other differentials to aortic dissection

A
  • ACS
  • Pericarditis
  • AA
  • MSK pain
  • PE
  • Mediastinal tumour
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8
Q

Treatment algorithm for aortic dissection

A

INITIAL

  • Suspected aortic dissection: haemodynamically unstable:
  • advanced life support with haemodynamic support: SpO2 94-96% / 88-92% if hypercapnic ; IV fluid resus- Ringer’s lactate/Hartmann’s solution, inotropes
  • opioid analgesia- morphine sulfate 2.5-10mg IV

ACUTE

1) Confirmed type A AD:
- BB- labetalol 50mg IV OR metoprolol 2.5-5mg IV
- OR non-dihydropyridine Ca-channel blocker- diltiazem OR verapamil (HR <60)
- analgesia - morphine sulphate 2.5-10mg
- vasodilator- sodium nitroprusside
- open surgery or endovascular repair

2) Confirmed Type B AD: complicated
- BB- labetalol 50mg IV OR metoprolol 2.5-5mg IV
- OR non-dihydropyridine Ca-channel blocker- diltiazem OR verapamil (HR <60)
- analgesia - morphine sulphate 2.5-10mg
- vasodilator- sodium nitroprusside
- endovascular repair or open surgery: TEVAR- thoracic endovascular aortic repair

3) Confirmed Type B AD: uncomplicated
SAME AS ABOVE
-endovascular repair- TEVAR

ONGOING

  • Chronic aortic dissection
  • > 90 days since symptom onset
  • BB= bisoprolol 5-10mg
  • additional antihypertensive, at least 2: angiotensin-II receptor antagonist (losartan 50mg for 18-75yrs), ACE inhibitor (enalapril 5mg), Ca-channel blocker (nifedipine 10mg), thiazide-like diuretic (indapamide 2.5mg)
  • lifestyle advice- stop strenuous exercise
  • RF management- LDL<70, smoking
  • EV repair or open surgery
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9
Q

Complications of AD

A
  • cardiac tamponade
  • aortic incompetence
  • MI
  • aneurysmal degeneration/rupture
  • regional ischaemia
  • left arm ischaemia/subclavian steal syndrome
  • endoleak
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10
Q

Prognosis of AD

A
  • syncope at presentation associated with worse outcomes

- deadly triad = hypotension/shock (not syncope), lack oof chest/back pain, branch vessel involvement

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219 Conditions (13 decks)

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