Aortic Dissection Flashcards
Aneurysm vs. Dissection
Weakening of all 3 layers vs. peeling apart b/w 2
Vasa Vasorum & Dissection Plane
B/w middle and outer 1/3 of media
5 Predisposing RFs for AD
HTN* Cocaine Pregnancy Trauma Cystic Medial Necrosis - Marfan's
Primary vs. Secondary Intimal Tear
Initial punching through of intima vs. reentry of blood back into lumen. Better surivival
2 Elements of Classification of AD
Duration: Acute (2 wks)
Anatomical Location - site of tear & extent of dissection
3 DeBakey Classifications
I: primary tear asc->desc
II: just asc
III: just desc
2 Stanford Classifications and Why (& treatment differential for each)
Doesn’t really matter where primary tear is, just if proximal is involved or not.
A: Proximal involved, surgical emergency (DeBakey I and II)
B: Proximal spared, medical treatment better (III)
Isthmus
Only site where aorta fixed, so trauma can def cause dissection
Most Likely Site of AD
1st 2 cm of asc aorta - bad because shitload of vessels and stuff there
Problem w/ Very Proximal Intima Tear
Rupture goes into pericardium, which usually has very low pressure. So then pericardium gets LV pressure and get immediate hemmorhagic tamponade -> obstructive shock and death
Major Cause(s) of Death in AD
Rupture or extension of dissecting hematoma
2nd Most Likely Rupture Spot
Into pleural cavity
How to Test for Retroperitoneal Rupture
Smack the CVA hard and it’ll hurt like my dick your ass Ronak
1 Extension Site (& repercussions)
Brachiocephalic a. Unequal BP b/w R and L arm (R way lower)
Most Common Re-Entry Point(s)
Common iliacs. Femoral bruits and shit
Syncope
From tamponade, person already dead
2 Mechs of Pulse Loss from Brachiocephalic (more common and more permanent)
Dissection extends up brachiocephalic and occludes - more permanent
Tear causes flap to transiently wall off a. - more common
3 Mechs of Aortic Insufficiency
Symmetric hematoma causes pulling apart - easy to fix
Asymmetric hematoma pulls away 1 leaflet, still easy
Torn Valve - much more serious
False Lumen Blood Supply
Limbs can be supplied by F lumens instead of T, and then repairing the dissection causes limb ischemia and amputation. So need to know what’s being perfused by F lumens
3 Important PE Findings (& important point)
Ridiculous HTN (diastolic > 140)
Despite that, shocky appearance
Deficiency of pulse - unequal in arms
PE findings very variable so need to check very freq
CXR Finding
Widened mediastinum
3 Major Complications of Acute AD
Rupture
Extension
Acute AR - problem bc heart can’t handle acute stuff well
AD Management (general)
Halt progression of dissecting hematoma - solve impulse (dP/dT) BEFORE BP (else can just make it worse)
Negative ionotropic agents. Dissection caused by pulsatile flow, so that increases w/ AL reduction so don’t reduce BP first. Reduce dP/dT w/ BBs**, then reduce SBP w/ vasodilators
Combined Beta and Alpha Blocker, so impulse and SBP Reducer
Labetolol
1 Diagnostic Test for AD (& why)
TEE bc fast
Surgical vs. Medical Management
Acute Prox Dissection, or distal if vital organ compromised or impending rupture or some other stuff vs. uncomplicated distal or stable arch, or stable chronic bc person already a survivor
