Vascular - Aorta Flashcards
Embryologic origin of aorta
aortic root - second heart field
ascending aorta to proximal descending aorta - neural crest
descending aorta and down - paraaxial mesoderm
what are the three Acute Aortic Syndrome?
- Aortic dissection
- Penetrating atherosclerotic Ulcer
- Intramural Hematoma
Layers of Aorta
Intima, media and adventitia
How to differentiate the three acute aortic syndrome?
by CTA
Penetrating atheroscleoritc ulcer-extravasation of contrast outside of typical boundary of aorta
intramural hematoma - no extravasation but look for attenuation of blood in the media
Dissection - intimal flap
Clinical Presentation of Acute Aortic syndrome: cut off fr asymmetric blood pressure?
≥20mmHg difference
Scoring system in Acute aortic syndrome?
AORTAS scoring
- hypotension
- aneurysm
- pulse deficit
- neurologic deficit
- severe pain
- sudden pain
≥2 - consider positive
Heart rate goal for acute aortic syndrome
60-80bpm (same in Braunwald)
Indication for surgery in aortic dissection stanford B?
- persistent or recurrent pain
- propagation/expansion
- malperfusion
- 1/3 eventually need surgery
What is Debakey type II aortic dissection
- involvement of Ascending aorta
in patient suspected with AAS, what is the importance of Ddimer?
- negative Ddimer has negative predictive value of 95%
Debakey Classification of Acute aortic dissection: Type IIIa vs IIIb
- IIIa - dissection tear limited to the descending aorta
- IIIb - tear extends below the diaphragm
Aortic Dissection of the aortic arch. what is the Stanford classification?
Stanford B
later in the chapter, also known as non-A, non-B dissections
in AAD, what is Type A SVS/STS aortic dissection classification
Type A tear entry - originates only in the ascending aorta (zone 0)
Type B - tear entry ZOne 1 and beyond
Blindspot of TEE in AAD
- distal ascending aorta
- proximal aorta arch
Classification of AAD based on duration. ESC
<14 days - acute
14-90 days - subacute
chronic - >90days
Malperfusion syndrome in AAD: static vs dynamic
occurs 30% in AAD with dynamic as most common
Dynamic malperfusion - pressurized false lumen pushing the septum towards the true lumen leading to collapse of the true lumen,obstructing the vessels
when to consider TTE in AAD
- setting of acute Type A dissection,
- quick and can be performed at bedside
85-90% sensitivity
Pretest risk assessment for Acute AD
- ADD-RS
for ≤ 1 - performed D-dimer
if >0.5 -> CTA
for >1 ->CTA
in pretest ADD-RS assessment: what are High-risk exam features
- pulse deficit
- systolic BP differential
- focal neurological deficit (in conjunction with pain)
- Murmur or aortic insufficiency
- Hypotension or shock state
for patient with hypotensive stanford B AD, what is the target blood pressure?
MAP of 70mmHg
in AAD, what are the complications requiring operative or interventional management?
- Malperfusion syndrome
- Progression of dissection
- Aneurysm expansion
- uncontrolled hypertension
Mortality rate for Stanford A AAD
18% undergoing surgery
56% treated medically
Dose of esmolol for AAD
250-500ug/kg IV bolus
continuous IV infusion oat 50-100ug/kg/hr, max dose of 200ug/kg/hr
Modified bentall procedure vs valve-sparing root replacement vs hemiarch replacement vs arch replacement
Modified bentall - Stanford A + dilated sinuses, AR
Valve-sparing - dilated root with normal aortic leaflets
Hemiarch - tear localize in the ascending aorta with a normal arch without distal malperfusion
arch replacement - extensive tear throughout the arch. branch graft techniques are preferred in managing arch vessels involved.
frozen elephant trunk. - extension to the descending aorta
Indications for intervention (Surgery or TEVAR) in stanford B AAD
- hemothorax
- refractory hypertension
- aneurysmal dilation >55mm
- rapid increase in aortic diameter (>5-10mm/yr)
- malperfusion
- recurrent symptoms
- rupture/impending rupture
- refractory pain
mortality rate with uncomplicated TBAD
- 8.7% treated medically
- 12% treated with endovascular repair
- 17% surgical repair
Clinical and imaging characteristics predicting of late aortic complications in initially uncomplicated TBAD
- primary entry tear diameter of >10mm
- initial aortic diameter >40mm
false lumen diameter >22mm
partially thrombosed false lumen
saccular false lumen formation
imaging after acute AD?
CTA or MRA at 1 to 3, 6, and 12 months and annually thereafter
drugs to avoid in AA
in 2024 ESC guideline in PAAD, cut off growth rate for TAA
ascending aorta and arch ≥3mm/year
the rest, ≥10mm/yr or ≥5mm/6 months
Surgical interventions for Sporadic AA
≥4.5cm at time of AV surgery or VCABG
>5mm a year growth rate
≥5.5cm cut off
Importance of Family History for AA
7x likelihood for AA
features for marfan syndrome
- Facial features 3 of 5 (dolichocephaly, downward slanting palpebral fissures, enophthalmos, retrognathia and malar hypoplasia.)
- pectus excavatum or chest asymmetry
- pectus carinatum deformity
- scoliosis or thoracolumbar kyphosis
- dural ectasia
- wrist and thumb signs
- plain flat foot
- hindfoot deformity
- spontaneous pneumothorax
- reduced elbow extension
skin straie
MVP
severe myopia
bifid uvula, abdominal pain and multiple food allergies.
syndrome?
think of Loeys-Dietz syndrome
syndrome?
- wide spaced eyes
-translucent skin - pretibial scars
- Ehlers-Danlos syndrome
why BAV is frequently associated with Ascending AA
shared embryonic origin between the valve and the root
types of inflammatory aortopathy
- Giant Cell arteritis ≥50yr
- Takayasu arteritis <50
diagnosis?
Giant Cell arteritis
diagnosis?
Takayasu arteritis
What are the genetic syndrome associated with ascending AA
- Familiar
- Marfan
- Loeys-Dietz
- Ehlers-Danlos
- Biscuspid
Recommended one-time screening for AA?
US preventive services task force:
- men 65-75 years of age with hx of smoking and selective screening for those who never smoker
SVS/STS
- all men ≥65
- women ≥65 with hx of tobacco use or family hx of AA
CLASS I recommendation for surgery for AAA
(ESC)
AAA is ≥5.5cm for men, ≥5.0 for women
endovascular is class I is with in ruptured AAA with suitable anatomy
Risk of rupture for AAA
5.3% for AAA between 5.5 to 7.0cm
other study:
9% between 5.5 to 5.9cm
10% between 5.0 to 6.9cm
33% for >7.0cm
recommendation for routine coronary angiography and systematic revasc for patient with CS prior to AAA repair
CLASS III
and also, if patient life expectancy is <2 years
recommendation for surgery for AAA with growth rate of ≥5mm/ 6months or ≥10mm in a year
class IIB only
- also for saccular AAA of ≥45 mm
AAA repair may be considered on this following scenarios.
- asymptomatic AAA of 50 to 55 mm in male
- symptomatic and growth rate ≥10mm/year
surveillance of AAA
25 to 29mm - every 7 years (in ESC- every 4yrs)
30 to 39mm - every 3 years (same with ESC)
40 to 49mm - every year (same for men,
for women 40-45 mm, every year. 45-49 mm - every 6 months)
50 to 54mm - every 3 to 6 months
(for men only, and every 6 months)
type of endoleaks that needs reintervention
Endoleak I and III
Type I endoleaks, which result from loss of complete sealing at the proximal (type IA) or distal (type IB) end of the stent graft, lead to increased pressure in the aneurysm sac and are associated with increased risk for rupture and therefore warrant repair.
Type II endoleaks, the most common, result from retrograde filling of the aneurysm sac by aortic branch vessels, usually by the lumbar or inferior mesenteric arteries.
Type III endoleaks are caused by separation of components or disruption of the endograft fabric and require treatment, usually by re- lining with a stent graft.
Type IV endoleaks are related to blood seeping through porous graft material and are self- limited
for post TEVAR/EVAR, when is the CCT and DUS be repeated as part of surveillance
at 1 month and 1 year post op
what is endoleak type V
Type V induces sac expansion without any visible endoleak.
Treatment may be considered for significant sac growth (≥10 mm) and consists of stent graft relining or definitive endograft explant and open surgical repair.
AAA surveillance according to ESC 2024.
female with 47mm AAA?
male with 37?
see pic
ascending and aortic root AA surveillance - that is seen at echo. (ESC)
see pic
40-44mm (36 - 44mm in women)
- baseline CCT or CMR
-rpt TTE in one year
— if growth rate (GR) is ≥3mm/yr —>rpt TTE every 6 months
— if GR is <3 mm/yr —> rpt TTE every 2 to 3 years
45-49mm
- confirm by CCT/CMR —> TTE yearly
50-52mm
- confirm by CCT/CMR
if Ascending AA, check for high risk feature
—>yes, class IIb for surgery if low risk
—>if no, rpr CCT/CMR after 6 months to check for GR (≥3mm/yr—>class IIb for surgery if low risk, if <3mm/yr —-> reimage every 6 months)
if AORTIC ROOT AA with BAV –> Class I indication (for TAV, class IIb for surgery if low risk)
53-54mm
- CCT/CMR for confirmation
—> if aortic root + BAV–> class I indication
—> if ascending AA —> class IIa
≥55mm
—> surgery
surveillance for AAA(ESC): Duplex USD vs CCT/CMR
DUS is recommended for AAA Surveillance
the only class I recommendation for surgery in Aortic Arch AA
low to intermediate operative risk with an aortic arch A AND recurrent episodes of chest pain not attributable to non-aortic causes, OPEN surgical replacement of the arch is recommended. CLASS I
cut off diameter for unruptured degenerative TAAA for elective repair
≥60mm
if ≥55mm, class IIa
cut off diameter for descending thoracic AA for elective repair
≥55mm
Classification of AAS
Standford vs Debakey
Standford A can be Debakey I or II
(if extends beyond ascending Aorta, Debakey I.
if only in the ascending aorta->Debakey II)
Standford B can be debakey IIIa or IIIb
(IIIa - DTA to diaphragm, IIIb- extends beyond diaphragm)
what is TEM aortic dissection classification
T- Type - Stanford
E - entry site ( by zone)
M- Malperfusion
cut off points for ADD-RS for it to be considered as high risk
ADD-RS ≥2
Components
- High risk condition
- High risk pain features
- HIgh risk examination feature
first line imaging technique for suspected AAS
- ECG-gated CCT from neck to pelvis
if CCT cannot be done (unstable patient), TOE is recommended
Medical management for AAS (1st step)
first is rate/pressure control with IV labetalol or esmolol with tarhert HR ≤60 bpm
- pain control
- pressure control
Cardiogenic shock related to AAS
- Cardiac Tamponade (pulsus paradoxus)
- Aortic regurgitation (diastolic murmur)
- major coronary occlusion by compression or dissection flap
Threshold for prophylactic aortic root or ascending AA
≥55mm
- Degenerative AA
- BAV AA
≥5.0mm
- BAV with risk factors (FHx of AAD or GR of ≥5mm/yr) OR low risk (<4%)
- Marfan syndrome
≥45mm
- BAV requiring AVR
- Marfan syndrome with risk factors (FMx of AAD, GR of >3mm/yr, severe AR/MR)
- familial thoracic AA (SMAD
40-45mm
- Loeys- Dietz syndrome (TGFBR1 or 2)
- Marfan syndrome with desire for pregnancy
Class I recommendation for intervention for Type B AAD
type B ADD with one of the following
- contained or free aortic rupture
- organ malperfusion
- extension of the dissection
- progressive aortic enlargement
- refractory hypertension - already on 3 antihypertensive meds
- refractory pain >12hours
***if yes (lower end of the pic)
-> Class II endovascular repair if subacute phase: 14-90 days
for TEVAR/EVAR, what is considered as favorable anatomy?
the aorta must have adequate proximal and distal landing zones of at least 20 to 25 mm in length and diameters that accommodate the endograft and adequate vascular access
Surgical repair for Aortic Arch Aneurysm?
- HEMIARCH RESECTION
- the arch vessels remain intact, with upper aortic arch as roof, and the remaining arch is replaced
FROZEN ELEPHANT TRUNK PROCEDURE
- allos total replacement of the arch and descending aorta in a single complex aneurysm
- treatment for type A dissection
Surgical repair for ASCENDING AA: modified bentall vs bentalls
Modified Bentall procedure
- treating ascending TAAs involving the root and associated with significant AV disease
- uses a composite graft consisting of a Dacron tune with prosthetic aortic valve
***Bentall. - > direct reimplantation of the coronary arteries, whereas modified requires formation og the ostial buttons that are then attached to the graft
Surgical repair for ASCENDING AA: David vs Yacoub vs Ross procedure
Valve-sparing root replacement - if with structurally normal AV leaflets and AR is secondary to dilatation of the STJ or aortic annulus
DAVID procedure - reimplanting the native valve within the Dacron graft
Yacoub procedure. - remodeling of the aortic root
ROSS procedure - pulmonary autograft
***pulmonary root is replaceedw itha cryopreserved homograft root
