AORTIC DISSECTIONAORTIC DISSECTION

Prof. Dr. Suat Nail ÖMEROĞLUProf. Dr. Suat Nail ÖMEROĞLU

The most catastrophic disease of the aortaThe most catastrophic disease of the aorta 5-10 patients/ 1 milion per year5-10 patients/ 1 milion per year Incidence is 0.2-0.8 % in autopsy seriesIncidence is 0.2-0.8 % in autopsy series M/F: 2.5-3M/F: 2.5-3 Most frequently seen 5.-6. decade of age.Most frequently seen 5.-6. decade of age.

MortalityMortality

First 24-48 hoursFirst 24-48 hours 20-50%20-50%– Increases 1% every passing hourIncreases 1% every passing hour

First 2 weeksFirst 2 weeks 75%75% First 3 monthsFirst 3 months 90%90%

DefinitionDefinition

Aortic dissection is an aortic wall disease.Aortic dissection is an aortic wall disease. Intimal layer separates from the medial layer Intimal layer separates from the medial layer

and this separation continues in general to the and this separation continues in general to the distal of the Aorta.distal of the Aorta.

PatogenesisPatogenesis

1. 1. Primary intimal tear theoryPrimary intimal tear theory– Proxymal dissections 95-100%Proxymal dissections 95-100%– Distal dissections 90-95%Distal dissections 90-95%

2. Occurence of intramural hematoma 2. Occurence of intramural hematoma theorytheory– Vasovasorum ruptureVasovasorum rupture– Rupture of penetrating atherosclerotic Rupture of penetrating atherosclerotic

ulcersulcers

Intimal tearIntimal tear

60-70% Ascending aorta60-70% Ascending aorta 10-20% Arcus aorta10-20% Arcus aorta 25% Descending aorta25% Descending aorta

Intimal tearIntimal tear

Intimal layer separates Intimal layer separates and it results in 2 and it results in 2 lumens: True lumen lumens: True lumen and False lumen.and False lumen.

EthiologyEthiology

HypertensionHypertension Medial degenerative diseaseMedial degenerative disease Genetic diseasesGenetic diseases Congenital heart and vascular diseasesCongenital heart and vascular diseases AtherosclerosisAtherosclerosis Inflammatory aortic diseasesInflammatory aortic diseases Travmatic injuriesTravmatic injuries Iatrogenic injuriesIatrogenic injuries Drug abuseDrug abuse PregnancyPregnancy

ClassificationsClassifications

Clinical classificationClinical classification Topografical classificationTopografical classification

– De BakeyDe Bakey– StanfordStanford– SvenssonSvensson

Clinical ClassificationClinical Classification

Acute:Acute: 0-14 days0-14 days Subacute:Subacute: 14 days- 2 months14 days- 2 months Chronic:Chronic: After 2 monthsAfter 2 months

Topografical ClassificationTopografical Classification

Stanford Stanford

ClassificatioClassificationn

Topografical ClassificationTopografical Classification

De Bakey De Bakey

RuptureRupture

Rupture is the most frequent cause of death Rupture is the most frequent cause of death and usually occurs at the site of intimal tear.and usually occurs at the site of intimal tear.

Type A dissectionType A dissection IntrapericardialIntrapericardial Dissection of arcus aortaDissection of arcus aorta IntramediastinalIntramediastinal Type B dissectionType B dissection Left pleuraLeft pleura

Organ malperfusionOrgan malperfusion

Serebral ischemiaSerebral ischemia Spinal ischemia Spinal ischemia Renal ischemiaRenal ischemia Visceral ischemiaVisceral ischemia Lower extremity ischemiaLower extremity ischemia Cardiac ischemiaCardiac ischemia

Clinical FindingsClinical Findings

PainPain Serebrovascular accidents (Syncope, stroke)Serebrovascular accidents (Syncope, stroke) CHFCHF Acute aortic valve insufficiencyAcute aortic valve insufficiency HypovolemiaHypovolemia Cardiac tamponadeCardiac tamponade Malperfusion signsMalperfusion signs

Pain in Acute Type A Pain in Acute Type A DissectionDissection

Pain in Acute Type B Pain in Acute Type B DissectionDissection

Clinical FindingsClinical Findings

Typical patient: 60 year old male patient with Typical patient: 60 year old male patient with hypertension, sudden severe painhypertension, sudden severe pain

Differential DiagnosisDifferential Diagnosis

Coronary ischemiaCoronary ischemia MIMI AIAI Aortic aneurysmsAortic aneurysms Mediastinal tumorsMediastinal tumors PerikarditisPerikarditis Pulmonary embolusPulmonary embolus StrokeStroke Visceral or lower extremity ischemiaVisceral or lower extremity ischemia

Physical ExaminationPhysical Examination

PalePale AnxietyAnxiety ShockShock Periferik perfüzyon bozukluğuPeriferik perfüzyon bozukluğu HypertensionHypertension 80 %80 % HypotentionHypotention 20 %20 % Neurologic dysordersNeurologic dysorders 20 %20 % BP DifferenceBP Difference

DiagnosisDiagnosis

ECGECG– Low voltageLow voltage– ST-T wave changesST-T wave changes

Blood testsBlood tests

DiagnosisDiagnosis

Chest x-rayChest x-ray CTCT MRIMRI TTETTE TEETEE AortographyAortography

To whom shall we perform To whom shall we perform angiography?angiography?

No need for patients with Acute type A No need for patients with Acute type A dissectiondissection

It can be performed to patients with Acute It can be performed to patients with Acute type B dissection, because CAD is frequenttype B dissection, because CAD is frequent

It must be performed to patients with It must be performed to patients with chronic dissectionchronic dissection

TreatmentTreatment

Surgical treatmentSurgical treatment Medical treatmentMedical treatment Endovascular treatmentEndovascular treatment Hybrid treatmentHybrid treatment

Treatment-AimTreatment-Aim

Stabilize the dissectionStabilize the dissection Avoid the ruptureAvoid the rupture Avoid organ ischemiaAvoid organ ischemia

Systolic BPSystolic BP 100-110 mmHg100-110 mmHg Mean BPMean BP 60-75 mmHg 60-75 mmHg Urine output and neurologic Urine output and neurologic

status should be monitorizedstatus should be monitorized

Treatment-Emergency UnitTreatment-Emergency Unit

Fluid replacementFluid replacement ECGECG Blood testsBlood tests Chest x-rayChest x-ray OO22

Analgesia (Morphine)Analgesia (Morphine) Invasive arterial monitoringInvasive arterial monitoring B-blockerB-blocker

Surgical TreatmentSurgical Treatment

Acute Type AAcute Type A Emergent surgical Emergent surgical treatmenttreatment

Acute Type BAcute Type B Endovascular or Endovascular or medical treatment (surgery for rupture, medical treatment (surgery for rupture, intractable sympoms or organ ischemia)intractable sympoms or organ ischemia)

Chronic Type AChronic Type A Elective surgical Elective surgical treatmenttreatment

Chronic Type BChronic Type B Surgery for Surgery for aneurysmatic aorta, organ ischemia.aneurysmatic aorta, organ ischemia.

41 year-old female with 8 children41 year-old female with 8 children ECG: Paroxysmal AF ECG: Paroxysmal AF EntubatedEntubated Diagnosis: Acute Diagnosis: Acute Stanford tStanford tyyppee A A AAortorticic

DissectionDissection HypertensionHypertension

Case ReportCase Report

Femoral or axillary arterial Femoral or axillary arterial cannulationcannulation

Venous cannulationVenous cannulation Venting from RUPVVenting from RUPV

Surgical TechniqueSurgical Technique

ResultResult

464 patients, 12 centers464 patients, 12 centers Mortality:Mortality:

Type A Type A Type BType B

SurgerySurgery 28 % 28 % 31 %31 %

MedicalMedical 58 % 58 % 10 %10 %

The results are even worse for the patients The results are even worse for the patients with paraplegia, visceral or renal with paraplegia, visceral or renal ischemia.ischemia.