Aortic Disssection. Dr Nikrish Hegde.
-
Upload
drnikrish-hegde -
Category
Health & Medicine
-
view
597 -
download
2
Transcript of Aortic Disssection. Dr Nikrish Hegde.
![Page 1: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/1.jpg)
AORTIC DISSECTION!
Dr. Nikrish S Hegde
![Page 2: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/2.jpg)
LEARNING OBJECTIVES! Identify the two types of aortic
dissection and list the indications for treatment.
Describe the imaging parameters and the typical and atypical imaging findings in aortic dissections.
Discuss the imaging features of complications that can arise from aortic dissections.
![Page 3: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/3.jpg)
IMPORTANCE! Most common
Fatal outcome
Prompt diagnosis and treatment.
![Page 4: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/4.jpg)
AORTA made of three layers, called from the
luminal side outward, the tunica intima, the tunica media and the tunica adventitia
![Page 5: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/5.jpg)
What is aortic dissection? Dissection is the result of a spontaneous
longitudinal separation of the aortic intima and adventitia caused by circulating blood gaining access to and splitting the media of the aortic wall
![Page 6: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/6.jpg)
TYPES:-DeBakey
Standford
![Page 7: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/7.jpg)
![Page 8: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/8.jpg)
![Page 9: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/9.jpg)
Type A dissections account for 60%–70% of cases and typically require urgent surgical intervention.
Stanford type B dissection involves the descending thoracic aorta distal to the left subclavian artery and accounts for 30%–40% of cases. Management takes the form of medical treatment of hypertension.
![Page 10: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/10.jpg)
Indications for immediate surgery Hemodynamic instabilty.Uncontrolled HTN.Diameter > 6cm. Ischaemic Complications.
![Page 11: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/11.jpg)
PRESENTATION. CHEST PAIN SYNCOPE RIGHT HYPOCHONDRIAL
PAIN ..ABNORMAL LFT OLIGURIA ..ANURIA ..ABNORMAL RFT NAUSEA ..VOMITING..PAIN
ABDOMEN..BLOODY DIARRHOEA.. LOWER LIMB ISCHAEMIA
![Page 12: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/12.jpg)
ACUTE VS CHRONIC The dissection is termed acute when it
is diagnosed within 14 days after the first symptoms appear.
It is termed chronic when it is diagnosed later .
![Page 13: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/13.jpg)
HELICAL CT AND AORTIC DISSECTION. Aortography. Shorter acquisition time, wide availability,
and high diagnostic accuracy and has, therefore, classically been the modality of choice for the evaluation of aortic dissection.
The intimal flap, type and extent of dissection ,presence of thrombus and the presence of associated complications and follow up changes.
![Page 14: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/14.jpg)
TECHNIQUE The examination begins with
conventional unenhanced CT.
Coverage begins 2 cm above the aortic arch and continues to the superior aspect of the femoral head.
We then inject 100 mL of nonionic at a rate of 2 mL/sec through a 20-gauge catheter positioned in the right arm. Helical CT is performed 30 seconds after administration of contrast
![Page 15: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/15.jpg)
![Page 16: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/16.jpg)
TYPICAL AORTIC DISSECTION The classic feature of aortic dissection is
a partition between the true and false channels.
Secondary findings include internal displacement of intimal calcifications or a hyperattenuating intima; delayed enhancement of the false lumen; widening of the aorta; and mediastinal, pleural, or pericardial hematoma .
![Page 17: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/17.jpg)
![Page 18: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/18.jpg)
![Page 19: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/19.jpg)
STANDFORD TYPE A
![Page 20: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/20.jpg)
![Page 21: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/21.jpg)
STANFORD B
![Page 22: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/22.jpg)
How do we distinguish false lumen from the true lumen?? SIZE POSITION-False channel usually arises
anterior in the ascending aorta and spirals to posterior and left lateral in descending aorta.
FLOW SECONDARY CHANGES – THROMBOSIS BEAK’S SIGN
![Page 23: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/23.jpg)
BEAK’S SIGN
![Page 24: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/24.jpg)
THROMBOSED FALSE LUMEN
![Page 25: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/25.jpg)
ATYPICAL AORTIC DISSECTION
INTRAMURAL HEMATOMA:Unenhanced CT shows a cuff or crescent of high attenuation and displacement of intimal calcifications. On enhanced CT scans, a smooth region of low attenuation can be seen
![Page 26: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/26.jpg)
![Page 27: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/27.jpg)
![Page 28: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/28.jpg)
![Page 29: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/29.jpg)
Penetrating atherosclerotic ulcer is defined as an atherosclerotic lesion with ulceration that penetrates the internal elastic lamina; such penetration facilitates hematoma formation within the media of the aortic wall
![Page 30: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/30.jpg)
![Page 31: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/31.jpg)
![Page 32: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/32.jpg)
Ruptured Type B Dissection
![Page 33: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/33.jpg)
![Page 34: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/34.jpg)
Atypical Configuration of the Intimal Flap
circumferential intimal flap
![Page 35: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/35.jpg)
filiform
![Page 36: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/36.jpg)
Mercedes-Benz sign
![Page 37: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/37.jpg)
CHANGES DURING FOLLOW-UP
Pseudoaneurysm
![Page 38: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/38.jpg)
![Page 39: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/39.jpg)
![Page 40: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/40.jpg)
![Page 41: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/41.jpg)
Healing of intramural hematoma
![Page 42: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/42.jpg)
![Page 43: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/43.jpg)
Progression of Intramural Hematoma
![Page 44: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/44.jpg)
![Page 45: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/45.jpg)
![Page 46: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/46.jpg)
Aneurysm of the false lumen
![Page 47: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/47.jpg)
PITFALLS The CT appearances of several entities
can cause them to be mistaken for atypical AAD.
![Page 48: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/48.jpg)
Mural thrombus
![Page 49: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/49.jpg)
CT scan shows an atheromatous thrombus with an irregular internal border in the thoracic descending. A thrombosed aortic dissection usually demonstrates a smooth internal border.
![Page 50: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/50.jpg)
periaortic lymphoma
![Page 51: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/51.jpg)
PSEUDODISSECTION
![Page 52: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/52.jpg)
Perivenous streaks combination of beam hardening and
motion orientation of such streaks typically
varies from section to section and extends beyond the confines of the aortic wall
minimize perivenous streaks by performing bolus injection into the right arm at a rate of 2 mL/sec
![Page 53: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/53.jpg)
Aortic motion artifact ascending aorta and is related to
movement of the aortic wall artifact is seen at the left anterior and
right posterior margins of the aortic circumference
a serrated appearance of the left anterior ascending aorta on two- or three-dimensional reconstruction images
![Page 54: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/54.jpg)
![Page 55: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/55.jpg)
BRANCH VESSEL OCCLUSION There are two types of branch-vessel occlusion.
1)STATIC2)DYNAMIC
![Page 56: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/56.jpg)
STATIC the intimal flap intersects or enters the
branch-vessel origin. Static obstruction is treated locally with an intravascular stent
![Page 57: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/57.jpg)
![Page 58: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/58.jpg)
![Page 59: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/59.jpg)
DYNAMIC the intimal flap spares the branch-vessel
wall but prolapses across the branch-vessel origin and covers it like a curtain . Dynamic obstruction is treated with a fenestration procedure
![Page 60: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/60.jpg)
![Page 61: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/61.jpg)
![Page 62: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/62.jpg)
ADVANCES
TEEMRITRIPLE-RULE-OUT -CT
![Page 63: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/63.jpg)
Transesophageal echocardiography secondary signs of an aortic dissection
such as aortic root dilatation, aortic regurgitation, coronary ostial patency, pericardial effusions, or regional abnormal wall motion can be diagnosed.
TEE can be performed in the emergency department at the bedside of unstable patients.
![Page 64: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/64.jpg)
![Page 65: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/65.jpg)
![Page 66: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/66.jpg)
![Page 67: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/67.jpg)
MR angiography suitable for the investigation of aortic
dissection in medically stable patients or those with chronic dissections
including lack of nonionizing radiation, multiplanar evaluation, and greater vessel coverage at high resolution with fewer sections.
It cannot be performed in unstable patients due to longer acquisition time and difficulty in monitoring, and it is not appropriate for patients with implanted electronic devices
![Page 68: Aortic Disssection. Dr Nikrish Hegde.](https://reader035.fdocuments.us/reader035/viewer/2022062405/556b8c05d8b42a6c7c8b52c4/html5/thumbnails/68.jpg)
TRIPLE-RULE-OUT -CT Assess the aorta, coronary arteries, and
pulmonary arteries and the middle and lower portions of the lungs during a single scan with use of several optimally timed boluses of contrast material and ECG gating.
Biphasic injection of iodinated contrast material (≤100 mL)