Βασιλικθ Ματζαράκη, MDΠΓΝ ‘’ΑΤΤΙΚΟΝ’’

33o Πανελλήνιο Καρδιολογικό Συνζδριο HILTON 1-3/11/2012

…He demonstrated the minute structure of blood vessels, showed before the Royal Society experiments proving that the inner and middle coat of an artery could be ruptured while the outer remained entire, and thus made clear the method of formation of chronic aneurysm, which had not before been understood. He noticed that the arteries were supplied with nerves, and pointed out that these probably regulated blood pressure…

1760 - first described on necropsy an acute aortic dissection

Frank Nicholls (1699 –1778)

KING GEORGE II

Acute Aortic Syndromes (AAS)

’’…Disease is very old , and nothing about it has changed. It is we who change as we learn to recognize what was formerly imperceptible.’’

Jean Martin Charcot

Acute Aortic Syndrome

Definition: Describes a collection of life-threatening acute injuries to aorta

(Vilacosta and Roman 2001) Types ( Classification) :

Aortic dissection (AD) (class I) Intramural hematoma (IMH) (class II) Localized dissection, intimal tear without flap, localized bulge Penetrating atherosclerotic ulcer (PAU) (Class IV) Traumatic transection (class V) Acute expanding aneurysm (class VI)

Consequences: Death caused by Ao rupture or associated mechanical

complications Type A AD mortality increases 1-2%/hr for first 48 hrs after

presentation Other AAS have increased mortality also

• ΑΑS’s common denominator is the media architectural dissolution

• 90% intimal’s tearAAS

IMHPAU

CLASSIC DISSECTION

Progression of one type AAS to another type

Pathophysiology

Contributing conditions for aortic dissection

• Untreated arterial hypertension (75%)• Cocaine use, cigarette smoking

• Connective tissue disorders

• Syndromic or non-syndromic hereditary conditionsMarfan’s syndrome

• Bicuspid aortic valve/Aortic coarctation

• Vascular inflammationTakayasou arteritisGiant cell arteritis

• InfectionTBC/ Syphilis

• Deceleration trauma (car accidents/ fall from

high)

• Iatrogenic factors (catheters/surgery)

Eur Heart J 2012;33:26-35

Αcute Aortic Dissection (AAD)

pressures at intima cause tearing false + lumen that maypropagate

Locations: 65% occur w/in

3 cm coronary ostia

10% occur in arch

10% occur in descending thoracic Ao Classifications:

Type A: ascending Ao (surgical) Type B: not involving ascending Ao (nonsurgical)

Aortic Dissectionclassification

Acute 2 weeksSubacute 2-6 weeksChronic > 6 weeks

Classification and complicationsSlide 24

Classification of aortic dissection

• DeBakeyType I ascending aorta –aortic arch

and distally

Type II ascending aorta

Type III descending and distal

IIIa descending

IIIb below diaphragm

• StanfordA all with ascending

B not ascending

6000-10000 cases per year in USA

1988-1996-Un Hospital Eppendford-Hamburg

AAS Epidemiology-IRAD study International Registry of Acute Aortic Dissection 1996-1998 2.6-3.5 cases per 100,000

2/3 male (65%)

Average age 63 years men/67 years women

Women have worse outcome (atypical symptoms/late diagnosis)

Type A dissection 62.3% (n=464 pts)

More common in winter time

Iatrogenic 4.3%

Increase of incidence to 16 /100000 men per annum

Hypertension 72%

Marfan syndrome 4.9% (mean age 36 years)

Nienaber et al. Circ 2004; 109:3014-3021

AAS Epidemiology

Traumatic aortic dissection 20% of road accident pts

40.000 motor vehicle deaths/annually in USA

8000 of the victims had aortic rupture

9-14% reach a hospital alive

2% ( ! ) survive

Location

Aortic isthmus 45%

Ascending aorta 23%

Descending aorta 13%

Abdominal aorta 5%Eur J Cardiothoracic Surg 2003;23:143-148.

52%

28%

Sweden 14500 pts 1987-2002

7 times fold

15times fold

Why is the incidence of aortic disease increasing? The demographic factor? … Older age

Better access to early diagnosis? …prolifiration of US,CT,MRI

… TRIPLE RULE OYT!

Life style habits? …weight lifting, Cocaine use

Better awareness in the medical community? …steep increase of pub/s by

1015% in ten years

… AAS acute aortic syndromes

… IMH a new disease

Better awareness of patients? …AHA cardiology pts page

…www.Iradonline.org

…www.aorticdissection.com

New treatment strategies ? …hybrids, endovascular tx!

Intramural HematomaKrukenberg 1920

Rupture of :

( a) vasa

vasorum or

(b) plaque

collection of blood

in media w/o

intimal tear

5-20% of AAS

May extend toward

lumen and lead to dissection

High rate of rupture

Ascending aorta (Class A) IMHs are surgical

Circ 2005;112:3802-3813/ Eur H J 2012;33:26-35

IMH : A variant of AAD2 DIFFERENT PATHOPHYSIOLOGICAL PROCESSES : a. Without intimal disruption (vasa vasorum)b. From PAU

ΙΜΗ - epidemiology Retrospective analysis 65 symptomatic pts with aortic

IMH

Group 1: 34 had IMH associated with PAU ( descending aorta)

Group 2: 31 unaccompanied by PAU ( ascending aorta most)

48% progression in group 1

8% progression in group 2

Circ 2002;106:342-348

Intramural Hematoma-Epidemiology Hypertension -the most common underlying condition

10% regression

28-47% progression to classic aortic dissection

20-45% risk of rupture

IRAD study

5.7% (58/1010 with AAD)

older (68.7 vs 61.7 years)

distal aortic involvement ( 60.3 vs 35.3%)

proximal aortic involvement high mortality (9/12 deaths)

Eur Heart J 2012;33:26-35

Penetrating atherosclerotic ulcer (PAU) Erosion of intimal plaque into media

May lead to IMH, dissection, aneurysm, pseudoaneurysm or rupture

Focul lession

Most often located in the descending Ao (>90%)

Multiple PAUs are often found

20% without IMH (fibrosis)

Age > 65y

Hypertension

Eur Heart J 2012;33:26-35

Acute expanding aortic aneurysm

Abdominal aortic aneurysms • < 4cm expand rate 2–4 mm /year • 4-5 cm expand rate 2–5 mm , and• >5 cm expand rate 3–7 mm

The rupture risk at 4 years is 2%, 10%, and 22%, respectively .

Abdominal aortic aneurysm is seen concomitantly in 42.1% of patients with PAU and 29.4% of patients with IMH.

Aneurysms in patients with PAU and IMH tend to be larger than those associated with classic aortic dissection (6.2 and 5.5 cm vs 5.2 cm, respectively)

Nienaber CA. Pathophys of AAS New York SS 2007: 83-98.

Conclusions 1AAS describes a collection of life-threatening acute

injuries to aorta

Hypertension is the most common risk

Men>women

Any mechanism that causes intimal damage and leads to weakening of the media can result in dissection

IMH – variant of AAD – treat similar to AAD and have similar prognosis

Conclusions 2PAU is associated with atherosclerotic disease and

can lead to dissection or perforation

Both IMH and PAU are found more often in the DA

Type A 30day mortality of 50% with no therapy

Type B 30day mortality of 10%

ευχαριστώ

Natural history of IMH• Remodelation• Progression• Partial Resolution• Total resolution• Dissection• Rupture• No change

Date of download: 10/25/2012Copyright © 2012 American Medical

Association. All rights reserved.

From: Clinical Prediction of Acute Aortic Dissection

Arch Intern Med. 2000;160(19):2977-2982. doi:10-1001/pubs.Arch Intern Med.-ISSN-0003-9926-160-19-ioi00192

Univariate Analysis of Signs and Symptoms Associated With Types A and B Acute Aortic Dissection*

Figure Legend:

—Drawing shows enlarging aortic aneurysm.

Macura K J et al. AJR 2003;181:303-307

©2003 by American Roentgen Ray Society

PAU EPIDEMIOLOGY