Aortic Dissection Aneurysms

Aortic Dissection and Aneurysms
Prepared by :
DR- muaath itmaizeh
Internal medicine resident
Abdominal Aortic Aneurysms
(AAA)
 Risk factors
 Elderly (>60)
 Familial trend (18% with 1° relative)
 Connective Tissue D/O (Marfan’s)
 Other aneurysms
 Atherosclerosis (HTN, Lipids, smoking, DM)
AAA
 Pathogenesis
 Intima infiltrated by atherosclerosis and thinned
media.
 Possible intraluminal thrombus and adventitia
infiltrated by inflammatory cells
AAA
 Average rate of growth 0.25-0.5 cm per

year.
 Larger aneurysms extend more rapidly than
smaller ones. (LaPlace law)
AAA
 Clinical Features
 Syncope (10-12%)
 Back and/or Abdominal Pain –severe and abrupt,
ripping or tearing sensation (50%)
 Shock –intraperitoneal rupture, massive blood
loss
 Sudden death
AAA
 Physical Exam
 Pain on palpation or not
 Retroperitoneal hematoma
 Cullen sign (periumbilical ecchymosis)
 Grey-Turner sign (flank ecchymosis)
 Scrotal hematoma or inguinal mass (blood dissecting

to these areas)
 Iliopsoas sign
 Femoral nerve neuropathy

AAA
 Found aneurysms refer to follow up

 >5cm diameter –increased chance of rupture
 <5cm –decreased chance of rupture
 Symptomatic aneurysms of any size =
Emergency!!
AAA
 Diagnosis
 Includes differential diagnoses of syncope, abd
pain, back pain and shock.
 If with combo of two or more think aortic dz.
AAA
 Radiologic Evaluation
 Should not delay operative treatment!!
 Plain abd film (calcified bulging)
 US (bedside, up to 100% sensitive, not reliable
to detect rupture)
 CT (with IV contrast only if stable)
 MRI
AAA
 ED Treatment
 Urgent surgical consult
 Make diagnosis & assist rapid transfer to OR
 2 large bore IVs
 Cardiac Monitor
 O2
 ? Blood transfusion
 IV fluid resuscitation –controversial amount b/c too
much can be harmful
 RADIOGRAPHIC STUDIES ONLY IF
UNLIKELY TO HAVE RUPTURED AAA!!!
AAA
 ½ of patients with ruptured AAA who

reach the OR die!
A Bit About Thoracic Aortic
Aneursym
 Presenting symptoms include esophageal,
tracheal, bronchial, or even neurologic
disorders.
 If it erodes to adjacent structures it is
immediately fatal!!
Aortic Dissection
 Pathogenesis
 Prominent cause of sudden death
 Presents with severe abd., chest, and back pain
 Violation of intima that allows blood to enter
media and dissect b/w intimal and adventitial
layers
 Common site is ascending aorta at ligamentum
arteriosum
Aortic Dissection
 Common presenting groups

 >50 yoa with HTN
 2/3 male
 Marfan’s syndrome
 Congenital heart disease
 Pregnancy
Aortic Dissection
 Stanford Classification
 Type A -involves ascending aorta
 Type B –involves descending aorta
 DeBakey Classification
 Type I –ascending, arch & descending aorta
 Type II –ascending only
 Type III –descending only
Aortic Dissection
 >85% abrupt, severe pain in chest or b/w scapula
 50% ripping or tearing
 Pain in anterior chest –ascending aorta (70%)
 Back pain (less common) –descending aorta
(63%)
 If dissection into carotid classic neuro symptoms
Aortic Dissection
 40% with neurologic sequelae (ex. paraplegia)
 Nausea, vomiting, diaphoresis
 Most have sense of impending doom!
Aortic Dissection
 Physical Exam
 Usually normal heart and lung exam
 May have aortic insufficiency
 <20% with decreased radial, femoral or carotid
pulse
 HTN
 Tachycardia
 Hypotension
Aortic Dissection
 Physical Exam
 Pericardial tamponade (muffled heart tones,
JVD, pulsus paradoxus)
 Hoarseness (compression of recurrent laryngeal
nerve)
 Horner’s Syndrome (compression of superior
cervical sympathetic ganglion)
Aortic Dissection
 Diagnosis
 Ischemic end-organ manifestation such as MI,
pericardial dz, pulmonary d/o, stroke
musculoskeletal dz of extremities,
intraabdominal ischemia.
Aortic Dissection
 Thoracic Dissection
 90% have abnormal CXR
 Widened mediastinum
 Abnormal aortic contour
 Pleural effusion
 Deviation of trachea, mainstem bronchi, or esophagus
 Intimal calcium visable & distant from edge (calcium

sign)
Aortic Dissection
 Diagnosis
 CT
 83-100% sensitive
 87-100% specific
 Use spiral CT with IV contrast
 Will not give anatomic details of arterial branches or

aortic valve competence.
 Modality of choice in unstable patient
Aortic Dissection
 Diagnosis
 Angiography
 “Gold standard”
 Shows all anatomy and involvement
 94% specific
 88% sensitive
 TEE
 97-100% sensitive
 97-99% specific
 Esophageal dz contraindication
Aortic Dissection
 In contrast to ruptured AAA,

SUSPECTED DISSECTIONS MUST BE
CONFIRMED RADIOLOGICALLY
PRIOR TO SENDING TO OR!!!
Aortic Dissection
 ED Treatment
 Treat hypertension
 β-blocker
 Esmolol 500µg/kg IV bolus over 1 minute then 50-150 µg/kg
minute
 Metoprolol 5mg q2min x3 IV then 2-5mg/hr
 Propranolol 20mg IV then 40mg, 8-mg q10min to 300mg
total
 Calcium channel blocker if β-blocker contraindicated
Aortic Dissection
 ED Treatment
 Vasodilator
 Nitroprusside 0.3 µg/kg/min IV
 Surgery
 OR for ascending aortic dissection
 Descending aortic dissection worse surgical risks –
controversial for repair
Any Questions????
Questions
 1. A patient with a suspected aortic

dissection should be immediately transferred
to OR without radiographic studies.
 A. True
 B. False
 2. Females are more likely than males to develop
aortic dissection.
 A. True
 B. False
 3. Dissection of the ascending aorta only is
DeBakey classification
 A. Type I
 B. Type II
 C. Type III
 D. Type A
 E. Type B
 4. a Patient with a ruptured AAA can present
with all of the following symptoms except
 A. Shock
 B. Syncope
 C. Sudden death
 D. Nausea and vomiting
 E. Headache
 5. Which of the following radiologic
modalities is considered the “gold standard”
for diagnosing an aortic dissection?
 A. CT
 B. MRI
 C. TEE
 D. Angiography
 E. CXR
Answers
 1. B
 2. B
 3. B
 4. E
 5. D

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Aortic Dissection and Aneurysms

 Average rate of growth 0.25-0.5 cm per

 Scrotal hematoma or inguinal mass (blood dissecting

 Femoral nerve neuropathy

 Found aneurysms refer to follow up

 ½ of patients with ruptured AAA who

 Common presenting groups

 Deviation of trachea, mainstem bronchi, or esophagus

 Intimal calcium visable & distant from edge (calcium

 Use spiral CT with IV contrast

 Will not give anatomic details of arterial branches or

 In contrast to ruptured AAA,

 1. A patient with a suspected aortic

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