H E L
s a ANG
Aortic Ddissection
r. L a r i
r ă r i
S e f Luc
@
Lecturer Dr. Larisa Anghel
23.02.2023
Anatomy
➢Thoracic aorta:
▪ aortic root;
▪ aortic arch; N G H E L
i s a A
▪ ascending aorta; . L a r
r i D r
▪ descending aorta Luc r ă
S e
@ aorta f
➢Abdominal
Anatomy
Dimensions vary depending on:
- age;
- sex; N G H E L
i s a A
L a r
ă r i Dr.
- body surface (height, weight, BMI).
Luc r
@ S e f
Anatomy
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Disecţia de aortă
Aortic dissection
➢ the separation of the layers of the aortic wall due to the rupture
of the intima, with the formation of a false lumen and a true
lumen that may or may not communicate;
➢ single entrance gate/ multiple exit gates H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Disecţia de aortă
Aortic dissection
➢ major surgical emergency;
➢ prevalence: 0,5 – 2,95/100 000/year (more common in men)
➢ maximum incidence between 50-70 years.
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Disecţia de aortă
Aortic dissection
DEATH: L
N G H E
- 33% in 24 hours;. Larisa A
i D r
- 50% Sin
e f
48
L u c hours
r ă r (1-2%/hour);
@
- 75% in 2 weeks if not diagnosed.
Disecţia
Aorticdedissection-
aortă etiology
➢ Atherosclerosis
➢ Connective tissue diseases:sdr. Marfan;
➢ HTA; E L
A N G H
➢ Aortic coarctation, aortic bicuspidia; arisa
D r . L
➢ Vasculitis (Takayasu, giant
c r ă r i
cell arteritis, syphilitic aortitis);
L u
➢ Toxics; @ Sef
➢ Chest injuries;
➢ Iatrogenic causes.
Disecţia de aortă - triggers
Aortic dissection
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Disecţia
Aortic de aortă
dissection - pathophysiology
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Disecţia
Aortic de aortă
dissection - pathophysiology
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Disecţia
Aortic de aortă
dissection - pathophysiology
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Disecţia
Aortic de aortă
dissection - pathophysiology
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Disecţia
Aortic de aortă
dissection - pathophysiology
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Disecţia
Aortic de aortă
dissection - pathophysiology
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Disecţia
Aortic de aortă
dissection - pathophysiology
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Disecţia
Aortic de aortă
dissection - pathophysiology
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Disecţia
Aortic de aortă
dissection - pathophysiology
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Aortic dissection - clasification
Anatomopathology:
H E L
➢Type I: entire aorta.
i s a ANG
➢Type II: localized in L a r
ascending aorta. ă r i Dr.
L u c r
@ S f
➢Type III: localized
e in
descending aorta.
Aortic dissection– Svensson classification
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Aortic dissection - clasification
Depending on the time of onset:
H E L
i s a ANG
➢acute: less than 14 D rdays;
. L a r
c r ă r i
➢subacute:
e f L u between 15 and 90 days;
@ S
➢chronic: more than 90 days.
Aortic dissection - clinic
The correct anamnesis, objective clinical examination
N G H E L and
is
paraclinical investigations will support rthe a A
definitive diagnosis.
r . L a
ă r i D
L u c r
@ S e f
Aortic dissection - clinic
➢ Brutal, dramatic onset, with severe chest pain and possible
immediate death;
➢ Pain (most common symptom of onset): N G H E L
i s a A
- maximum intensity fromDthe . L a r
beginning;
r i r
- lancinating L u c r ă
character, like a dagger blow;
@ Se f
- location: retrosternal (ascending aorta), interscapulovertebral
(descending aorta), neck, jaw (aortic arch).
Aortic dissection - clinic
➢ hypovolemic shock, with/ without cardiac tamponade;
➢ peripheral pulse;
➢ diastolic murmur (AI); N G H E L
i s a A
➢ pericardial rubbing; . L a r
r i D r
➢ cardiogeniceshock;
L u c r ă
@ S f
➢ hemoptysis, hematemesis.
Aortic dissection - clinic
Frequently male, 60 years old, hypertensive,
H E L
symptomatic due to sudden onset of chest pain.
i s a ANG
. L a r
Careful!!! If the ECG is normal, theDr
suspicion of
c r ă r i
S e f Luhigher.
dissection should be even
@
Aortic dissection - paraclinic
➢ ECG:
- mandatory for differential diagnosis with AMI;
H E L
i s a ANG
➢ Biologic:
. L a r
D r
- mild leukocytosis; ucrări
e f L
S bilirubin (hemolysis of sequestered blood) and D-
@ LDH,
- increased
dimers.
Aortic dissection– chest X-ray
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
True lumen / false lumen differential diagnosis
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Aortic dissection type A
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Aortic dissection type B
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
N G H E L
i s a A
. L a r TTE Aortic
r i D r
L u c r ă dissection
@ Se f
ATTENTION!!!
➢ a normal ETT assessment does not rule out aortic
dissection;
G H E L
➢ artifacts in the aortic lumen may besconfuseda A N with the
L a r i
dissecting fold;
i D r .
u c r ă r
➢ in patients
S e f L
with chest pain and LV wall contractility
@
disorders, make sure that aortic dissection is not the
cause of myocardial ischemia.
Aortic dissection - CT
➢ most used;
➢ extension of dissection
to the aorta and on the
H E L
ANG
emerging arteries;
➢Not: a r i s a
Dr. L
- aortic insufficiency; crări
e f L u
@ Sdoor;
- inlet / outlet
- type 3 aortic dissection.
Aortic dissection– chest x-ray and CT
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Aortic dissection - angiography
➢entrance gate;
➢ extension on the
collateral branches; N G H E L
i s a A
➢ aortic insufficiency - . L a r
r i D r
mechanism; L u c r ă
@ S e f
➢ coronary
angiography.
Aortic dissection– diferential diag.
➢ acute myocardial infarction;
➢ pulmonary thromboembolism;
➢ acute aortic insuficiency of other causes; NGHEL
i s a A
➢ pericarditis; . L a r
r i D r
➢ mediastinal u c
tumors.
L r ă
@ Se f
Aortic dissection– complications
➢Cardiac tamponade
➢Rupture of the aorta with mediastinal, pleural or abdominal
hemorrhage
H E L
➢Renal failure secondary to renal ischemia sa ANG
L a r i
➢Abdominal ischemia D r .
c r ă r i
➢Death (bleedingLshock)
u
@ S e f
➢Aortic regurgitation
➢Stroke
➢MI
Aortic dissection– treatment
• BP 100-120 mmHg
• VD N G H
only E L
associated
i s a A
. La r with BB
r i D r
L u c r ă
@ S e f
Aortic dissection– surgical tratament
➢ Indications:
N G H E L
- in proximal dissection;
i s a A
.
- in complicated distal dissection: L a r
compromising a vital organ
r i D r
Luc r
or imminent rupture. ă
@ S e f
Aortic dissection– surgical treatment
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Aortic dissection - monitoring
➢ contraindicated physical exertion;
➢ low BP <130 mmHg; E L
A N G H
➢ echocardiographic evaluation a r i s a
annually;
D r . L
➢ control at 1,u3,
c 6,
r ă r
12i months, then annually;
e f L
@ S
➢ preferably evaluated by IRM; if IRM is not
possible, then CT or transesophageal ultrasound.
H E L
i s a ANG
. L a r
r i D r
L u c r ă
@ S e f
Aortic dissection– KEY POINTS!!!
➢ CV Emergency !!!
E L
➢ Key element - chestarpain; i s a A N G H
D r . L
➢ ETT f/ CT;
L u c r ă r i
@ Se
➢ Immediate intervention !!!!
