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Aortic a. b. c.
Dissection Intimal tear forms in part of aorta Blood flows into newly created false lumen False lumen can extend and compress true lumen. Extension can impair blood flow to branches of aorta and compromise perfusion to organs fed by those branches.
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Predisposing Factors a. Chronic hypertension poorly controlled b. Cystic Medial Necrosis i. Degeneration of the intima media of the aortic wall ii. Present in Marfans Syndrome c. Bicuspid Aortic valve i. 1/3 of patients with congenital bicuspid aortic valve will also have degeneration of the intima media and risk for dissection d. Aortitis i. Lupus and other inflammatory syndromes/processes e. Pregnancy f. Blunt Trauma Pathophysiology of Dissection Formation Degeneration of Intima Media + Flexion Stress on Aorta + High DP/DT (forceful heartbeat causing abrupt pressure changes in aorta)
Intimal Tear
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Classification of Aortic Dissection a. Classification is made according to which part of the aorta has a false lumen NOT according to where the initial intimal tear is i. Debakey Classification 1. Class 1 false lumen involving the ascending aorta AND additional portions 2. Class 2 false lumen involving ONLY the ascending aorta 3. Class 3 false lumen involving ONLY the descending aorta ii. Stanford Classification 1. Type A any false lumen involvement in the ascending aorta 2. Type B false lumen involvement in only the descending aorta
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Location of Intimal Tear a. Ascending Aorta 58% b. Transverse Arch 10% c. Descending Aorta 30% d. Abdominal Aorta 2% Blood Supply Impairment a. If the false lumen extends it can compress the branch arteries that supply blood to organs, causing various symptoms and varied organ involvement b. Example of extension to renal arteries
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Clinical Features a. Pain more sharp and severe than the pain of an MI b. GI Symptoms nausea/vomiting. Can be extreme if blood supply to gut is impaired but that is rare c. Neuro Symptoms due to compromised blood supply to brain. Question of appropriate intervention if level of consciousness and neuro is already impaired prior to surgery.
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Extremity Ischemia dependent on branch artery involvement Organ Ischemia dependent on branch artery involvement Aortic Rupture Aortic Valve Insufficiency if dissection moved toward valve, false lumen can compress valve from behind, compromising valve function. Valve must be re-suspended with surgery.
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Diagnostics a. Patient presents with severe anterior or posterior chest pain i. EKG to r/o MI ii. Pain associated with dissection is so severe that if pain was from an MI, it would definitely show up on EKG dont wait for troponins. b. Differential BP in right vs left arms clue to diagnosis c. CXR can show sometimes d. Gold Standards i. CT Scan most widely accepted as standard for diagnosis ii. TEE can occur intra-operatively to see extent if CT Scan could not be done iii. MRI iv. Aortography 1. Shows compression of true lumen, opacification of false lumen, branch involvement and primary intimal tear Management Suspicion Control BP CT Scan Type 1 or 2 Surgery Type 3 uncomplicated Observe medical management Type 3 - complicated Surgery
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Surgical Treatment a. Excise portion of aorta most prone to rupture b. Excise primary intimal tear when feasible c. Type 1 or Type A i. Replace ascending aorta ii. Aortic Valve re-suspension or replacement iii. Aortic Root Replacement d. Technique i. Cannulation of Right Atrium and usually femoral artery must occur in order to work on aorta ii. Clamp ascending aorta iii. Excise area with tear iv. Prepare proximal and distal stumps of aorta with Teflon felt strups v. Insert Dacron graft between prepared proximal and distal stumps and sew graft into place. vi. Reattach coronaries if root replacement e. Rarely replace transverse arch due to need for prolonged circulatory arrest and complications associated with it f. Issues i. Additional intimal tears are common and even after surgery the tears and aneurysm can remain and cause problems ii. False lumen can remain and cause issues as well g. Type B i. Complicated Type B Indications for Surgery 1. Aortic Rupture 2. Expansion of dissection on serial CT 3. Inability to control pain 4. Inability to control BP 5. Progression with organ compromise ii. Surgery may not fix issues 1. Additional intimal tears are common and even after surgery the tears and aneurysm can remain and cause problems 2. False lumen can remain and cause issues as well Post-Care and Follow Up a. Annual CT Scans b. Pharmacological BP Control i. Angiotensin II Blocker especially helpful Cozaar c. Weight and lifting restrictions
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Mortality Data a. Acute Dissection Untreated Time Elapsed Mortality 24 hours 40% 1 week 75% 3 months 90% b. Early Mortality When Treated Type Type A Type B Medical Treatment 75% 15-20%
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c. Long-Term Survival i. 5 year survival rate 50% ii. Issues 1. False lumen persists causing problems 2. Acute rupture of chronic aneurysm = sudden death Note about Marfans Syndrome a. Prone to dissections related to Cystic Medial Necrosis and degeneration of the intima media b. Deficient in a protein, fibillin, that causes this instability in the tissue c. Angiotensin II Blockers are very effective in post-treatment as they seem to reverse this protein deficiency d. When operating on a patient with Marfans it is mandatory to do an aortic root replacement as the dissection often will extend into this area and cause future issues