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Diseases of the aorta

Heart Disease
Braunwald
CV R4
Supervisor:

Aorta
Intima, media, adventitia
ascending, arch, descending
Aortic isthmus: arch-descending junction

Aortic aneurysm
Definition: pathological dilatation of the normal
aortic lumen involving one or several segments

Fusiform (common), saccular


Pseudoaneurysm: well-defined collection of
blood and connective tissue outside the vessel wall

Abdominal aortic aneurysm

Age (M>55 y/o; F>70 y/o)


Atherosclerosis
Infrarenal arota: no vasa vasorum at media
Gene (Marfan, Ehlers-Danlos syndrome)
Prevalence: >3%
Aneurysm rupture: 80% into left retroperitonium
cavity

Abdominal aortic aneurysm


Pain: most common, at hypogastrium or back, not
affected by movement

Asymptom
Rupture triad: abdominal or back pain; palpable/
pulsatile abdominal mass; hypotension (<1/3 cases)

Bruit (+/-)
Abdomianl echo, CT, MRA, aortography

Abdominal aortic aneurysm


Surgical indication: rupture; size >45 cm;
expanding rapidly (>0.5 cm/year)

Coronary angiography
Medication control: Hyperlipidemia,
hypertension, cigarette smoking

CT follow up every 36 months

Thoracic aortic aneurysm


Descending aorta > ascending aorta
Cystic media degeneration: weakening aortic
wall (elastic fiber degeneration)

Marfan syndrome: autosomal dominant


Ahterosclerosis
Syphilis: ascending aorta
Infectious aortitis / mycotic aneurysm

Thoracic aortic aneurysm


40% asymptom, pain
A-V shunt, superior vena cava syndrome
(mass effect), tracheal deviation, hematemesis
CT, TEE > TTE
Surgery: >5cm (mean expansion rate= 0.43 cm/year)
Op risk: 5%

Thoracic aortic aneurysm


Annuloaortic ectasia: elastic fiber degeneration
+ aortic regurgitation

Aortic valve replacement

Aortic dissection

Tear in aortic intima


Antegrade, retrograde
false lumen, intimal flap, true lumen
Acute (2/3), chronic (1/3)
Ascending (65%), arch (20%), descending
thoracic (10%), abdominal (5%)
Mortality: 1% per hour

Aortic dissection

Peak: 6070 y/o


Hypertension, bicuspid aortic valve
Marfan syndrome (cystic media degeneration)
3rd trimester pergnancy
Blunt trauma
IABP
Prior cardiac surgery

Aortic dissection
Severe tearing pain (sudden onset), CHF,
syncope, CVA, ischemic peripheral
neuropathy, paraplegia, cardiac arrest,
sudden death
Anterior pain only: 90% ascending
Interscapular pain only: 90% descending

Aortic dissection
Hypertension (descending), hypotension (ascending)
Pseudohypotension (involving brachiocephalic
vessel)

Pulse deficit (transient), AR, neurological finding


(proximal, conscious level or spinal cord ischemia)

AMI (RCA > LCA)


Pleural effusion (left side), cardiac tamponade
Horner syndrome

Aortic dissection
Calcium sign: 1.0cm (suggestive, not
diagnostic)

Normal CXR cannot exclude dissection


EKG: LVH (1/3); absence of ST and T
change; AMI (involving coronary a.)
Initial diagnosis rate: 62%

Aortic dissection

Mortality: 25% (<24h), 50% (1w), 75% (1m), 90% (1y)


BP favor RA
BP on LA if higher BP in LA than RA
SBP: 100120mmHg,
mean BP: 6075mmHg
Pain control, beta-blocker, nitroprusside, ACEI
Hypotension: prefer levophed
Pericardiocentesis for cardiac tamponade

Atypical aortic dissection


Intramural hematoma:
rupture of vasa vasorum,
aortic dissection without intimal flap,
10% type B dissection,
failed diagnosis in aortography,
high risk for aneurysm formation,
medication (distal) or surgery (proximal)

Atypical aortic dissection


Penetrating atherosclerotic ulcer:

old, hypertension
no false lumen,
Aortography is standard
no definite treatment

Aortic atheromatous disease

Aortic atherothrombotic emboli


Age, hypertension, DM, hyperlipidemia, vascular
disease
Most common in descending thoracic aorta
Coumadin is for high risk patients to prevent
embolic event
Post-operative stroke

Cholesterol embolization syndrome


Cholesterol crystal from ulcerated atheromatous
plaques
blue-toe or purple-toe syndrome
Elevated ESR & eosinophil
Reduced complement level
No specific therapy

Acute aortic oolusion

Infrarenal aorta at bifurcation


Saddle embolus
Af / RHD, MI, DCM, aneurysm
Bilateral leg pain, weakness, numbness, paresthesia,
Cold, cyanosis, absent pulse, diminished or absent deep
tendon reflexes
Aortogram
Heparin, transcatheter, operation
life-long anticoagulant

Primary tumor of aorta

< 50 Cases
Equal in thoracic and abdomen aorta
Back pain
Aortography, biopsy
Prevent embolization

Peripheral artery diseases


Heart Disease
Braunwald Zipes Libby
sixth edition, 2001
CV R4
Supervisor:
Jul 1st , 2004

Peripheral artery diseases

< 60 y/o population: <3%


> 75 y/o population: >20%

Peripheral artery diseasesrisk factors

Peripheral artery diseases

Peripheral artery diseases


Intermittent claudication:
pain, ache, fatigue, or discomfort in the affected leg
during exercise, particularly walking (oxygen demand)
resolved with rest within few minutes
Buttock, hip, thigh
Gastrocnemius muscle is most common
Walking Impairment Questionnaire
Arterial embolism, vasculitis / arteritis, secondary
compression, lumbar sacroradiculopathy (neurogenic
pseudoclaudication, standing)

Peripheral artery diseases


Rest pain
Inadequate blood flow
Skin fissure, ulceration, or necorsis
DM neuropathy or ischemic neuropathy

Peripheral artery diseases


Physical examination:
Absent pulse distal to the stenotic site
Bruit of the stenotic site
Muscle atrophy, hair loss, cool skin, poor
healing, pressure sore,

Peripheral artery diseases

Peripheral artery diseases


Ankle/brachial index (ABI):

SBP ratio (normal: >=1)


ABI <0.9 : 95% sensitive for PAD
ABI 050.8 with claudication: critical limb ischemia
ABI <0.5 or ankle BP <55mmHG: poor ulcer healing

MR angiography: 95% sensitivity and specificity


Contrast angiography

Peripheral artery diseasestreatment


Risk factor modification
Control DM, HTN, smoking cessation
Antiplatelet therapy: ticlopidine, plavix
Exercise: improve maximal walking distance than
PTA
Angioplasty / stents and surgery

Trental: RBC flexibility and anti-inflammatory


Pletal: unknown
Beta-blocker: controversial

Thromboangitis obliterans

Young smokers
Medium and smalll vessels of the arms
Cause unknown? Type I and III collagen
Pain, digit ulceration, Raynaud phenomenon
Abnormal allen test (2/3)
Tx: Cessation smoking, prostacyclin analogue,

Acute limb ischemia

Arterial embolism (Af)


thrombosis with plaque ruprure
dissection,
trauma

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