Aortic Disorders

risk factors for getting a TAA

(MaaaK) atherosclerosis (associated risks like HLD, HTN, tobacco, obesity) presence of other aneurysms male prior aortic dissection chest trauma aortitis known famhx age

risk factors for aortic dissection

(Pregnant Bicuspid Hearts Coordinate Cardiac Marriage) HTN male inflammatory diseases aortic aneurysm RF's atherosclerosis vasculitis turner syndrome trauma cocaine use coarctation prior cardiac surgery collagen vascular disorders - Marfan's congenital aortic abnormalities prior aortic valve surgery high intensity weights/exercise pregnancy bicuspid aortic valve

common findings of coarctation of the aorta

-systolic murmur at LUSB, radiates to back -systolic HTN in upper extremity -brachial/radial-femoral pulse delay -weak or unobtainable LE pulses -CXR shows "3" sign and rib notching

in most adults, an aortic diameter >/= _____cm is considered aneurysmal

3

AAA rarely rupture at less than _____cm

5

only _____% of surgery patients from a ruptured AAA survive

50

TAA's occur when there is > ______% increase in diameter. and ______% of patients are asymptomatic

50 95

USPSTF recommends a one time screening for AAA's by US in men ages ____-_____ who have ever smoked also in males _____years or older with a sibling or parent who had an AAA. also in females _____or older with history of smoking or famhx

65-75 55 65

aneurysm rupture/dissection has a_______% mortality rate

90

when can AAA patients elect to repair with open or endovascular surgery?

>/= 5.5 cm rapid expansion of AAA

elevated _____-________ can help confirm clinical suspicions of aortic dissection

D-dimer

complications of coarctation of the aorta

HTN aortic aneurysm aortic dissection re-coarctation pregnancy risk rupture/dissection ICH left sided HF

in adults, the classic presenting sign of coarctation of the aorta is

HTN claudication (pain in lower extremities with exertion)

gold standard TAA diagnostic test

MRI angiography

what genetic/developmental diseases can lead to TAA?

Marfan's Loeys-Dietz Ehlers-Danlos congenital bicuspid valve

abnormal production or degradation of the structural components of the aortic wall: elastin and collagen

TAA

what are some complications of TAA repair?

TAA rupture paraplegia stroke Thoracic aortic dissection

MC diagnostic measure for TAA

TEE (Transesophageal echo)

diagnostic test of choice if suspected acute Type A aortic dissection or if patient is hemodynamically unstable

TEE at bedside in ER or OR

2/3 of aortic aneurysms are ___________ and 90% are at or below __________ _______

abdominal renal arteries

what imaging do you use to screen for an AAA?

abdominal US

what imaging do you order for an asymptomatic patient who has an AAA?

abdominal US CT and MRI for pre-op planning and post-op follow up

MC true arterial aneurysm

abdominal aortic aneurysm

how do patients feel when they become symptomatic of TAA?

acute chest, back, neck or abdominal pain compression symptoms if rupture - hypotension, shock, sudden death

what kinds of things degenerate elastin and collagen in the aortic wall, leading to TAA?

aging tobacco HTN atherosclerosis

how often do you obtain imaging with US for a patient who has an AAA that is less than 4.5 cm? what if it is >/= 4.5 cm?

annually every 6 months

thoracic aortic dissections can cause (3)

aortic regurgitation cardiac tamponade end organ ischemia

MC locations for TAA's

aortic root ascending aorta descending aorta

how do you manage an aortic dissection?

ascending (type A) requires immediate surgery descending (type B) needs medical management, pain control, reduce BP with esmolol or labetalol to SBP 100-120 within 20 minutes, nitro, surgery if doesn't resolve long term, do life-long control of BP with BB or CCB, or minimally invasive endovascular stent grafting

what are the 4 main categories of TAA's?

ascending aortic aneurysm aortic arch aneurysm descending aortic aneurysm thoracoabdominal aneurysm

what are the symptoms in a non-ruptured AAA?

asymptomatic abd/back or flank pain abd bruit pulsatile abdominal mass thromboembolic complications limb ischemia

risk factors for AAA's

atherosclerosis male age smoking famhx caucasian other large vessel aneurysms connective tissue disorders HLD

how do we treat coarctation of the aorta

balloon angioplasty followed by stent + aggressive bp control

why do TAA's present in so many different ways?

because of branching with the brachiocephalic trunk: right and left carotid arteries/right and left subclavian arteries

coarctation of the aorta is associated with

bicuspid aortic valve VSD (Ventricular septal defect) PDA (patent ductus arteriosus)

stent-graft is used to line the aorta and exclude the aneurysm sac from circulation

endovascular surgical repair

affects the entire circumference of a segment of the vessel, resulting in a diffusely dilated artery - mostly symmetrical. what appearance is this?

fusiform

post surgical prognosis is (good/bad), but the leading cause of death in post surgical patients is

good MI

when can you do surgical repair in an asymptomatic TAA patient?

if TAA is 5.5 cm (Ascending or descending) if TAA is 6-7cm (For descending with high surgical risk) if TAA is > 4.5cm and genetically mediated if TAA has an accelerated rate of growth of 0.5cm/6months if there is evidence of dissection

what physiologically happens when aging, tobacco, HTN, and atherosclerosis break down the aortic wall?

inflammation oxidative stress proteolysis biomechanical wall stress

uncommon but important risk factors of TAA

inflammatory disorders (Giant cell/temporal arteritis, takayasu arteritis, RA) genetic predisposition connective tissue disorders (Marfan, ehlers danlos, turner syndrome) coarctation of the aorta

a true aneurysm must involve all 3 layers of the arterial wall. what are those layers?

intima media adventitia

risk factors for AAA rupture

large aneurysm diameter HTN smoking rapid expansion > 1 cm/year decreased FEV1 history of cardiac or renal transplant female symptoms

a ruptured AAA is a _____Event. ____% die before reaching the hospital

lethal 50

who gets screened for AAA?

males 65-75 with history of smoking

thoracic aortic dissections can propogate proximally or distally or bleed into the _________

media (hematoma)

what modifiable risk factor is most likely to cause rupture of an AAA?

ongoing tobacco use

does endovascular or open surgical repair of AAA have more complications?

open surgical repair

replacement of diseased aortic segment with tube or bifurcation prosthetic graft

open surgical repair

when do AAA patients get urgent surgical repair?

pain, tenderness, indicating impending rupture regardless of diameter

where is rib notching usually observed?

posterior 1/3 of ribs 3-8

the rate of growth of TAA's is _______. Serial CT and MR angiography studies should be performed using the same _________technique at the same _______

progressive imaging center

collection of blood leaking out of artery but confined next to vessel surrounding tissue

pseudo-aneurysm/false aneurysm

how do you manage asymptomatic TAA patients?

reduce CV risk (stop smoking, take a statin, etc.) Control BP (goal is 105-120) educate patient on S/S screen for other aneurysms screen for genetically mediated disease repeat serial imaging every 3-6 months after initial study, then annually if no growth. continue with 3-6 months if growth.

involves only a portion of the circumference, resulting in an outpouching of the vessel wall - asymmetrical. what appearance is this?

saccular (Berry)

what are the S/S of a ruptured AAA?

severe pain syncope hypotension palpable abdominal mass excruciating abd pain radiating to back grey-turner sign/cullen's sign (cullen is purple around umbilicus and grey-turner is at flank)

what is the clinical triad for aortic dissection?

sharp abdominal pain (Tearing or ripping in character) variation in pulse (blood pressure difference of 20mmHg between right and left arms) mediastinal and/or aortic widening on CXR

conservative management for patients with AAA <5.5 cm

smoking cessation aspirin statin surveillance refer if > 4.5 cm urgent referral if symptomatic

aortic dissection types

stanford debakey

what are the classifications of abdominal aortic aneurysms?

suprarenal AAA pararenal AAA juxtarenal AAA infrarenal AAA

what infections can lead to TAA?

syphilis TB mycotic

what vasculitis syndromes can lead to TAA?

takayasu's giant cell arteritis

what is an aortic dissection?

tear in aortic intima (uncommon, but catastrophic caused by cystic necrosis or trauma)

what is laplace's law?

tension = pressure x radius

what locations can aortic aneurysms be?

thoracic (aortic root, ascending, or descending) abdominal thoracoabdominal

TAA means?

thoracic aortic aneurysm

segmental full thickness dilation of a blood vessel having at least 50% increase in diameter compared with normal

true aneurysm

why is the MC site of an AAA at or below the renal arteries?

tunica media composition has less collagen and elastin below the renal arteries

what imaging do you order for a hemodynamically stable symptomatic AAA patient?

urgent abdominal CT

what imaging do you order for a hemodynamically unstable symptomatic AAA patient?

urgent abdominal CT +/- abdominal US

how do you manage a symptomatic TAA?

urgent repair

key findings of TAA on xray

widening of mediastinum enlargement of aortic knob displacement of trachea from midline

how do we diagnose coarctation of the aorta?

echo MRI/CT

classic presentation of AAA

elderly male smoker CAD emphysema renal impairment

Diagnostic of choice for TAA in the ER

CT angiography with contrast

diagnostic test of choice if patient is hemodynamically stable

CTA MRA

most coarctations of the aorta are found in (children/adults)

children

narrowing of descending aorta typically at the isthmus

coarctation of the aorta

if you decide to do surgery on an AAA, the risk for perioperative morbidity and mortality increases with

coexistent CAD smokers with COPD older female patients with renal dysfunction

TAA pathophysiology

degeneration fusiform aneurysms affecting proximal aorta change in aortic compliance aneurysm formation atherosclerosis in descending aorta exacerbates medial degeneration aortic ulcers --> dissection or rupture mycotic aneurysms --> infection damaging the wall

what does the murmur of aortic regurgitation sound like? aka?

diastolic decrescendo murmur heard best at Erb's point/base, sometimes at apex. austin flint murmur

complications of TAA

dissection rupture death