Post on 21-Dec-2015
Diseases of the aorta
Heart Disease
Braunwald
CV R4 李威廷醫師Supervisor: 李貽恆醫師
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 >4—5 cm; expanding rapidly (>0.5 cm/year)
• Coronary angiography• Medication control: Hyperlipidemia,
hypertension, cigarette smoking
• CT follow up every 3—6 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: 60—70 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: 100—120mmHg,
• mean BP: 60—75mmHg
• 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 李威廷醫師Supervisor: 李貽恆醫師
Jul 1st , 2004
Peripheral artery diseases
< 60 y/o population: <3%> 75 y/o population: >20%
Peripheral artery diseases—risk factors
Peripheral artery diseases
Peripheral artery diseasesIntermittent 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 05—0.8 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 diseases—treatment
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