Aortic Dissection, Aortic Syndromes & Aneurysmal Diseases by KEYUR.pptx

Acute aortic syndromes

1. Aortic Dissection Aortic Syndromes & Aneurysmal Diseases Presented by: Dr. Keyur Bhimani Guided by: Dr. SARBARI SWAIKA (hod AND Professor) Department of Emergency Medicine Dr. D.Y. Patil Medical College, Hospital & Research Centre

2. 🔹 Acute Aortic Syndromes Overview Definition : Spectrum of life-threatening aortic conditions. Includes: Aortic Dissection, Intramural Hematoma (IMH), Penetrating Atherosclerotic Ulcer (PAU). Need for Rapid Diagnosis Mortality increases 1-2% per hour untreated.

3. 🔹 Anatomy of the Aorta Ascending Aorta Aortic Arch Descending Thoracic Aorta Abdominal Aorta Wall Layers : Intima (inner) Media Adventitia (outer )

4. Anatomy The gross anatomy of the aorta is divided into the following segments: ( 1) aortic root; ( 2) sinotubular junction; ( 3) ascending aorta; ( 4) aortic arch; ( 5) isthmus and descending (thoracic) aorta; and ( 6) abdominal aorta.

5. The basic components of the aorta are the intima , media , and adventitia .

6. 🔹 Aortic Dissection

7. 🔹 Pathophysiology Aortic layers: Intima, Media, Adventitia Tear in intima → blood enters media → forms a false lumen . Propagation may cause malperfusion or rupture. Complications: limb ischemia, stroke, renal failure, cardiac events

8. 🔹 Case Presentation 56-year-old male with tearing chest pain to back History: Hypertension, hyperlipidemia, smoking Vitals: Hypotension, Tachycardia, SpO2 95% Exam: Muffled heart sounds, JVD

9. 🔹 Critical Bedside Actions ABC assessment Oxygen, large-bore IV access 20 ml/kg crystalloid bolus Fluid bolus even if unclear etiology in cases of hypotension

10. 🔹 History Taking Hints Sudden, maximal 'ripping' chest pain Pain migration possible Risk factors: HTN, Marfan’s , Ehlers- Danlos , cocaine use

11. 🔹 Physical Examination Hints Shock signs, BP difference >20 mmHg Heart sounds: Muffled, Diastolic murmur Neuro and abdominal exams

12. 🔹 Classification of Aortic Dissection Stanford Classification : Type A: Ascending Aorta involvement. Type B: Descending Aorta only . DeBakey Classification : I: Ascending, Arch, Descending II: Ascending only III: Descending only

13. 🔹 Risk Factors Hypertension (most important) Connective tissue disorders (e.g., Marfan syndrome) Bicuspid Aortic Valve Trauma Cocaine use Aging Family history Smoking Atherosclerosis

14. 🔹 Clinical Features Sudden , tearing chest/back pain Syncope, Dyspnea Pulse deficits, Murmur of AR Neurological deficits (stroke )

15. 🔹 Differential D iagnosis Clinical DDx: ACS Pulmonary embolism Pneumothorax Aortic regurgitation without dissection Oesophageal rupture Tamponade Pericarditis

16. 🔹 Emergency Diagnostics ECG: Normal or ACS mimic Echo: Tamponade , dissection flap CXR: Widened mediastinum Labs: CBC, Coagulation, Cardiac enzymes

17. 🔹 Aortic Dissection Detection-Risk Score (ADD-RS ) The goal is to rapidly identify patients at high risk and to provide a framework for additional diagnostic testing based on a pretest probability of disease. It is known as the aortic dissection detection-risk score (ADD-RS) Aortic Dissection Detection-Risk Score (ADD-RS) , which assigns points based on specific high-risk conditions, pain features, and examination findings to aid in identifying the likelihood of aortic dissection .

18. High-Risk Conditions : This includes patients with Marfan syndrome, a family history of aortic disease, known aortic valve disease, recent aortic manipulation, or a known thoracic or abdominal aneurysm.  It is score of 1. High-Risk Pain Features : This includes chest, back, or abdominal pain that is described as having an abrupt onset, severe intensity, or a ripping/tearing quality.  The presence of such pain features also contributes a score of 1 .

19. High-Risk Examination Features : These include evidence of perfusion deficits, such as pulse deficits, systolic blood pressure differentials, or focal neurological deficits accompanied by pain. Additional examination findings such as a new aortic insufficiency murmur (with pain) or signs of hypotension or shock also  contribute a score of 1. Each criterion carries a score of 1 .

20. If the score is 0 or 1, a D- dimer level is taken. If it is <500 ng /ml, the workup for AD is halted. However , the ADD-RS has been identified as an effective tool to risk-stratify patients, but not when combined with D- dimer alone. Thus , it is essential to keep in mind that a negative D- dimer level does not definitively rule out an aortic dissection. If the D- dimer level is >500 ng /ml, CTA is considered . A score of 2 or 3 classifies the patient as high risk, and CTA or other confirmatory imaging must be performed.

21. 🔹 Diagnostic Approach First-Line : CT Angiography (Gold Standard) Others : TEE (unstable patients) MRI (best tissue detail but slower) Supportive : D- dimer (high negative predictive value)

22. Left: Parasternal long axis: Enlarged aortic root, intimal flap. Right: Type B dissection diagnosed by colour Doppler TEE showing a turbulent flow through a secondary tear from the true lumen to false lumen

23. S uprasternal N otch V iew

24. 🔹 Emergency Treatment: Hypotension IV fluid bolus (20 ml/kg) Vasopressors if needed Pericardiocentesis if tamponade Blood transfusion if bleeding

25. 🔹 Emergency Treatment: Hypertension BP target: SBP 100–120 mmHg, HR 60–80 bpm IV Beta-blockers ( Labetalol ) Calcium channel blockers Adjunct: Sodium Nitroprusside

26. 🔹 Management of Aortic Dissection Type A (Ascending): Emergency surgery . Type B (Descending): BP control (Beta-blockers), Medical management .

27. 🔹 Prognosis Early surgery reduces mortality drastically. Type B favorable if uncomplicated . Mortality: Type A (surgery 26%, no surgery 58%), Type B (medical 11%, surgical 31 %)

28. 🔹 IMH INTRAMURAL HEMATOMA

29. 🔹 INTRAMURAL HEMATOMA (IMH) Definition : Hematoma within aortic wall without intimal tear Symptoms: Severe chest, back, or abdominal pain

30. 🔹 The diagnosis of IMH is based on: Focal crescentic thickening of the aortic wall of ≧5 mm in aortic wall with a smooth inner surface. Displaced intimal calcification inwardly. Absence of flap, intimal Tear, or flow within the hematoma. NCCT: a hyperattenuating rim or crescent along the curvature of an aortic wall. CECT: non-enhancing low attenuation rim

31. 🔹 Echocardiographic signs for diagnosis of IMH : Areas of echolucency within the aortic wall and no intimal flap or flow in the aortic wall Focal thickening of the aortic wall: Normal aortic wall thickness is < 3mm. Wall thickness must be > 5-7mm to be diagnostic for IMH. Presence of mixed echogenicity within the aortic wall. Absence of intimal flap, and false lumen. Absence of detectable internal flow: employment of color doppler flow is important to differentiate IMH from AD; The luminal surface in IMH tends to be smooth and continuous .

32. 🔹 PAU PENETRATING AORTIC ULCER

33. 🔹 Penetrating Aortic Ulcer Definition: Atherosclerotic plaque rupture causing wall discontinuity Common Site: Descending thoracic aorta Typical Patient: Men aged 70–80 years 🔹 Symptoms of Penetrating Aortic Ulcer Sharp chest, back, or abdominal pain Hemoptysis or hematemesis if rupture occurs Sometimes incidental finding on imaging

34. 🔹 PAU diagnostic findings Extensive atherosclerosis with severe intimal calcifications and atherosclerotic plaques. Focally displaced and separated intimal calcifications. Contrast extravasation . Focal IMH, with longitudinal spread limited by media fibrosis. Possibly enhancing an aortic wall .

35. 🔹 Aneurysmal Diseases

36. 🔹 Case Presentation 75-year-old obese male History: COPD, Hypertension, Smoker Symptoms: Sudden flank/back pain (2 hrs) Vitals: HR 98 | RR 24 | BP 190/105 | T 36.9°C Mild abdominal tenderness Ultrasound: 8 cm Aneurysm

37. 🔹 Case Questions Ultrasound: Large AAA (8 cm) Risk of rupture: Extremely High (>7 cm)

38. 🔹 Introduction AAA rupture is fatal if untreated Mortality: 85-90% post-rupture Early diagnosis critical

39. 🔹 What is AAA? Localized dilation >50% normal aortic diameter Clinical AAA if aorta >3 cm

40. 🔹 Aneurysmal Diseases Aneurysm Types : Thoracic (TAA) Abdominal (AAA ) Symptoms : Often asymptomatic. Rupture = sudden death .

41. 🔹 Causes of AAA Atherosclerosis Genetic ( Marfan's , Ehlers- Danlos ) Infections (Syphilis, Salmonella) Smoking, Aging

42. 🔹 Epidemiology Men > Women (4-5x) White > Other ethnicities Age >55 Risk factors: Smoking, Emphysema, Family History

43. 🔹 Types of AAA Saccular : Outpouching with neck Fusiform : Circumferential Pseudoaneurysm : Adventitia only Mycotic : Infection-related

44. 🔹 Clinical Presentation Classic Triad (rare): - Abdominal/back pain - Pulsatile mass - Hypotension Symptoms often subtle

45. 🔹 Bedside Management Airway, Breathing, Circulation Immediate surgical consult if rupture Blood transfusion ready

46. 🔹 Differential Diagnoses Renal colic Diverticulitis GI bleed Myocardial infarction Musculoskeletal back pain

47. 🔹 History & Physical Examination Deep palpation above umbilicus Doughy abdomen (retroperitoneal bleed) Obesity reduces palpation accuracy

48. 🔹 Diagnostic Tests Labs: Type & cross match, CBC, Coag ulation profile Imaging: - Ultrasound: Bedside, quick - CT Angiography: Gold standard - MRI: Limited use

49. 🔹 Emergency Treatment Stabilize patient Intubate if unstable Fluid and blood resuscitation Surgery is definitive treatment

50. 🔹 Management of Aneurysms Surveillance : AAA <5.5cm: Monitor every 6-12 months . Surgery Indicated If : AAA >5.5cm TAA >6.0cm Rapid growth > 0.5cm/year

51. 🔹 Indications for Repair Symptomatic AAA Aneurysm >5.5 cm (men), >5.0 cm (women) Rapid expansion or rupture

52. 🔹 Repair Options Open Repair Endovascular Aneurysm Repair (EVAR)

53. 🔹 Risk of Rupture <5.5 cm: <1%/year >5.5 cm: 9-32%/year >7 cm: Extremely high risk

54. 🔹 Disposition Immediate OR if unstable/ruptured ICU if high-risk stable Outpatient if small & asymptomatic

55. 🔹 Clinical Key Points Asymptomatic until rupture High mortality without early diagnosis Screening: Smokers/men 65-75 yrs Early repair critical

56. 🔹 Summary Acute aortic syndromes are medical emergencies. Early imaging is key. Type A: Surgery; Type B: BP control. AAA screening prevents catastrophic ruptures . Remember that chest pain with an elevated troponin does not rule out ‘AD’. Patients with ‘AD’ can present with neurologic deficit, chest pain etc. that may initially make you think about ischemic CVA and STEMI. “Recognize, diagnose, act fast — that saves lives.”

57. 🔹 THANK YOU 🔹