Aortic Disease Lecture
Transcript of Aortic Disease Lecture
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Aortic EmergenciesAortic Emergencies
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ObjectivesObjectives
Abdominal aortic aneurysmsAbdominal aortic aneurysms
Mycotic aneurysmsMycotic aneurysms
Aortic dissectionAortic dissection
Epidemiology and pathophysiologyEpidemiology and pathophysiology
Clinical presentation and diagnosisClinical presentation and diagnosis
ManagementManagement
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Abdominal AorticAbdominal Aortic
Aneurysm (AAA)Aneurysm (AAA) Most common site of arterialMost common site of arterial
aneurysmaneurysm
Most commonly infrarenalMost commonly infrarenal 15-37 cases per 100,000 life years15-37 cases per 100,000 life years
15,000 deaths annually15,000 deaths annually
! " # o$er age 50 ! " # o$er age 50 %re$alence increases &ith age%re$alence increases &ith age
'are in &omen under 55 yrs'are in &omen under 55 yrs
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AAAAAA
AgeAge
(mo)ing(mo)ing
AtherosclerosisAtherosclerosis
*amily +istory*amily +istory
MenMen CC
+ypertension+ypertension
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AAAAAA
.rue $s .rue $s
pseudoaneurysmpseudoaneurysm
ElastinElastin CollagenCollagen
/nammation/nammation
atural historyatural history
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AAAAAA
2sually asymptomatic until2sually asymptomatic until
rupturerupture
%hysical eam%hysical eam
4ac) painabdominal pain &ith4ac) painabdominal pain &ith
syncopesyncope
6reat masuerader6reat masuerader
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AAAAAA
Clinical diagnosisClinical diagnosis
2ltrasound2ltrasound
C.C.
M'/M'AM'/M'A
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Aortic Repair SurgeryAortic Repair Surgery
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AAAAAA
'is) of rupture related to si8e'is) of rupture related to si8e 9arger aneurysms gro& faster9arger aneurysms gro& faster :bser$e:bser$e Electi$e repairElecti$e repair Emergent repairEmergent repair
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Aortic Stent GraftAortic Stent Graft
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Aortic Stent GraftAortic Stent Graft
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Thoracic AorticThoracic Aortic
AneurysmAneurysm ; cases per 100,000 patient years; cases per 100,000 patient years
Most commonly in ;Most commonly in ;thth < 7< 7thth decadesdecades
MalesMales
+ypertension+ypertension
CC
asculitisasculitis
AtherosclerosisAtherosclerosis
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Thoracic AorticThoracic Aortic
AneurysmAneurysm %ain%ain
C+*C+*
Myocardial ischemiaMyocardial ischemia
Mediastinal erosionMediastinal erosion
eurologic manifestationseurologic manifestations
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Thoracic AorticThoracic Aortic
AneurysmAneurysm C='C='
C.C.
M'/M'/
AngiographyAngiography
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Thoracic AorticThoracic Aortic
AneurysmAneurysm AscendingAscending ArchArch escendingescending Cra&ford Classi>cationCra&ford Classi>cation
! .ype /? %roimal descending to proimal .ype /? %roimal descending to proimalabdominalabdominal
! .ype //? %roimal descending to infrarenal .ype //? %roimal descending to infrarenal! .ype ///? istal descending &ith abdominal .ype ///? istal descending &ith abdominal
! .ype /? %rimarily abdominal .ype /? %rimarily abdominal
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Thoracic AorticThoracic Aortic
AneurysmAneurysm Management based on si8e andManagement based on si8e and
locationlocation
Medical managementMedical management! 4lood pressure control4lood pressure control
! (erial imaging(erial imaging
! (ur$eillance for signs and symptoms(ur$eillance for signs and symptomsof gro&th or lea)agof gro&th or lea)ag
! 4 bloc)ers4 bloc)ers
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Thoracic AorticThoracic Aortic
AneurysmAneurysm (urgical indications(urgical indications
! (ymptoms(ymptoms
! 5 ! ; cm si8e in ascending aorta5 ! ; cm si8e in ascending aorta
! ; ! 7 cm in descending aorta; ! 7 cm in descending aorta
! gro&th @ 1 cm per yeargro&th @ 1 cm per year
! E$idence of dissectionE$idence of dissection! Arch and Cra&ford // ha$e highestArch and Cra&ford // ha$e highest
morbidity and mortality after repairmorbidity and mortality after repair
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ycotic Aneurysmycotic Aneurysm
%rimary or secondary%rimary or secondary
(eptic emboli(eptic emboli
Contiguous infecti$e focusContiguous infecti$e focus
.rauma .rauma
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ycotic Aneurysmycotic Aneurysm
Arterial traumaArterial trauma
4acterial endocarditis4acterial endocarditis
9ocal or concurrent infection9ocal or concurrent infection /mmunosuppressed/mmunosuppressed
AgeAge
(taphylococcus, (almonella,(taphylococcus, (almonella, .reponema .reponema
MycobacteriumMycobacterium
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ycotic Aneurysmycotic Aneurysm
%ainful, pulsatile mass in contet%ainful, pulsatile mass in contet
of fe$erof fe$er
:$erlying inammation in /2:$erlying inammation in /2 ComplicationsComplications
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ycotic Aneurysmycotic Aneurysm
9eu)ocytosis, anemia9eu)ocytosis, anemia
4lood cultures4lood cultures
/maging/maging
.reatment .reatment
! (urgery(urgery
! Antibiotics for at least " &)sAntibiotics for at least " &)s
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Aortic !issectionAortic !issection
5-30 cases per5-30 cases per
million people permillion people per
yearyear
MaleMale
+ypertension,+ypertension,
atherosclerosisatherosclerosis
%re-eisting aortic%re-eisting aortic
diseasedisease
CC
.rauma .rauma
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Aortic !issectionAortic !issection
(hear stress(hear stress
/ntimal tear/ntimal tear
Cystic medial necrosisCystic medial necrosis
*alse lumen*alse lumen
/ntramural hematoma/ntramural hematoma Aortic ulcersAortic ulcers
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Aortic !issectionAortic !issection
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Aortic !issectionAortic !issection
StanfordStanford"lassi#cation"lassi#cation
Type A$Type A$ascendingascendingaortaaorta
Type %$ aortaType %$ aorta
distal to leftdistal to leftsubclaviansubclavian
e4a)eye4a)eyClassi>cationClassi>cation
.ype /? both .ype /? bothascending andascending anddescendingdescending
.ype //? only .ype //? only
ascending aortaascending aorta .ype ///? only .ype ///? only
descending aortadescending aorta
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Aortic !issectionAortic !issection
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Aortic !issectionAortic !issection
(tanford(tanfordClassi>cationClassi>cation
.ype A? .ype A?ascending aortaascending aorta .ype 4? aorta .ype 4? aorta
distal to leftdistal to left
subcla$iansubcla$ian
!e%a&ey!e%a&ey"lassi#cation"lassi#cation
Type '$ bothType '$ bothascending andascending anddescendingdescending
Type ''$ onlyType ''$ onlyascending aortaascending aorta
Type '''$ onlyType '''$ onlydescendingdescendingaortaaorta
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Aortic !issectionAortic !issection
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Aortic !issectionAortic !issection
%ain is the most common%ain is the most common
presenting complaintpresenting complaint
! Abrupt more speci>c thanAbrupt more speci>c thandescriptiondescription
Cardiac manifestationsCardiac manifestations
eurologic manifestationseurologic manifestations isceral organ in$ol$mentisceral organ in$ol$ment
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Aortic !issectionAortic !issection
igh clinical suspicionigh clinical suspicion
Smooth muscle myosin heavySmooth muscle myosin heavy
chainchain "R"R
C.C.
2ltrasound2ltrasound M'/M'/
AngiogramAngiogram
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Aortic !issectionAortic !issection
9ac)s speci>city9ac)s speci>cityalonealone
MediastinalMediastinal&idening&idening Altered aorticAltered aortic
con>gurationcon>guration
isplacedisplacedcalci>cationscalci>cations
%leural eusion%leural eusion
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Aortic !issectionAortic !issection
+igh clinical suspicion+igh clinical suspicion
C='C='
"T"T
2ltrasound2ltrasound
M'/M'/
AngiogramAngiogram
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Aortic !issectionAortic !issection
S"T angioS"T angio
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Aortic !issectionAortic !issection
.&o distinct .&o distinct
lumenslumens
+elical+elical Allo&s $isuali8ationAllo&s $isuali8ation
of lesion and otherof lesion and other
structuresstructures
%atient must lea$e%atient must lea$ethe Ethe E
ContrastContrast
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Aortic !issectionAortic !issection
+igh clinical suspicion+igh clinical suspicion
C='C='
C.C.
*ltrasound*ltrasound
M'/M'/
AngiogramAngiogram
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Aortic !issectionAortic !issection
.EE better than .EE better than
..E ..E
4edside test4edside test :perator:perator
dependentdependent
4lind spots4lind spots
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Aortic !issectionAortic !issection
+igh clinical suspicion+igh clinical suspicion
C='C='
C.C.
2ltrasound2ltrasound
R'R'
AngiogramAngiogram
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Aortic !issectionAortic !issection
(ensiti$e and(ensiti$e and
speci>cspeci>c
o contrasto contrast .ime consuming .ime consuming
ot &idelyot &idely
a$ailablea$ailable
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Aortic !issectionAortic !issection
+igh clinical suspicion+igh clinical suspicion
C='C='
C.C.
2ltrasound2ltrasound
M'/M'/
AngiogramAngiogram
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Aortic !issectionAortic !issection
(ensiti$e and(ensiti$e and
speci>cspeci>c
/n$asi$e/n$asi$e .ime consuming .ime consuming
Can be doneCan be done
intraoperati$ely ifintraoperati$ely if
neededneeded
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Aortic !issectionAortic !issection
+igh clinical suspicion+igh clinical suspicion
C='C='
C.C.
2ltrasound2ltrasound
M'/M'/
AngiogramAngiogram
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Aortic !issectionAortic !issection
Medical managementMedical management
! ecrease stress on &allecrease stress on &all
! 4 bloc)ers4 bloc)ers! asodilatorsasodilators
(urgical inter$ention(urgical inter$ention
! Any dissection in$ol$ing the ascendingAny dissection in$ol$ing the ascending
aortaaorta
! (ymptomatic or complicated descending(ymptomatic or complicated descending
aortic dissectionsaortic dissections
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SummarySummary
Clinical suspicion is )eyClinical suspicion is )ey
iagnosis based on clinicaliagnosis based on clinical
presentation and imagingpresentation and imaging Anatomy and si8e determineAnatomy and si8e determine
managementmanagement
/n$ol$e consultations early as/n$ol$e consultations early asemergent surgery is oftenemergent surgery is often
necessarynecessary
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Spotlight Case January 2004
Crushing Chest Pain:A Missed Opportunity
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Case: Crushing Chest Pain
A 62-year-old female presented with 12 hoursof crushing chest pain. Her blood pressure was140/90, heart rate 110, and respiratory rate 16.
An EKG revealed left ventricular hypertrophywith strain. Review of the chest x-ray in theemergency department (ED) revealed noabnormalities. She was treated for an acute
coronary syndrome (ACS) with heparin, aspirin,morphine, and a nitroglycerin drip. Cardiacenzymes were drawn.
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The patient was admitted to the cardiac careunit. Seven hours after admission, the patientbecame hypotensive, with a systolic blood
pressure in the 80s and a heart rate in the120s. A repeat EKG revealed no significantchanges. Right-sided leads showed no
evidence of right ventricular infarct. The firstset of cardiac enzymes was equivocal, and aCPK-MB was minimally elevated.
Case (cont.): Crushing Chest Pain
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Chest Pain in the Emergency Dept.•Chest pain is a common complaint inthe ED
•Correct and timely diagnosis is criticaland linked to morbidity and mortality inmany diagnoses
–Acute coronary syndrome
–Pulmonary embolism
–Aortic dissection
.
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Diagnosis of Chest Pain in the ED
von Kodolitsch Y, et al. Arch Intern Med. 2000;160:2977-82.
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Case (cont.): Crushing Chest PainThe team re-reviewed the chest x-rayand discovered an abnormality in the
aorta: a 1-cm separation between theintimal calcification and the adventitialoutline of the descending aorta (the
“calcium sign”), consistent with aorticdissection.
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Chest X-ray with Calcium Sign (arrow)
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Aortic Dissection•Mortality rates approach 1% per hour
•Diagnosis is missed in 25%-50% ofpatients
•Survival exceeds 90% with promptdiagnosis and management
Spittell PC, et al. Mayo Clin Proc. 1993;68:642-51. Klompas M. JAMA. 2002;287:2262-72. Nienaber CA, et al. N Engl J Med. 1993;328:1-9.
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Aortic Dissection
•Classic presentation includes acute-onset,severe chest/back pain described as “tearing”or “ripping”
•Atypical presentations are common–15% of patients report NO pain
•Supportive findings include pulse deficit, newaortic regurgitation, tamponade, and focal
neurological deficits•Majority of patients have no specific physicalfindings
Spittell PC, et al. Mayo Clin Proc. 1993;68:642-51.Hagan PG, et al. JAMA. 2000;283:897-903.
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Aortic Dissection: Physical Exam Findings
Klompas M. JAMA. 2002;287:2262-72.
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Aortic Dissection•90% of patients with aortic dissection have anabnormal CXR
•Abnormal aortic contour and widenedmediastinum are the most common findings
•A NORMAL CXR DOES NOT RULE OUTAORTIC DISSECTION!
Spittell PC, et al. Mayo Clin Proc. 1993;68:642-51.Hagan PG, et al. JAMA. 2000;283:897-903.
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Aortic Dissection: CXR Findings
Klompas M. JAMA. 2002;287:2262-72.
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Case (cont.): Crushing Chest Pain A transesophageal echocardiogram revealed anascending aortic dissection. Anticoagulation
therapy was discontinued, beta-blocker therapy wasinitiated, and cardiothoracic surgery was called. The patient was transported to the operating room.Upon arrival in the operating room, the patient
became progressively hypotensive, coded, anddied. Post-mortem autopsy revealed hemorrhageinto the pericardium.
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Transesophageal Echocardiography of
Aortic Dissection
Video
http://webmm.ahrq.gov/spotlightcases.aspx?ic=45http://webmm.ahrq.gov/spotlightcases.aspx?ic=45
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What are risk factors you would
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yask about for cardiac etiologies
for chest pain?• Smoking
• Family history
• Hyperlipidemia• Left ventricular hypertrophy
• Hypertension
• Cocaine• ge
• !ast History
What characteristics of the chest
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pain might make you more
concerned for cardiac chest pain?• Location
• ssociated Symptoms
• "uality• Chronology
• #nset
• $uration
• %ntensity
• &'acerbating• (elieving
• Situation
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ny e'am findings that might
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y g ghelp distinguish cardiac from non
cardiac chest pain?• General Appearance
– may suggestseriousness ofsymptoms.
• Vital signs – marked difference in
blood pressure betweenarms suggests aorticdissection
• Palpate the chest wall – Hyperesthesia may be
due to herpes zoster
• omplete cardiace!amination – pericardial rub
– signs of acute A" or A# – "schemia may result in
$" murmur% #& or #'
• (etermine if breathsounds are symmetricand if wheezes%crackles or e)idence ofconsolidation
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ny tests that might help that
you can do in the &(?• &)*
+ S, elevation of - .mm or new " in / leads
• Sens 012 + bove 3 S, depression or ,4wave inversion
• Sens 562
• False positive rate 7 .52
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ny tests that might help that
you can do in the &(?• ,roponin8 C)8 myoglobin
+ C)49: ;;46
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What is your differential?
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What e'am findings might you
look for?• cute 9%
• Hypotension in one e'tremity
•ortic murmur • Aeurologic deficits8 including paraplegia8 stroke8 ordecreased consciousness
• Syncope8 tamponade8 and sudden death due to
rupture of the aorta into the pericardial space• Shock8 hemothora'8 and e'sanguination
• cute lower e'tremity ischemia
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6= percent of acute aortic dissections can be
identified based upon some combination of the
following three clinical features. %mmediate onset of aortic pain with a tearing
and@or ripping character
/ 9ediastinal and@or aortic widening on chest
radiograph> Bariation in pulse and@or blood pressure between
the right and left armBon kodolitsch 8 SchwartD *8 Aienaber C Clinical prediction of acute aortic
dissection rchives of %nternal 9edicine /
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What tests could you do and
why?• CG(4sensitivity =>2
• C, sensitivity 6028 specificity ;52
• ,&&
• 9(% sensitivity 6;28 specificity ;12
• ortogram sensitivity ;;28 specificity 602
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Chest !ain in the
&mergency $epartment
&sther Chen8 9$ssistant !rofessor
$epartment of &mergency 9edicine
niversity of !ennsylvania
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I,he :ig FiveJFive life4threatening causes of Chest !ain
• cute coronary syndrome
• ortic dissection• !ulmonary &mbolism
• ,ension !neumothora'
• Esophageal Rupture
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,he %mmediate *oals
. :CKs@StabiliDation@(esuscitation
+ %B8 #/8 monitor8 pulse o'imeter
/ &C*
> (@# the I,he :ig FiveJ
ti $i ti
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ortic $issection
• Definition: + %ntimal tear with entry of blood into the media
+ IdissectsJ between the intima and adventitia
• . site ascending aorta at the ligamentumarteriosum
• Stanford Classification: + involves Ascending aorta Mw@ or w@o descendingN
• ;
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ortic $issection
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ortic $issection
• %ncreased risk + *roup -1< yoa with hypertension
+ *roup : younger pts with 9arfanKs8 &hler4$anlos8
pregnancy
• 9ortality + ,ype
• Untreated: 75%
• Surgically treated: 15-20%
+ ,ype :• >/4>=2 with or without surgery
ortic $issection
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ortic $issectionClinical !resentation
• History
+ -6
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ortic $issectionClinical !resentation
• "uestion Which of the following presentationscan be seen with aortic dissection?
Stroke
: !araplegia
C bdominal pain
$ ortic insufficiency
& !ericardial tamponade
F Hoarseness* WheeDing
H $ysphagia
ortic $issection
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ortic $issectionClinical !resentation
• Associated sy#pto#s based on progression of dissection
• Carotid arteries stroke
• Spinal arteries paraplegia
• Abdominal aorta/renal arteries/iliacs: bdominal@flank pain
• Coronary arteries aortic insufficiencyE pericardial
effusion@tamponade
• Laryngeal nerve compression hoarseness
• Tracheal compression: dyspnea@stridor@wheeDing
• Esophageal compression: dysphagia
ortic $issection
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ortic $issectionClinical !resentation
• !hysical &'am
+ Symptoms@signs as above
+ 9ost commonly normal heart and lungs• ortic insufficiency murmur in .=4/
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ortic $issection$iagnosis
• CG(
+ ;12 with some abnormality
• widened mediastinum most common• left pleural effusionE indistinct aortic knobE
displaced8 calcified intima - =mm from outer aortic
wall
• C, vs ,&& vs aortogram
ortic $issection
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CG(
ortic $issection
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C, Scan
ortic $issection
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rteriogram
ti $i ti
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ortic $issection,reatment
• Considering it? + / large bore %BKs8 monitor8 ,QC8 &C*
• :lood pressure + $ecrease the shear force on the intima to minimiDe
progression• Lower arterial blood pressure
• $ecrease LB contractility
• Question: + Why not nipride alone?
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