LA DISSEZIONE AORTICA · the aorta. Through this tear blood enters, and dissects down the laminar...
Transcript of LA DISSEZIONE AORTICA · the aorta. Through this tear blood enters, and dissects down the laminar...
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Emergenze-Urgenze in Cardiochirurgia
LA DISSEZIONE AORTICA
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Dissezione Aortica
red blood clot
true lumenfalse lumen
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• Scissione longitudinale della media aortica da parte di una colonna di sangue
• La scissione della media occupa circa metà della circonferenza dell’aorta e può estendersi per tutta la lunghezza del vaso
• Lo scollamento creato dal sangue crea un secondo lume o falso lume
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Dissecting aortic aneurysm (aortic dissection). This
gross picture highlights a 6cm wide aortic intimal and
partial medial tear just above the aortic valve. Most
dissections start with a intial tear in the first 10cm of
the aorta. Through this tear blood enters, and dissects
down the laminar plain of the media. It often will re-
enter the vessel lumen in the abdominal aorta or even
lower (illiac or femoral arteries).
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Dissecting aortic
aneurysm. This is a
segment of the abdominal
aorta showing the two
seperated walls of the
dissecting aneurysm (the
blood has been removed).
The media is seperated
easily, like the pages of a
book.
Inner 1/3 of media
Outer 1/3 of media with adventitia
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CLASSIFICAZIONE
Classificazione di De Bakey
• Tipo I: dissecazione dal tratto ascendente al discendente
• Tipo II: dissecazione limitata all’arco a al tratto ascendente, senza coinvolgimento del tratto discendente
Tipo III: dissecazione della sola aorta discendente
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CLASSIFICAZIONEClassificazione di Stanford
Tipo A: interessamento aorta ascendente
Tipo B:interessamento arco aortico e/o aorta discendente, non l’ascendente
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Fattori predisponenti
• Ipertensione (75-90% dei casi)
• S. di Marfan e Collagenopatie
• Malformazioni aortiche congenite
• Valvulopatie aortiche acquisite
• Gravidanza (rara)
• Forme iatrogene (cateterismi)
• Abuso di Cocaina
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Quadri clinici e sintomatologia
• Lacerazione e sede della lacerazione
• Progressione dello scollamento con coinvolgimento aa. collaterali
• Sindrome da compressione
• Sindrome da rottura
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SintomiDOLORE (Migrante)
50% STENOCARDICO 30% ADDOMINALE
10% DORSALE 6% LOMBARE
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•Right carotid
compression from
dissected blood
•Blood dissected upward
from aortic tear
–Can dissect upward
toward carotids or
downward toward
coronaries
–Therefore, symptoms
may reflect those of a
stroke or heart attack
SINTOMI LEGATI ALLA
PROGRESSIONE
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SINTOMI LEGATI ALLA
PROGRESSIONE
SINDROMI ISCHEMICHE
DELL’ARCO
-disturbo della coscienza
-lipotimia
-mono- emiparesi
-plegie
-scomparsa polsi periferici arti
sup.
-asimmetrie di pressione dx-sx
OCCLUSIONE AA.SPINALI
-parestesie
-paraplegie
-paraparesi.
OCCLUSIONE AA.RENALI
-anuria
-ematuria
-infarto renale
-ipertensione nefrovascolare
-dolore (colica renale)
OCCLUSIONE AA.
MESENTERICHE
-dolori addominali
-infarto intestinale
OCCLUSIONE AA. ILIACHE
-simula ischemia acuta dell’arto
-sciatalgia
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SINDROME DA COMPRESSIONE
• S. Mediastinica per compressione n. laringeo ricorrente
• S. di Horner per compressione del ganglio stellato
• S. da compressione esofagea con disfagia
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SINDROME DA ROTTURA
• Pericardio
• Cavità Pleurica
• Addome
• Blood
dissected
proximally
through the
media
• Hemopericar
dium resulted
• Cardiac
tamponade
may be
present due
to the
extreme
hemorrhage
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PROGNOSI Acute Type A dissection is a surgical disease
Previous natural history studios show 80-90% one
month mortality
Two recent series have indicated a 60% one month
mortality with non-operative medical therapy
STORIA NATURALE DELLA DISSEZIONE
SOPRAVVIVENZA TIPO B
SOPRAVVIVENZA TIPO A
Senza trattamento, Ao
dissecazione ha un’alta
mortalità
Il 35% dei pz non curati
muore entro le prime 24
ore, il 50% entro 48 ore, il
70% dopo una settimana e
l’80% entro 2 settimane.
Il tipo B ha prognosi
migliore
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Iter diagnostico iniziale nel pz con sospetta dissezione aortica
• Esami ematochimici(CPK,CK-MB, T(I)troponina,
conta bianchi, D-dimero, emocromo, LDH…)
• ECG
• RX TORACE
• ECO
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Diagnostica per immagini(1)
Chest X-ray
1. Mediastinum widening
2. Displacement of intima
calcification
3. Displacement of
endotrachea tube and NG tube
4. Left pleural effusion (signs
of dissecting ruptire)
left pleural effusionmediastinum widening
0 10 20 30 40 50 60 70 80
Sensitivity (%)
Displaced intimal
calcification
Pleural effusion
Wide mediastinum
Abnormal aortic contour
Ch
est
X-R
ay F
ind
ing
s
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Diagnostica per Immagini (2)
CT scan
1. Intimal flap
2. Displacement of intimal
calcification
3. Differential contrast
enhancement of true v.s. false
lumen
T
F
Intimal flap
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Diagnostica per Immagini(3)
MRI
1. Intimal flap
2. Slow flow and clot in false
lumen
Partition of a three-dimensional contrast-
enhanced MRA shows intimal flap
(arrows ) in the distal aortic arch and
descending aorta.
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Diagnostica per Immagini(4)
Transesophgeal echocaediogram
1. Freely movable flap within the lumen of the vessel
2. Differential Doppler detection of true v.s. false lumen
T
F
Freely movable flap
within the aorta
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A dissection flap can be seen
spanning the aneurysmal ascending
aorta. A defect is noted in the central
part of the flap consistent with an
entry point from the true into the
false lumen.
Colour flow Doppler demonstrates
the communication between true and
false lumens.
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A dissection flap can be
seen within the ascending
aorta.
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Diagnostica per Immagini (5)
Angiography
1. Intimal flap
2. True and false lumen (may be
failure if the false
channel is thrombosed)
3. Aortic regurgitation
4. Coronary artery
Oblique arteriogram of the thoracic aorta
demonstrates the double-barrel aorta sign
of aortic dissection. Both the true and false
lumina are opacified
T
F
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PROGNOSI
STORIA NATURALE DELLA DISSEZIONE
Senza trattamento, la
dissecazione ha un’alta
mortalità:
prime 24 ore 35%
entro 48 ore 50%
dopo una settimana 70%
entro 2 settimane 80%.
Il tipo B ha prognosi migliore
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DIAGNOSI E TRATTAMENTO DELLA DISSEZIONE AORTICA
STABILITÀ EMODINAMICA INSTABILITÀ EMODINAMICA
Diagnosi certa
Diagnosi sospetta
Intervento chirurgico
Terapia Intensiva
Conferma diagnosi
(TEE)
Sala operatoria
Anestesia generale
+ monitoraggio
(TEE)
NegativoPositivo
Diagnostica
inadeguata
Diagnosi
sospetta
TAC
Pos
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TERAPIA (1)
• Pz in ACR con PEA:
RCP
Considerare
PERICARDIOCENTESI
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TERAPIA (2)
Dissezione aortica tipo A
Terapia Chirurgica URGENTE
– Any dissection involving the ascending
aorta
– Symptomatic or complicated descending
aortic dissections
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TERAPIA (3)
Dissezione aortica tipo B
Terapia Medica
– Per ridurra P.A. e stress sulla parete arteriosa
B bloccanti
Vasodilatatori
– Per il dolore morfina, NO FANS
Terapia Chirurgica
– Symptomatic or complicated descending aortic
dissections
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TYPE A
AORTIC
DISSECTION
tear location
true lumen
false lumen
TYPE A AORTIC DISSECTION
clots in false lumen and aortic arch reentryTYPE A AORTIC DISSECTION
clots in false lumen
The ruler has been inserted into
the tear in the intima that has
given rise to the dissection of
this vessel. This is a view of the
intimal surface of the aorta
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A Cabrol interostial coronary
graft or an ultra short (1.5-cm)
graft-to-left-main extension
occasionally is employed when
low-lying ostia cannot be
mobilized.
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