1. Jakub Honěk Kardiologická klinika 2.LF UK a FN Motol
Diseases of aorta
Jakub Honěk
Kardiologická klinika
2.LF UK a FN Motol

2. Overview Anatomy and physiology Abdominal aortic aneurysm (AAA)
Aneurysm of thoracic aorta
Aortic dissection

3. Anatomy Ascending aorta Aortic arch Descending aorta Abdominal aorta
Aortic root
ST junction
Tubular part
Aortic arch
Aortic isthmus
Descending aorta
Abdominal aorta
Suprarenal segment
Infrarenal segment
Bifurcation

4. Physiology Elasticity, pulse wave

5. Physiology Arterial stiffness
Zieman SJ. Arterioscler Thromb Vasc Biol 2005;25:

6. AAA Localized distension of aortic diameter >50% 90 % subrenal
(>3.0cm in women, >3.4 cm in men)
90 % subrenal
Progresses over time
5x more frequent in men
Prevalence ↑ with age
Multifactorial etiology
Risk factors simillar to atherosclerosis, pathophysiology is different - aortic wall remodelling

7. AAA Clinical features Mostly asymptomatic!
Rarely patient palpates pulsatile mass, or feels pulsations
Mostly first smyptoms occur due to complications
Peripheral thromboembolism
AAA rupture (first sign in 40%!)

8. AAA rupture Emergent, life threatening situation
Mortality 80–90 % when optimally treated
90% retroperitoneal rupture
Clinical triad
PAIN (amdominal/lumbar, radiation to groins)
PULSATILE MASS
HYPOTENSION (circulatory shock)

9. AAA diagnostic imaging
Duplex ultrasound
Fast, cheap, screening of pts.
in risk, follow-up
CTA/MRA
Optimal resolution, anatomy
DSA
Invasive treatment, luminography
Screening
Effective in risk groups (pts. With family history, CAD, PAD, male smokers >65 yrs…)
Prevention of fatal complications, elective operation/inetervention

10. Treatment – stable AAA
Lifestyle changes, follow-up, blood pressure control (beta-blockers)
Preventive operation/intervention
Indication based on AAA diameter:
> 55 mm
> 10 mm increase/year
Modified by BSA, sex, comorbidities

11. Treatment – stable AAA Surgery Endovascular treatment Conservative
Resection of aneurysmal sac, implantation of vascular prosthesis
Endovascular treatment
Implantation of stentgraft
Femoral approch
Simila longterm results to surgery
Conservative
Follow-up, risk of rupture

13. Treatment – ruptured AAA
Emergent surgery/endovascular tretament
Patient stabilization, fast imaging
Up to 50% pts. die before reaching hospital
30-40% die die before reaching op. Theatre
40-50% of the operated die
Overall mortality 80-90%

14. Aneurysm of thoracic aorta
Less frequent than AAA (10/ )
Same definition
60% ascending, 5-10% arch, 30-35% descendning
Anuloaortic
ectasia

16. Aneurysm of thoracic aorta
Multiple etiologies – genetic, degenerative, infectious, inflammatory
Bicuspid aortopathy
Cystic medial degeneration
Mostly assymptomatic
Symptoms of complications: Ao regurgitation, embolization, compression sy., dissection, rupture
Iamging: TTE, TEE, CTA, MRA, DSA

17. Aneurysm of thoracic aorta Treatment
BP control
Follow-up
Elective surgery
Bonow et al. Braunwalds heart disease.

18. Aortic dissection Incidence: 3/100 000 per year High mortality
Untreated: 25%/24h, 50%/week
Optimal treatment: 20%/30 days
Intimal tear – entry
Intimal flap, false lumen
Reentry

19. Aortic dissection risk factors
Arterial hypertension
Genetically triggered thoracic aortic disease
Marfan syndrome
Bicuspid aortic valve (bicuspid aortopathy)
Ehlers-Danlos syndrome
Congenital diseases
Coarctation of aorta
Tetralogy of Fallot
Atherosclerosis of aorta
Iatrogenic or blunt trauma
Catheterisation or stenting
Surgery (CABG, valve replacement, operation of aorta)
Intraaortic balloon contrapulsation
Trauma (road traffic accidents)
Gravidity
Cocaine abuse
Inflammatory and infectious diseases
Takayasu arteritis, giant cell arteritis, syphilis

20. Aortic Dissection - classification
Stanford De Bakey
Entry: 65% root, 20% isthmus, 15% other

21. Aortic dissection Clinical manifestation
Pain
severe, sudden, sharp – stabbing, tearing („stabbed in the chestwhit a knife“)
Retrosternal (+radiation to neck, jaw), between scapulae, abdominal, back
Acute heart failure, MI, syncope, stroke, paraplegia…

22. Aortic dissection Diagnostic approach
Urgent situation – fast diagnosis
Rare disease vs. Common diseases
Physical exam, ECG, lab (D dimers)
Ideal imaging test – fast, available, good resolution – CTA
Trasthoracic echo - bediside

24. Aortic dissection Therapy
Urgent situation, high mortality in first hours
Multidisciplinary approach
Initial management:
BP control (beta blockers)
Pain control
Hemodynamic stabilization
In type A – plan urgent surgery
In type B – conservative/ surgery/endovascular

25. Aortic dissection Therapy