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AAA & TAA

Cardiology

QuestionAnswer
Pseudoaneurysm well defined collection of blood & conn tissue outside vessel wall
Most common site of AAA formation: infrarenal abdominal aorta
Atherosclerotic dz of aorta may produce: stenotic obstruction or aneurysmal dilatation
Aneurysm types Saccular; fusiform
Most common aneurysm type Fusiform: symmetrical dilation (involves full circumference of aortic wall)
Aneurysm defn: 1.5x or > the normal diameter of the vessel.
Aneurysm type: comparative prevalence Abdominal (85%) > thoracic aneurysm (15%)
Half of newly detected AAAs are: <5cm (& 2/3 eventually require repair)
AAAs usually involve: aortic bifurcation (& often involve common iliac arteries)
AAA & Rupture 80% rupture into left retroperitoneum (may contain it); remainder rupture into peritoneal cavity (=> uncontrolled hemorrhage & rapid circulatory collapse)
Healthy, young normal aorta: size about 2 cm
Considered Aneurysm at size: > 3 cm
AAAs arise in areas of: dense athero-sclerosis, eroding & weakening the wall which leads to dilatation then rupture
90% of AAAs originate where: below renal arteries (infrarenal); 10% suprarenal
Infrarenal aneurysm may exhibit: stenosis (narrowing) of aorta
AAA: Surgery recommended when: >5 cm; women: appropriate at 4.5 - 5.0 cm
Decline of aortic elasticity & distensibility is accelerated in pts with: HTN, hyperlipidemia, & atherosclerosis of coronaries & other arteries.
AAA: Risk Factors Tobacco; Age; HTN; lipid; Atherosclerosis; Male; FH
FH in AAA: 1/4 of AAA pts have first degree relative with hx of AAA
AAA Risk Factors for Rupture Size (5cm female, 6 cm male); rapid progression (>1cm/yr); female; FH; unctrld HTN; SMK; COPD
AAA: what may prompt earlier endovasc repair? Rapid expansion (>1 cm/yr) & pt preference (in 4.5-5.5 cm range)
AAA Prognosis 80% mortality with rupture
Cystic medial necrosis occurs most frequently in: ascending aorta; aortic wall weakening => fusiform aneurysm
Cystic medial necrosis assoc with: conn tissue dz (Marfan, Ehlers-Danlos syndrome, RA); aortic valve replacement
Asc TA: Etiologies CMN, Bicuspid valve; AI; Arteritis/ Vasculitis; Collagen vasc dz (RA, Marfan, Ehlers-Danlos, Reiter); HTN; Syphilis; Atherosclerosis
Desc TA: predominant cause = atherosclerosis
Desc TA: called thoracoabdominal if they: extend below level of diaphram into abd aorta
TAA: Tx: >5 cm surgery (if Sx or rapid expansion: then sooner)
TAA: Clinical Findings > 50% pts ASx at dx; Sx due to vascular consequence or mass effect
TAA: if surgery required, need: coronary angiography
TAA: Inc rupture risk at smaller diameters with: Marfan; bicuspid valve
TAA: Asc Aorta: surgery indicated at: ≥ 5.5 cm (=/> 5.5)
TAA Marfan/ Bicuspid Valve: surgery indicated at: ≥ 5.0 cm (=/> 5.0)
TAA Aortic valve replacement: surgery indicated at: ≥ 4.0 cm (=/> 4.0)
TAA Desc Aorta: surgery indicated at: ≥ 6.0 cm (=/> 6.0)
TAA: Prognosis M&M higher than with AAA; 5 yr if unrepaired (>6 cm) is 20-25% (most deaths due to rupture or CAD)
Aortic dissection: usual direction of extension antegrade (driven by the forward force of aortic blood flow); sometimes retrograde from site of intimal tear
Aortic dissection: intimal tear in aorta creates a false lumen between: media & adventitia
Aortic dissection: >95% occur in the: Ascend aorta just distal to aortic valve or just distal to left subclavian at ligamentum arteriosum
Aortic Dissection: Increased risk in: pregnancy (1/4 of all female cases <40 yrs & most in last trimester); conn tissue dz (Marfan, Ehlers Danlos); Bicuspid Aortic Valve or Coarctation
Aortic Dissection: Debakey I = Ascending A extending to distal
Aortic Dissection: Debakey II = Ascending aorta only
Aortic Dissection: Debakey III = Descending aorta only
Aortic Dissection: Stanford A = Any involvement of ascending aorta
Aortic Dissection: Stanford B = Not involving ascending aorta
Aortic Dissection: Proximal = DeBakey Types I & II or Stanford Type A
Aortic Dissection: Distal = DeBakey Type III & Stanford type B
Aortic Dissection: Clinical Findings Acute: sudden, severe excruciating ripping chest pain (ascending) or scapular (descending); most hypertensive or nml
Aortic Dissection: PE Increased or decreased BP; pt may be in shock; wide pulse pressure; diminished / asymmetric peripheral pulses; aortic insufficiency murmur if ascending aorta; syncope
Aortic Dissection: poss Sx devt Acute aortic regurgitation (CHF indicates valve involvement); focal neuro (CVA may develop)
Aortic Dissection: mgmt: Type A = Surgical repair, may require AVR
Aortic Dissection: mgmt: Type B = Medical therapy (IV propranolol or nitroprusside)
Aortic Dissection: mgmt: All pts = aggressive BP control; yearly imaging or if increased Sx
Aortic Dissection: Prognosis Op mortality of type B 2x that of type A (bc comorbid illness); 30% have prog enlarging aneurysm that eventually req repair
Sudden onset ripping, tearing chest pain, diminished pulses = Aortic dissection
Flank pain, hypotension, pulsatile abdominal mass = AAA
RF/etiology of ascending aortic aneurysm: CMT (cystic medial necrosis)
RF for TAA/AAA: In order: tobacco, age, HTN, HLD, other atherosclerosis
2 components of Aorta thoracic (ascending, arch, descending); Abdominal
3 layers of aorta: Intima; Media; Adventitia
Intima: thin, inner layer (delicate, easily traumatized)
Media: thick middle layer (*strength of the aorta comes from media)
Adventitia: somewhat thin outer layer (contains mainly collagen)
Strength of the aorta lies in: media (= laminated, intertwining elastic tissue/ multiple layers, in a spiral manner, max tensile strength w/ distensible & elastic
Pseudoaneursym well defined collection of blood & conn tissue outside vessel wall
Atherosclerotic vs inflammatory inflame = extreme of atherosclerotic aneurysm
pathogenesis of AAAs: multifactorial: genetic, environ, hemodynamic & immunological; Chlamydia pneumoniae?
Aorta most affected by atherosclerotic process: infrarenal abdominal aorta
most common site of AAA formation: infrarenal abdominal aorta
Atherosclerotic dz of aorta may produce: stenotic obstrusion or aneurysmal dilatation
Aneurysm types Saccular; fusiform
Most common aneurysm type Fusiform
Has a fairly symmetrical dilation (involves full circumference of aortic wall) Fusiform
More localized dilation (outpouching of a portion of aortic wall) Saccular aneurysms
Flow disturbance thru the aneurysmal aortic segment: blood may stagnate along walls, cause mural thrombus (may embolize)
Aneurysm defn: 1.5x or > the normal diameter of the vessel.
Aneurysm type cf prevalence Abdominal more common than thoracic aneurysm
Half of newly detected AAAs are: <5cm (& 2/3 eventually require repair)
AAA & COPD: COPD pts: rupture of smaller AAAs more likely
AAAs usually involve: aortic bifurcation (& often involve common iliac arteries)
AAA & Rupture 80% rupture into left retroperitoneum (may contain it); remainder rupture into peritoneal cavity (=> uncontrolled hemorrhage & rapid circulatory collapse)
Healthy, young normal aorta: size about 2 cm
Considered Aneurysm at size: > 3 cm
AAA Incidence in Men vs Women 10:1
AAA: men over 55 2%
AAAs arise in areas of: dense athero-sclerosis, eroding & weakening the wall which leads to dilatation then rupture
90% of AAAs originate where: below renal arteries (infrarenal); 10% suprarenal
Infrarenal aneurysm may exhibit: stenosis (narrowing) of aorta
AAA: Surgery recommended when: >5 cm or if growing >0.5cm in 6 months or >1cm per year
Decline of aortic elasticity & distensibility is accelerated in pts with: HTN, hyperlipidemia, & atherosclerosis of coronaries & other arteries.
Loss of aortic elasticity loss of elastin & increase in collagen (=> lack of distensibility)
AAA: Risk Factors Tobacco; Age; HTN; lipid; Atherosclerosis; Male; FH
FH in AAA: 1/4 of AAA pts have first degree relative with hx of AAA
Initial dx test to screen for & follow known AAA = Abdominal US:
Abdominal US: advantages 100% sensitivity, no contrast, low cost
AAA: CT scan pre-op or if US indeterminate; better defines shape & location/ extent of AAA
AAA: Catheter aortography may: underestimate diameter
AAA Risk Factors for Rupture Size (5cm female, 6 cm male); rapid progression (>1cm/yr); female; FH; unctrld HTN; SMK; COPD
AAA Surveillance Trend: bigger AAA, more frequent surveil
AAA: for average risk pts, a threshold of ?? cm in diameter is appropriate for elective repair 5.5 cm
AAA: what may prompt earlier endovasc repair? Rapid expansion (>1 cm/yr) & pt preference (in 4.5-5.5 cm range)
AAA Endovascular repair: No justification for: endovascular repair at smaller diameters
AAA: for women, elective endovasc repair is appropriate at: 4.5 or 5.0 cm
AAA Prognosis 80% mortality with rupture
AAA mgmt: Risk factor mod (stop SMK, aggressive HTN & Lipid Rx), med mgmt to slow progression
AAA operative mortality: Elective = 2-5%, Expanding = 5-15%, Ruptured: >50%
Criteria for Endovascular Repair: Proximal neck: length: min 15 mm; diameter: max 28 mm; angulation: <60 degrees
Criteria for Endovascular Repair: Iliac arteries Common iliac a.: variable diameters; ext iliac a. <7 mm
USPSTF Screening Guidelines for AAA: repair what in who? large AAA (> 5.5 cm) in men btw 65-75 w/ Hx of SMK; No gdln for men 65-75 no hx SMK; gdln against screen in women
USPSTF AAA Screen Consensus stmt All M 60-85; All F 60-85 w/ 1 or more CVD risk factor; M&F > 50 w/ FH AAA
Thoracic aneurysm: prevalence Far less common than AAAs
Thoracic aneurysm: classified by: pt of aorta involved ( ascending, arch or descending TA)
Thoracoabdominal AA = desc TA extends distally to involve AA
TAA: prevalence Less common than AAA w/ diff pathogenesis; 60% = aortic root & ascend A; 40% desc A; 10% arch
Sm mx cell drop out & elastic fiber degen w/ media of cystic spaces filled w/ mucoid matl = Cystic medial necrosis
Cystic medial necrosis occurs most frequently in: ascending aorta
Cystic medial necrosis leads to: aortic wall weakening => fusiform aneurysm
Aneurysm from cystic medial necrosis often involve: aortic root & may consequently result in AI
CMN is accelerated by: HTN (occurs somewhat w/ aging)
CMN assoc with: conn tissue dz (Marfan, Ehlers-Danlos syndrome, RA); aortic valve replacement
Ascending TA: Etiologies CMN, Bicuspid valve; AI; Arteritis/ Vasculitis; Collagen vasc dz (RA, Marfan, Ehlers-Danlos, Reiter); HTN; Syphilis; Atherosclerosis
Ascending aneurysms usually caused by: CMN
If Asc aneurysm due to atherosclerosis, assoc with: diffuse aortic atherosclerosis
Aortic Arch aneurysms often contiguous with: aneurysms of asc OR desc A & can be caused by any of the etiologies above.
Desc TA: predominant cause = atherosclerosis
Desc TA: tend to originate: just distal to origin of L subclavian; may be fusiform or accular
Aortic Arch Aneurysm: Etiologies Ext of Asc or Desc aneurysms; Hx trauma or deceleration injury
Desc TA: called thoracoabdominal if they: extend below level of diaphram into abd aorta
TAA: Spontaneous rupture prevalence less common than AAA (bc inc of Sx due to compression of surrounding structures)
TAA: Tx: >5 cm surgery (if Sx or rapid expansion: then sooner)
Sx pts or w/ AI: Inc incidence of rupture
TAA: Clinical Findings > 50% pts ASx at dx; Sx due to vascular consequence or mass effect
TAA: Vascular Sx AI with CHF, or thromboembolism causing stroke, lower extremity or mesenteric ischemia, renal infarct
TAA: Mass Effect SVC syndrome, tracheal deviation, cough, hemoptysis, dysphagia, hoarseness
Ascending or arch An can cause compression of: SVC or innominate v. => obstruction of venous return
Desc/ arch An: may cause compression of: trachea or main stem bronchus => tracheal deviation, wheezing, cough & positional dyspnea, hemoptysis or recurrent pneumonitis
Desc/ arch An: Compression of esophagus can cause: dysphagia & compression of recurrent laryngeal n. can cause hoarseness
TAA: Clinical Findings Pain ( 25% pts) from direct compression of intrathoracic structures or chest wall; substernal or in back/ neck; steady, deep & severe?
TAA Rupture: excruciating pain; may be assoc w/ aortic dissection
Rupture occurs most commonly into: L intrapleural space or mediastinum; results in severe hypotension
Desc An rupture into: adjacent esophagus => life threatening hematemesis
TAA Evaluation CXR (only rule in, cannot R/O); Echo (TTE vs TEE); CT/ MRI
TAA: Pos CXR: Must differentiate from anterior mediastinal mass (ie thymoma, lung CA)
TAA: if surgery required, need: coronary angiography
Echo: TTE vx TEE TTE only good to visualize aortic root (good for Marfan); TEE to visualize entire aorta, but is semi invasive (CT/ MRI better)
TAA Mgmt: major factors in rupture risk Size & rate of growth
TAA Mgmt: Annual growth rate for <5cm aneurysm 2%
TAA Mgmt: Annual growth rate for 5-5.9 cm 3%
TAA Mgmt: Annual growth rate for >6 cm 7%
TAA: Inc rupture risk at smaller diameters with: Marfan; bicuspid valve
Asc Aorta: surgery indicated at: ≥ 5.5 cm (=/> 5.5)
Marfan/ Bicuspid Valve: surgery indicated at: ≥ 5.0 cm (=/> 5.0)
Aortic valve replacement: surgery indicated at: ≥ 4.0 cm (=/> 4.0)
Desc Aorta: surgery indicated at: ≥ 6.0 cm (=/> 6.0)
Aortic Root Replacement: Bentall: Dacron graft w/ prosthetic valve sewn directly into aortic annulus; coronary arteries reimplanted into the graft (op mortality risk 5%)
Aortic Root Replacement: David = valve sparing Bentall (re-implant native valve within dacron graft)
TAA: Prognosis M&M higher than with AAA; 5 yr if unrepaired (>6 cm) is 20-25% (most deaths due to rupture or CAD)
TAA: 1 month op mortality = 8-20%
TAA: operative complications pulmo comps & damage to laryngeal or phrenic n., carotid or subclavian a. poss
Tear in aortic intima usu preceded by medial wall degen/ CMN = aortic dissection
Aortic dissection: intimal tear in aorta creates a false lumen between: media & adventitia
Aortic dissection: time course May be acute or chronic
Aortic dissection: >95% occur in the: Ascend aorta just distal to aortic valve or just distal to L subclavian at lig arteriosum
Intimal tears resulting in dissection: prevalence: 65% Ascend A; 20% Desc A; 10% A Arch; 5% Abd A.
Aortic Dissection incidence 3/100,00/year (7,000 cases/year in US); most common in 6th-8th decade; M>F 2:1 2:1
Aortic Dissection: Increased risk in: pregnancy (1/4 of all female cases <40 yrs & most in last trimester); conn tissue dz (Marfan, Ehlers Danlos); Bicuspid Aortic Valve or Coarctation
Aortic Dissection: 80% of pts are: Hypertensive
Aortic Dissection: Clinical Findings Acute: sudden, severe excruciating ripping chest pain (ascending) or scapular (descending); most hypertensive or nml
Aortic Dissection: poss Sx devt Acute aortic regurgitation (CHF indicates valve involvement); focal neuro (CVA may develop)
Aortic Dissection Eval: CXR = wide mediastinum, poss L sided pleural effusion
Aortic Dissection Eval: Echo = 98% sensitive, 99% specific, +/- pericardial effusion
Aortic Dissection Eval: CT helpful in: acute presentation
Aortic Dissection Eval: MRA/MRI useful for: serial follow up
Aortic Dissection Eval: EKG = LVH, nonspecific or inferior abnormalities (dissections preferentially extend into Right coronary ostium)
Aortic dissection: CXR = Wide aortic silhouette & mediastinum; Left pleural effusion; 10%-20% normal
Aortic Dissection: mgmt: Type A = Surgical repair, may require AVR
Aortic Dissection: mgmt: Type B = Medical therapy
Aortic Dissection: mgmt: Type B: Exceptions to med tx: Rupture, Limb/ visceral ischemia, Saccular morphology, ongoing pain, uncontrolled HTN, Marfan, AI
Aortic Dissection: mgmt: Chronic & asymptomatic = medical Rx
Aortic Dissection: mgmt: All pts = aggressive BP control; yearly imaging or if increased Sx
Aortic Dissection: Prognosis Op mortality of type B 2x that of type A (bc comorbid illness)
Aortic Dissection: 5 yr survival: repaired Type A = 70-80% repaired type A
Aortic Dissection: 5 yr survival: repaired Type B = 50-70% repaired type B
Aortic Dissection: Prognosis: chronic type B 30% => progressively enlarging aneurysm that eventually requires repair
Aortic aneurysm etiologies = atherosclerosis (most common); Marfan (esp TAA); aortitis (mycotic, salmonella, syphilis, other infxn), giant cell arteritis
Complications of aortic aneurysm rupture (esp if >5.5cm); thromboembolism; distal ischemia
Aortic aneurysm dx studies U/S; CT; aortography (used before surgery); CXR (to show calcifications)
Aortic dissection etiologies: HTN; Marfan; cystic medial necrosis; iatrogenic comp of cath
Aortic dissection pathophysiology intimal tear with formation of false channel in media by hematoma
Aortic dissection on CXR = wide superior mediastinum; displaced trachea; L pleural effusion; enlarged aortic knob
Which medication (ACE, diuretic, CCB, sotalol) will decrease morbidity of patient with AAA? Sotalol
Created by: Abarnard