Case 1. Aortic Disasters. Case 2. Case 3. Diagnosis, Imaging Techniques and Management
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1 Aortic Disasters Diagnosis, Imaging Techniques and Management Eric R. Snoey, MD Alameda County Medical Center Oakland, CA 1 Case 1 51 yo female presents with sharp anterior chest pain while at rest. She says the pain is worse with movt. No associated symptoms. Pain is improved in ED Pmhx: Asthma, Turner s Syndrome Fmhx: none PE: VS: 125/85, 75, 24, 37, Pulse Ox: 100% Otherwise normal examination W/u: Cxr, EKG, CBC, Trop/Myo x2 : normal Dispo: home, ETT, PMD f/u 2 Case 2 32 yo male presents with mid chest pain after a minor parking lot MVA. He denies striking any part of the car. He seems more upset than sick Pmhx: none Fmhx: father with cardiac dz Case 3 57 yo male presents with acute onset upper Abd Pain accompanied by SOB. No n/v/d/c, fever or prior hx of similar pain. Pmhx: HTN, Smoking, occ alcohol Fmhx: none PE: VS 95/65 (says BP always low), 70, 24, 37 Otherwise normal W/u: Chest X-ray, EKG, CBC, CMP: normal PE: VS: 165/110, 95, 24, 37, Pulse Ox: 100% + Mid epigastric tenderness W/u: Cxr, EKG, CMP, Lipase : normal ED US. Dispo: home with 3 day f/u 3 4 1
2 Case 4 65 yo female presents with chest pain - acute onset, sharp and associated with weakness and dizziness. Pmhx: HTN, Smoking, occ alcohol Fmhx: none Case 4 - continues 65 yo female presents with syncope PE: VS: 100/70, 146, 24, Pulse Ox: 95% PE: VS: 105/70, 95, 24, 37, Pulse Ox: 100% Normal examination W/u: Cxr, EKG, CMP, Trop/Myo : normal Observed for 4 hours pain improves Cath lab activated: 30% LAD and Diagonal branch stenosis Patient sent home with Lipitor and coumadin Dx: HTN medication reaction, atypical CP 5 6 One month later Aortic Dissection 7 8 2
3 Definitions.. Aneurysm: localized dilatation of the entire vessel wall involving all three layers Dissection: hematoma within the arterial media causing a lengthwise separation Aortic Transection: traumatic tear of aorta usually at lig arteriosum Classification (Stanford) 9 Type A Type B 10 DNA Epidemiology is Destiny ~ 0.5-1% of MI rate Long standing HTN (not atherosclerosis) Elastin and connective tissues disorders Marfan s, Cystic medial necrosis, Pregnancy, Cardiac Disorders Coarctation, Bicuspid aortic valve Turner s syndrome Trauma Acute stressors Cocaine/Met amphetamine
4 Case 1 51 yo female presents with sharp anterior chest pain while at rest. She says the pain is worse with movt. No associated symptoms. Pain is improved in ED Pmhx: Asthma, Turner s Syndrome Returned to ED 48 hours later in Arrest Post mortem: Pericardial tamponade from AD Case 2 32 yo male presents with mid chest pain after a minor parking lot MVA. He denies striking any part of the car. He seems more upset than sick Pmhx: none Fmhx: father with cardiac dz Father had a Aortic Dissection from a Bicuspid valve survived to have surgery This patient died at home the next day Age-related Risk Factors associated with aortic dissection Acute Aortic Syndrome Risk factor AD > 40 y AD < 40 y P value Marfan syndrome 2% 49% <.001% Hypertension 74% 35% <.001% Bicuspid valve 3% 16% <.001% Prior aortic valve replacement 5% 13% <.01% Atherosclerosis 31% 2% <.001% Classical AD True and false lumen Longitudinal spread Intramural Hematoma Localized hematoma No Doppler flow/contrast on CT Penetrating Aortic Ulcer Typically descending aorta Rupture atherosclerotic plaques 20% 70% 10% 95% of Aortic Dissection occurs > 40 yo 15 Haro et al. EM Clinics, Nov
5 Natural history Type A: 1-2%/hour mortality rate (untreated), 50% at 30 days Type B: Mortality 10% at 30 days if uncomplicated *International Registry of Aortic Dissection 17 Anatomy Presentation is Destiny Aortic Dissection is a disorder that varies in TIME and SPACE Maximal at onset, May come and go (15% painless), Follows aortic anatomy Pain Type Proximal (front-back, top-down Distal radiation), (Neck/jaw pain uncommon) Chest anterior 65% 27% Chest Posterior + Other 10% Symptoms 57% Ant & Post 8% 16% Neck - Neurologic: transient 8% loss of vision, numbness, 0% Abd weakness 6% or dysarthria etc 4% - Limb ischemia or pain Sharp - Syncope, SOB, 64% 68% Tearing/Ripping 50% 52% Migratory 16% 19% *International Registry of Aortic Dissection Pain 18 Case 3 57 yo male presents with acute onset upper abd pain accompanied by SOB. +Mild chest pain earlier in day. No n/v/d/c, fever or prior hx of similar pain. Pmhx: HTN, Smoking, occ alcohol Fmhx: none PE: VS: 165/110, 95, 24, 37, Pulse Ox: 100% + Mid epigastric tenderness W/u: Cxr, EKG, CMP, Lipase : normal ED US
6 Presentation Physical findings of AD present in < 50% of cases Mechanism of obstruction Signs Proximal Distal Method of pulse deficit and/or neuro sxs Hypertension 35% 70% Hypotension 12% 2% Pulse Deficit 18% 9% AI Murmur 44% 12% Neuro Deficit 6% 2% *International Registry of Aortic Dissection Case 4 - continues 65 yo female presents with syncope seen yesterday for chest pain and BP medication reaction PE: VS: 100/70, 146, 24, Pulse Ox: 95% Cath lab activated: 30% LAD and Diagonal branch stenosis Retrospectoscope: EKG shows pericarditis 23 6
7 Diagnosis Clinical Suspicion/Appropriate patient type PLUS Sudden, atypical or migratory pain, tearing, mixed cardiovascular/neuro presentations Physical Exam: Excludes alternative diagnosis AI murmur, Pulse deficits Diagnosis can not be made without imaging study 26 Chest radiography 65% sensitive Widened knob Double wall sign Effusion or cap Wide mediastinum
8 CT MRI TEE Advantages: accuracy, intimal tear localization, dx of AI and pericardial effusions Advantages: accurate, excellent anatomic detail Disadvantages: requires sedation and cardiologist Disadvantages: slow,unavailable, costly
9 Serologic screening Experimental.. Smooth muscle myosin heavy chain (SMMHC) Soluble elastin fragments (selaf) D-dimer: sensitivities % Small, retrospective studies,? methods Unclear cut off (500 or lower),? whether accurate in Intramural hematomas? Sensitivity and low specificity means potential misses and/or many unnecessary imaging studies Treatment Stop extension of dissection Control dp/dt - ie contractility of the aorta Decrease blood pressure and decrease heart rate Target: lowest blood pressure that allows for normal mental status, SBP ~ Pain control Stabilization for surgery (Type A) Drugs Goal is reduction of Force and Rate of contraction Variant mgt scenarios Drug Nipride Propranolol(Esmolol) Blood press Contractility Dissection + Hypotension/CHF: Diff Dx AI: gentle rate control, early surgery Pericardial tamponade: IVF, early surgery (pericardiocentesis worse outcome..) MI: gentle rate control - early surgery, (avoid ASA, antithrombotics) Labetalol Dissection + Neuro deficits Trimethaphan Obstructive: gentle pressure and rate reduction (hold if neuro deficit widens), early surgery Fenoldopam
10 Surgery Noninvasive Endografts, Stents and Fenestration Reserved for most (80%)Type A and any (20%) Type B with vascular or neurologic complications Isolated Arch dissections medical Tx Uncomplicated Type B treated medically - B-blockers/anti-HTN vs endovascular grafts and stents How not to miss AD Know the subtle presentations - think beyond the textbook Mixed Neuro/Cardiac, Extremity Pain/Cardiac Explore the risk profile (Turners/Marfans/FamHx) If ACS/PE/MSK just isn t fitting, think AD Look for the AI, Abnl pulse, migratory sxs CT when in doubt
Its 2:00 AM... Aortic Disasters. Case 1 (cont) Definitions.. Epidemiology. Diagnosis, Imaging Techniques and Management
Aortic Disasters Diagnosis, Imaging Techniques and Management Eric R. Snoey, MD Alameda County Medical Center Oakland, CA Its 2:00 AM... 64 yo female presents with 4 hours of R flank pain, nausea and fatigue.
Its 2:00 AM... Aortic Disasters. Case 1 (cont) 11/12/2010. Diagnosis, Imaging Techniques and Management
Aortic Disasters Diagnosis, Imaging Techniques and Management Eric R. Snoey, MD Alameda County Medical Center Oakland, CA Its 2:00 AM... 64 yo female presents with 4 hours of R flank pain, nausea and fatigue.
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