Aortic arch pathology. Cerebral ischemia following carotid artery stenosis.

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Myra Holmes
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1 Important: -Subclavian Steal Syndrome -Cerebral ischemia Aortic arch pathology. Cerebral ischemia following carotid artery stenosis. Mina Aubeed & Alba Hernández Pinilla

2 Aortic arch pathology Common arch anomalies: double aortic arch, right sided aortic arch, patent ductus arteriosus Aortic arch aneurysm Aortic arch dissection

The two parts to the aorta have smaller arteries branching off of them. The condition occurs equally in males and females.

3 Double aortic arch It s the most symptomatic type of aortic arch variant. It s about 50-60% of vascular rings. Some of the arches that should have disappeared are still present at birth in addition to the normal arch. Aorta is made up of two vessels instead of one. The two parts to the aorta have smaller arteries branching off of them. The condition occurs equally in males and females. It is often present in people with certain chromosome abnormalities. Symptoms: The double aortic arch may press on the trachea and esophagus, leading to trouble breathing and swallowing. Double aortic arch often causes serious respiratory distress in young infants. These will have characteristic inspiratory and expiratory wheeze, stridor, or croup-like cough

Diagnosis: Chest x-ray CT or MRI scan Echocardiography Esophagoscopy and bronchoscopy may be helpful in finding out the degree and level of compression.

4 Diagnosis: Chest x-ray CT or MRI scan Echocardiography Esophagoscopy and bronchoscopy may be helpful in finding out the degree and level of compression. Treatment: Via a left posterolateral thoracotomy. Incision through the third or fourth intercostal space. Prognosis: Mortality for the repair of a vascular ring was 1,6%. Overall survival was 96% at 35 years. Most children feel better right after surgery, although some may continue to have breathing symptoms for some time after surgical repair. This is most often due to weakness of the trachea because of the pressure on it before surgical repair.

Right sided aortic arch It s a type of anomaly characterized by the aortic arch coursing to the right of the trachea It just occurs in approximately 0,1% of the population.

5 Right sided aortic arch It s a type of anomaly characterized by the aortic arch coursing to the right of the trachea It just occurs in approximately 0,1% of the population. Classified into 3 types: - I: right-sided aortic arch with mirror image branching - II: right-sided aortic arch with aberrant left subclavian artery - III: right-sided aortic arch with isolation of the left subclavian artery Diagnosis: Plain radiograph CT/MRI

Patent ductus arteriosus Congenital cardiac anomaly where there is persistent potency of the ductus arteriosus, which is a normal connection of the fetal circulation between the aorta and the

6 Patent ductus arteriosus Congenital cardiac anomaly where there is persistent potency of the ductus arteriosus, which is a normal connection of the fetal circulation between the aorta and the pulmonary arterial system that develops from the 6th aortic arch Occurs 1 in 2000 full term neonates A large PDA normally gives a loud continuously machine-like murmur Diagnosis: Plain radiograph Echocardiography (direction of flow) CT Treatment: Medical: -Prostaglandin E1: to keep ductus open -Indomethacin: to close the ductus Endovascular: -Various closure devices Surgical -Clipping or ligation to close

7 Aortic arch aneurysm Aneurysms (bulging of the aorta) occur due to molecular and connective tissue changes in the wall of the aorta. These changes in the wall of the aorta sometimes cause: atherosclerosis and other times cystic medical degeneration (a breakdown of the muscular layer in the aorta), resulting in aneurysms. An aortic arch aneurysm which can involve: -the blood vessels that supply to your head and neck. Symptoms: Most people do not have symptoms Dull, vague chest pain Shortness of breath Hoarseness Dry cough Diagnosis: Chest x-ray Echocardiogram Additional tests may be needed like: CT scans, MRI scans, angiogram

Open surgery associated with high rates of mortality (5-20%) and neurological

8 Treatment: OPEN REPAIR: remains the gold standard in aortic arch repair for aneurysms or dissections. Open surgery associated with high rates of mortality (5-20%) and neurological impairment (5-18%). ENDOVASCULAR STRATEGIES (EVAR): - Hybrid Arch Repair - Chimney Repair - Custom-Made Scalloped, Fenestrated, and Branched Grafts

9 Aortic arch dissection Separation of the layers within the aortic wall. Tears in the intimal layer result in the propagation of dissection (proximally or distally) secondary to blood entering the intima-media space. Mortality is high. Before left subclavian Causes: -Hypertension -Smoking -Pregnancy -Aortic aneurysms -Connective tissue disorders: - Marfan syndrome -Ehlers-Danlos syndrome Symptoms: -Neck or jaw pain -Unequal pulses/bp between upper extremity -Acute onset of aortic regurgitation murmur

Treatment: -Pain and blood pressure control -Indications for operative intervention if: *Ongoing chest pain despite adequate blood pressure control

10 Treatment: -Pain and blood pressure control -Indications for operative intervention if: *Ongoing chest pain despite adequate blood pressure control *Evidence of impending rupture on CT scanning *In case of aneurysm, if it s greater than 6cm *Extension of the dissection *Limb or visceral ischemia

11 Subclavian Steal Syndrome (SSS) Atherosclerotic stenotic plaque at the origin of subclavian artery prior to vertebral artery. Vertebral artery flow reversed during exercise: -Upper extremity steals cerebral flow -Manifests as posterior neurologic symptoms Symptoms: -Upper extremity claudication.coldness, tingling, muscle pain -Posterior neurologic signs.visual disturbances, ataxia, vertigo

Diagnosis: -Duplex scanning showing reversal of flow Treatment: -Bypass grafting when necessary That s why when you want to measure blood pressure and you are are

12 Diagnosis: -Duplex scanning showing reversal of flow Treatment: -Bypass grafting when necessary That s why when you want to measure blood pressure and you are are running out of time or lazy doctor you should measure the right arm because subclavian atherosclerosis is more common there. Even though the best way is both arms.

13 Cerebral ischemia following carotid artery stenosis.

Anatomy The carotid artery begins at the aorta in the chest as the common carotid and courses up through the neck to the head Near the larynx, the common carotid divides into the external and

14 Anatomy The carotid artery begins at the aorta in the chest as the common carotid and courses up through the neck to the head Near the larynx, the common carotid divides into the external and internal carotid arteries The external carotid arteries supply blood to the face and scalp The internal carotid arteries supply blood to the brain The most common location of atherosclerotic plaque buildup is the carotid bifurcation where the common carotid divides into the internal and external carotid arteries.

What is carotid artery stenosis A progressive narrowing of the carotid arteries in a process called atherosclerosis Over time, the buildup of fatty substances and cholesterol narrows the carotid

15 What is carotid artery stenosis A progressive narrowing of the carotid arteries in a process called atherosclerosis Over time, the buildup of fatty substances and cholesterol narrows the carotid arteries > decreases blood flow to the brain and increases the risk of a stroke There are three ways in which carotid stenosis increases the risk of stroke: 1.Plaque deposits can grow larger and larger, severely narrowing the artery and reducing blood flow to the brain. Plaque can eventually completely block (occlude) the artery. 2.Plaque deposits can roughen and deform the artery wall, causing blood clots to form and blocking blood flow to the brain 3.Plaque deposits can rupture and break away, traveling downstream to lodge in a smaller artery and block blood flow to the brain

16 Risk factors Age Smoking Hypertension Abnormal lipids or high cholesterol Diabetes Obesity Sedentary lifestyle Family history of atherosclerosis, either coronary artery disease or carotid artery disease

17 Symptoms 3 groups of symptoms a) TIA b) Stroke (80% ischemic stroke, 20% hemorrhagic) c) Retinal ischemia Symptoms are most likely to first appear with a mini-stroke, transient ischemic attack (TIA) Amaurosis fugax: transient loss of vision, usually for a few seconds or minutes caused by interference to the blood supply to parts of the brain or eye by tiny emboli or by spasm of the arteries supplying the eye. Weakness, tingling, or numbness on one side of the face, one side of the body, or in one arm or leg Sudden difficulty in walking, loss of balance, lack of coordination Sudden dizziness and/or confusion Difficulty speaking (called aphasia) Confusion Sudden severe headache Problems with memory Difficulty swallowing (called dysphagia)

18 Diagnosis Doppler ultrasound Magnetic resonance angiography Computerized tomography angiography Cerebral angiography (carotid angiogram)

19 Treatment 1. Lifestyle changes 2. Medication Antiplatelet (aspirin, clopidogrel) Cholesterol-lowering statins Antihypertensive medications (diuretics, ACE inhibitors, angiotensin blockers, beta blockers, calcium channel blockers, etc.) 3.. Surgery Symptomatic patients with > 70% stenosis- MUST be operated Asymptomatic patients with > 70 % stenosis- can be operated but don t have to.

Carotid endarterectomy (CEA) Recommended in symptomatic patients with stenosis greater than 70 % Reduce incidence of ipsilateral stroke from 26% to 9% at 2 years in patients presenting with either

20 Carotid endarterectomy (CEA) Recommended in symptomatic patients with stenosis greater than 70 % Reduce incidence of ipsilateral stroke from 26% to 9% at 2 years in patients presenting with either TIA or stroke and carotid lesions of 70% stenosis or greater. Recommended for patients who have no symptoms and have blockage greater than 70% Among patients with moderate blockage of 50 to 69%, surgery reduces the risk of stroke but less dramatically Carotid endarterectomy cannot be performed when the internal carotid artery is completely occluded, because complete thrombectomy is difficult and residual clot may embolize, creating additional lesions

to high-grade carotid stenosis greater than 70% 2) have other medical conditions that increase the risk of

21 Carotid artery stenting Minimally invasive endovascular procedure that compresses the plaque and widens the lumen of the artery Angioplasty / stenting is typically indicated for select patients who 1) have moderate to high-grade carotid stenosis greater than 70% 2) have other medical conditions that increase the risk of surgical complications 3) have recurrent stenosis 4) have stenosis that was caused by prior radiation therapy

22 Treatment results Without treatment, 26% of patients with TIAs and more than 70% with carotid stenosis will develop permanent neurologic impairment (CVA) from continued embolization at 2 years Transient cranial nerve injury occurs in about 10% of cases after endarterectomy and may cause tongue weakness, hoarseness, mouth asymmetry, earlobe numbness, and dysphagia Restenosis or occlusion is uncommon after carotid endarterectomy (5% 10% at 5 years) and appears to be equally uncommon after carotid stenting For endarterectomy, using a prosthetic patch for closure of the arteriotomy can reduce restenosis

23 Thank you

Carotid Stenosis (carotid artery disease)

1 Carotid Stenosis (carotid artery disease) Overview Carotid stenosis is a narrowing of the carotid arteries, the two major arteries that carry oxygenrich blood from the heart to the brain. Also called