Animesh Rathore, MD 4/21/17. Penetrating atherosclerotic ulcers of aorta
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1 Animesh Rathore, MD 4/21/17 Penetrating atherosclerotic ulcers of aorta
2 Disclosures No financial disclosures Thank You Dr. Panneton for giving this lecture for me. I am stuck at Norfolk with an emergency
3 Outline Aortic histology Aortic wall pathology Penetrating aortic ulcer versus IMH Etiology Diagnosis Clinical presentation Management What s new Conclusions
4 Microanatomy of the vessel wall
5 Aorta
6 Aortic wall pathology Aortic dissection Aneurysm Aortic intramural hematoma (IMH) Penetrating aortic ulcer (PAU)
7 IMH v PAU IMH: Collection of blood confined to media Typically circumferentially containing blood containing space without intimal discontinuity PAU: focal defect in the elastic lamina of the aortic wall that leads to localized medial Presenter disruption name and potential rupture
8 IMH vs PAU
9 IMH: CT scan and TEE
10 IMH classification
11 CT scan for PAU
12 PAU vs IMH WHY THE CONFUSION Often present together Both have intimal violation and flow in aortic wall (usually media) Overlapping clinical presentation
13 What else is relevant Ulcer like projection (ULP): localized blood filled pouch protruding into IMH with depth > 5 mm. Same contrast enhancement as true lumen, seen without atherosclerotic plaque unlike PAU Intramural blood pool (IBP): Contrast filled pol inside the IMH on postcontrast CT without communication with true lumen Enhanced false lumen: strongest predictor of IMH related events Journal of vascular surgery January 2017 Vol 65, Issue 1, Pages 30-39
14 Etiology Manifestation of degenerative aortic pathology Combination of hypertension and atherosclerotic disease IMH: spontaneous rupture of vasa vasorum in medial layer or as a result of PAU Neovascularization or rupture of atherosclerotic plaque, rarely trauma 80% PAU have associated IMH (Mayo clinic series) J Thorac Cardiovasc Surg. 127:
15 Clinical presentation Abrupt onset of severe pain in chest, neck, back and / or abdomen (like acute aortic syndrome) Risk factors: old age, hypertension diffuse atherosclerotic disease of thoracic aorta 5.7 % acute aortic syndromes Presenter related to name IMH in IRAD database (16% progress to dissection) Majority in descending thoracic aorta (60%) Circulation. 2005;111(8):1063.
16 Clinical presentation PAU: 2-7 % of acute aortic syndrome. PAU: > 70 years with multiple cardiovascular risk factors. Periaortic hematoma and hemorrhagic pericarditis more frequent with IMH than dissection Eur J Vasc Endovasc Surg Dec;38(6): Epub 2009 Oct 2.
17 Natural history Spontaneous resolution in % Progression to classic dissection or aneurysm Mortality ~ 20.7% (proximal 39.1%), distal (8.3%): comparable to dissection Normal aortic diameter is predictor of IMH regression without complications > 40 mm aortic diameter 30- fold > 10 mm IMH thickness 8- fold risk
18 Natural history Type A PAU: risk of rupture as high as % Type A IMH: mortality as high as % (with medical therapy) due to progression to dissection, rupture or aneurysm Type B PAU with IMH: bad prognosis (mortality upto 60%) Other poor prognostic predictors: age >70, concomitant PAU and IMH, max aortic diameter > 40 mm, aortic thickness > 10 mm J Vasc Surg. 2002;35(6):1179.
19 Diagnosis CT angiogram IVUS MR angiogram TEE Triple rule out coronary CT angiography
20 Management Asymptomatic Expectant management with HTN control, antiplatelet and statin, pain control Symptomatic (general principles) Ascending aorta involvement: Presenter surgical repair name Descending aorta: endovascular repair (TEVAR) May have higher risk for spinal cord ischemia
21 Outcomes IMH with medical therapy: about 77 % regress at 3 years, survival >90% at 5 years Surgical group higher risk TEVAR safe and effective (Panneton et al) Up to 70 % survival with type a pathology Rapid progression of endovascular technology in ascending aorta and aortic arch territory JVS, 2014;60(5), 1402
22 What s new Hybrid approach Frozen elephant trunk
23 Arch based endovascular devices
24 Thoracoabdominal devices
25 Conclusion IMH and PAU represent rare but potentially life threatening aortic pathology With careful patient selection and implementation of correct treatment modality successful outcomes are achieved New less invasive endovascular technology is around the corner
26 THANK YOU Animesh Rathore, MD RPVI Sentara Vascular Specialists Call anytime:
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