Χρόνιος διαχωρισμός αορτής υπερηχοκαρδιογραφική παρακολούθηση ή άλλη; Α. Παπασπυρόπουλος ΕΠΙΜΕΛΗΤΗΣ ΓΝ.ΝΙΚΑΙΑΣ ΠΕΜΠΤΗ 8-2-2018
The Normal Aorta (conduit function + control ) *Aortic expansion is about 0.9mm in men and 0.7mm in women for each decade of life Wall is composed histologically of three layers: a thin inner tunica intima lined by the endothelium; a thick tunica media characterized by concentric sheets of elastic and collagen fibres with the border zone of the lamina elastica interna and externa, as well as smooth muscle cells; and the outer tunica adventitia containing mainly collagen, vasa vasorum, and lymphatics.
Introduction Aortic dissection Intramural hematoma Penetrating atherosclerotic ulcer Aortic pseudoaneurysm Rupture(or contained rupture)of an aortic aneurysm Traumatic aortic ADD DISCRETE AD PAU IMH IATROGEN transection 62% 38%
Definition chronic aortic diseases 2 situations addressed in the guidelines: - Chronic aortic dissection After the acyte phase (>90 days) Discovered incidentally
Case 1 ΑΣΘΕΝΗΣ ΜΕ ΛΟΙΜΩΞΗ ΑΝΑΠΝΕΥΣΤΙΚΟΥ ΣΕ ΑΚΤΙΝΟΓΡΑΦΙΑ ΘΩΡΑΚΟΣ ΔΙΕΥΡΥΝΣΗ ΜΕΣΟΘΩΡΑΚΙΟΥ Ακτινολογικό ΓΝ Νίκαιας, Μπούχρα ΕπιμΑ
Case 1 Στην συνεχεία γινεται CT ΔΙΑΧΩΡΙΣΤΙΚΟ TYPB Ακτινολογικό ΓΝ Νίκαιας, Μπούχρα ΕπιμΑ
Case 2 Contrast was injected in proximal aorta An 80-year-old woman. Symptomatic severe aortic stenosis was referred to cath lab to perform a diagnostic coronary angiography, as evaluation for transcatheter aortic valve implantation. PI: myocardial revascularization surgery, multiple co-morbidities.
Case 2 Echocardiographic evaluation detected an aneurismatic dilatation of the aortic root with an image compatible with a flap dissection Ascending aorta dilatation (74 mm)
Case 2 Thoracic angio-ct : extension of the aortic dissection from the valve plane to the aortic arch before brachiocephalic trunk, with partial thrombosis of the false lumen confirming the diagnosis of chronic type A aortic dissection. Ascending aorta dilatation (80 mm)
Χρόνιος διαχωρισμός αορτής Υπερηχοκαρδιογραφική παρακολούθηση ή άλλη;
Non invasive imaging for diagnosis TEE: Is not the technique of choice for full assessment of the aorta Proximal aortic segments in clinical practice. Permits assessment of the aortic valve, which is often involved in diseases of the ascending aorta Can look at other cardiac structures Via the suprasternal view, aortic arch aneurysm, plaque calcification, thrombus, or a dissection membrane may be detectable ΤΕΕ / 3d TEE: High -resolution images
Non invasive imaging for diagnosis CT / Contrast enhanced: Plays a central role in the diagnosis, risk stratification, and management of aortic diseases Obtain a complete 3D dataset of the entire aorta. Detect endoleaks after stent-graft repair. Allows detection of maximal diameter of dilation, the presence of atheroma thrombus, IMH, penetrating ulcers, calcifications extension of the disease to the aortic branches Triple-rule out pulm embolism coronary anatomy Aortic dissection
Ακτινολογικό ΓΝ Νίκαιας, Μπούχρα ΕπιμΑ Case 3
Non invasive imaging for diagnosis MRI: Maximal aortic diameter Involvement of aortic branches in aneurysmal dilation or dissection Presence of mural thrombus Occasionally fail to show the intimal flap The disadvantage of MRI is the difficulty of evaluating aortic valve calcification of the anchoring zones, which is important for sealing of stent grafts. Wall edema
Non invasive imaging for diagnosis Abdominal ultrasound: Abdominal aorta accurately measure the aortic size, wall lesions such as mural thrombus or plaques Colour Doppler great interest of abdominal aorta dissection, detect perfusion of both false and true lumen potential re-entry sites or obstruction of tributaries Contrast-enhanced ultrasound is useful in detecting, localizing, and quantifying endoleaks when this technique is used to follow patients after EVAR.
Non invasive imaging for diagnosis Aortography: Information about the shape and size of the aorta Miss discrete aortic aneurysms Intravascular ultrasound: To optimize visualization of the aortic wall, can be used particularly during endovascular treatment
Non invasive imaging for diagnosis Positron emission tomography: To detect: Inflammatory vascular disease (e.g. Takayasu arteritis ) Endovascular graft infection
Comparison of Imaging Techniques Sensitivity of imaging modalities Specificity of imaging modalities
Complications of Chronic Aortic Dissection Anastomotic leakage, disruption, dehiscence Pseudoaneurysm Progressive AR Involvement of aortic branches Perigraft infection Compression of graft by hematoma Aneurysmal dilatation of false lumen Compression or collapse of true lumen Anastomotic stenosis Development of recurrent dissection or aneurysm proximal to a graft in patients in whom a supracoronary procedure has been performed Aortoesophageal or aortopulmonary fistula Graft herniation into thoracotomy defect
Diagnosis of complications Chronic Dissection
Recommendations for Follow-up of Chr. Aortic dissection
Follow-up after endovascular treatment for aortic diseases *
Follow-up after endovascular treatment for aortic diseases
Biomarker in Chronic Aortic Dissection
Chronic Thoracic Aortic Aneurysms Ascending aortic aneurysms / TTE and CT or MRI Aortic arch aneurysm / CT or MRI 55mm Descending aortic aneurysms / TEE or CT or MRI
Case 4 28-03-2012 Acute Dissection TYP A
Case 4
Case 4 Reason for study (17-12-2012) AVR AND AORTIC ROOT REPLACEMENT. Conclusions: Normal left ventricle cavity size with preserved systolic function. Localized basal septum appears akinetic. Normal right ventricle with impaired function. TAPSE = 1.30 cm. Aortic valve not well seen, appears tricuspid aortic valve with good opening. Normal aortic root. Normal estimated PA pressure.
SUMMARY The imaging techniques have greatly increased. TTE continues to be the technique most used in clinical practice for aortic root assessment. CT has the advantage of its high-resolution assessment of the entire aorta and excellent accuracy on size measurements. MRI offers the greatest morphologic and dynamic information of the aorta without radiation. New advances such as time-resolved 3D phase-contrast velocity (fourdimensional flow) on MRI, electrocardiographically gated MDCT will permit further improvement in the definition of the aorta diseases.