Aortic Emergencies Nick Taylor Registrar Teaching 2013
Part 1 ABDOMINAL AORTIC ANEURYSM
WHY? Mortality of rupture up to 90%
Why? >60 Male IHD risks
HOW? Asymptomatic Abdo/back/flank pain Syncope, low BP
Exam 30% <4cm 50% 4-5cm 75% >5cm Easily missed
DIAGNOSIS USS CT
TREATMENT Observe <5cm unruptured Repair > 5cm unruptured (La Place) Repair ruptured
TREATMENT Endovascular vs Open
TREATMENT Haemodynamics
Part 2 ACUTE AORTIC DISSECTION
Why? 40% immediate death 1% /hr thereafter 20% peri-operative 50-70% post surg survival
What? Predominately Thoracic 2-15/100000 Under-recognised Older men
How? Swings 37million times /year! Initimal tear with medial degeneration dp/dt
Which? Stanford A or B De Bakey I, II, III
How? Increased wall stress Medial layer problems Iatrogenic Other
Who?
But... CVS complications Syncope Neurologic ENT Resp GIT
Diagnosis ECG XDP CXR
Diagnosis CT TTE TOE
Figure 13. Transthoracic echocardiogram of a patient with Marfan syndrome with mitral valve prolapse and 4-cm ascending aortic aneurysm. WRITING GROUP MEMBERS et al. Circulation 2010;121:e266-e369 Copyright American Heart Association
Figure 18. Type A aortic dissection and extent of involvement depicted on axial CT images from the cranial to caudal direction. WRITING GROUP MEMBERS et al. Circulation 2010;121:e266-e369 Copyright American Heart Association
WRITING GROUP MEMBERS et al. Circulation 2010;121:e266-e369 Copyright American Heart Association Figure 25. AoD evaluation pathway.
WRITING GROUP MEMBERS et al. Circulation 2010;121:e266-e369 Copyright American Heart Association Figure 26. Acute AoD management pathway.
What to do Shear forces No evidence
What to do Beta Block Then Dilate if needed
What to do: Surgical Type A: OT (mortality halved) Type B: Medical 80% (mortality 10%) Surgical 20% (mortality 30%)
Refs Wittels K. Aortic emergencies: Emerg Clin N Am (2011) 789-800 Upadhye S, Schiff K: Acute Aortic Dissection in the ED. Emerg Clin N Am (2012) 307-327
Refs Br J Surg. 2013 Jun;100(7):863-72. doi: 10.1002/bjs.9101. Epub 2013 Mar 8. Systematic review and meta-analysis of the early and late outcomes of open and endovascular repair of abdominal aortic aneurysm. Stather PW, Sidloff D, Dattani N, Choke E, Bown MJ, Sayers RD. Source Vascular Surgery Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK. pws7@le.ac.uk Abstract BACKGROUND: Any possible long-term benefit from endovascular (EVAR) versus open surgical repair for abdominal aortic aneurysm (AAA) remains unproven. Longterm data from the Open Versus Endovascular Repair (OVER) trial add to the debate regarding long-term all-cause and aneurysm-related mortality. The aim of this study was to investigate 30-day and long-term mortality, reintervention, rupture and morbidity after EVAR and open repair for AAA in a systematic review. METHODS: Standard PRISMA guidelines were followed. Random-effects Mantel-Haenszel meta-analysis was performed to evaluate mortality and morbidity outcomes. RESULTS: The existing published randomized trials, together with information from Medicare and SwedVasc databases, were included in a meta-analysis. This included 25 078 patients undergoing EVAR and 27 142 undergoing open repair for AAA. Patients who had EVAR had a significantly lower 30-day or inhospital mortality rate (1 3 per cent versus 4 7 per cent for open repair; odds ratio (OR) 0 36, 95 per cent confidence interval 0 21 to 0 61; P < 0 001). By 2-year follow-up there was no difference in all-cause mortality (14 3 versus 15 2 per cent; OR 0 87, 0 72 to 1 06; P = 0 17), which was maintained after at least 4 years of follow-up (34 7 versus 33 8 per cent; OR 1 11, 0 91 to 1 35; P = 0 30). There was no significant difference in aneurysm-related mortality by 2 years or longer follow-up. A significantly higher proportion of patients undergoing EVAR required reintervention (P = 0 003) and suffered aneurysm rupture (P < 0 001). CONCLUSION: There is no long-term survival benefit for patients who have EVAR compared with open repair for AAA. There are also significantly higher risks of reintervention and aneurysm rupture after EVAR
Acad Emerg Med. 2013 Feb;20(2):128-38. doi: 10.1111/acem.12080. Systematic review: emergency department bedside ultrasonography for diagnosing suspected abdominal aortic aneurysm. Rubano E, Mehta N, Caputo W, Paladino L, Sinert R. Source Department of Emergency Medicine, SUNY Downstate Medical Center, Brooklyn, NY, USA. Abstract BACKGROUND: The use of ultrasound (US) to diagnose an abdominal aortic aneurysm (AAA) has been well studied in the radiology literature, but has yet to be rigorously reviewed in the emergency medicine arena. OBJECTIVES: This was a systematic review of the literature for the operating characteristics of emergency department (ED) ultrasonography for AAA. METHODS: The authors searched PubMed and EMBASE databases for trials from 1965 through November 2011 using a search strategy derived from the following PICO formulation: Patients-patients (18+ years) suspected of AAA. Intervention-bedside ED US to detect AAA. Comparator-reference standard for diagnosing an AAA was a computed tomography (CT), magnetic resonance imaging (MRI), aortography, official US performed by radiology, ED US reviewed by radiology, exploratory laparotomy, or autopsy results. AAA was defined as 3 cm dilation of the aorta. Outcomeoperating characteristics (sensitivity, specificity, and likelihood ratios [LR]) of ED abdominal US. The papers were analyzed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS) guidelines. RESULTS: The initial search strategy identified 1,238 articles; application of inclusion/exclusion criteria resulted in seven studies with 655 patients. The weighted average prevalence of AAA in symptomatic patients over the age of 50 years is 23%. On history, 50% of AAA patients will lack the classic triad of hypotension, back pain, and pulsatile abdominal mass. The sensitivity of abdominal palpation for AAA increases as the diameter of the AAA increases. The pooled operating characteristics of ED US for the detection of AAA were sensitivity 99% (95% confidence interval [CI] = 96% to 100%) and specificity 98% (95% CI = 97% to 99%). CONCLUSIONS: Seven high-quality studies of the operating characteristics of ED bedside US in diagnosing AAA were identified. All showed excellent diagnostic performance for emergency bedside US to detect the presence of AAA in symptomatic patients