Acute Aortic Syndromes

Acute Aortic Syndromes Vera H. Rigolin, MD, FASE, FACC, FAHA Professor of Medicine Northwestern University Feinberg School of Medicine Medical Director, Echocardiography Laboratory Northwestern Memorial Hospital Immediate Past-President, American Society of Echocardiography Disclosures Disclosures: None that pertain to this presentation. Acute Aortic Syndrome • Aortic dissection • Intramural hematoma • Atherosclerotic plaque rupture • Penetrating ulcer • Aneurysm rupture All have similar clinical presentations Sudden onset severe chest/back pain Aortic Dissection • Annual incidence is 10-30 per million • Usually occurs in pts with pre-existing aortic conditions – Aneurysms, Marfan’s, bicuspid AV, HTN • Intimal tear into media. Column of blood propagates prox and distal to tear. Types of Aortic Dissection Feigenbaum’s Echocardiography, 7th ed. 2010 Complications of Aortic Dissection • Pericardial effusion • Complete or partial aortic rupture • Compromise of branch vessels • Coronary artery compromise • Aortic pseudoaneurysm • Aortic insufficiency History • 52 yo M w/ HTN, HL presented with chest pressure and headache. • Chest pressure began after pt began after a migraine. • Describes chest sensation as constant "pressure" in substernal, as if "someone were pressing on my chest”. • Chest pressure was constant, lasted until pt received SLNG in ED. • In ED, noted new heart murmur. EKG was non-ischemic. CXR negative for acute process. Trop=0.02 • Echo with Doppler/stress echo ordered PLAX PLAX PLAX Suprasternal Notch Apical 5 Chamber Spectral Doppler Intra-op TEE Mechanisms of AR in Aortic Dissection Feigenbaum’s Echocardiography, 7th ed. 2010 65 yr old Asian Female Complaining of Chest Pain M-mode AV PLAX Accuracy of TEE for Diagnosis of Aortic Dissection Feigenbaum’s Echocardiography, 7th ed. 2010 Intramural Hematoma • Variant of aortic dissection • Hemorrhage into media without rupture into lumen • Defined as area of crescenteric thickening of wall of >7 mm. No communication to lumen • 60% located in descending aorta • Often associated with atherosclerosis • Ascending aorta IMHs are surgical Dissection vs Hematoma Feigenbaum’s Echocardiography, 7th ed. 2010 History • 79 yr old female with h/o HTN, COPD • Presented with hypertensive urgency and neck/face pain and headache Aortic Arch Descending Aorta Another Case 95 yr old with back pain who died from multiorgan failure a week later This was incidentally noted on a CT Slide Courtesy of Kameswari Maganti, MD Penterating Ulcer • Begins as ulceration of atherosclerotic plaque • Results in disruption of intima and media • Penetration through adventitia can result in aortic rupture • Typical imaging characteristics: Focal outpouching of aortic wall; often with atherosclerosis Penetrating Ulcer Feigenbaum’s Echocardiography, 7th ed. 2010 Penetrating Aortic Ulcer (2-8% of AAS) • Atherosclerotic lesion penetrates internal elastic lamina into media • Associated with variable degree of IMH • May lead to pseudoaneurysm, rupture or late aneurysm • Acute chest or back pain • More common in desc ao (61%), abdominal ao (30%), arch of aorta (7%) • 25% of PAUs are incidentally detected Slide Courtesy of Kameswari Maganti, MD Penetrating Ulcer J Am Coll Cardiol. 57(11):1327, 2011 Mar 15. Summary • Aortic dissection, intramural hematoma and penetrating ulcer known as acute aortic syndromes • Clinical presentations are similar • TEE is useful in defining diagnosis, location and associated complications Thank You.

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Clinical Characteristics in STEMI-Like Aortic Dissection Versus STEMI-Like Pulmonary Embolism
A V ARCHIVES OF M VASCULAR MEDICINE Research Article More Information *Address for Correspondence: Oscar MP Clinical characteristics in STEMI- Jolobe, MRCP, Manchester Medical Society, Medical Division, Simon Building, Brunswick Street, Manchester, M13 9PL, UK, like aortic dissection versus Tel: 44 161 900 6887; Email: [email protected] STEMI-like pulmonary embolism Submitted: 07 July 2020 Approved: 30 July 2020 Published: 31 July 2020 Oscar MP Jolobe* How to cite this article: Jolobe OPM. Clinical Manchester Medical Society, Medical Division, Simon Building, Brunswick Street, Manchester, characteristics in STEMI-like aortic dissection M13 9PL, UK versus STEMI-like pulmonary embolism. Arch Vas Med. 2020; 4: 019-030. DOI: 10.29328/journal.avm.1001013 Abstract Copyright: © 2020 Jolobe OPM. This is an open access article distributed under the Creative Dissecting aortic aneurysm with ST segment elevation, and pulmonary embolism with ST segment Commons Attribution License, which permits elevation are two of a number of clinical entities which can simulate ST segment elevation myocardial infarction. unrestricted use, distribution, and reproduction in any medium, provided the original work is Objective: The purpose of this review is to analyse clinical features in anecdotal reports of 138 dissecting properly cited. aortic aneurysm patients with STEMI-like presentation, and 102 pulmonary embolism patients with STEMI-like presentation in order to generate insights which might help to optimise triage of patients with STEMI-like clinical Keywords: Aortic dissection; Pulmonary presentation. embolism; ST-elevation; Percutaneous coronary intervention Methods: Reports were culled from a literature search covering the period January 2000 to March 2020 using Googlescholar, Pubmed, EMBASE and MEDLINE.
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Aortic Diseases Esc Guidelines on the Diagnosis and Treatment of Aortic Diseases
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Appendix A: Doppler Ultrasound and Ankle–Brachial Pressure Index
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Core Keyword List, March 2017.Xlsx
Vascular Medicine Core Keywords Disease States/Risk Factor Terms Therapeutic Terms Imaging/Diagnostic Terms abdominal aortic aneurysm (AAA) ablation angiography acute aortic syndrome amputation ankle-brachial index (ABI) acute limb ischemia (ALI) angioplasty brachial artery reactivity antiphospholipid antibody syndrome anticoagulation carotid intima medial thickness (CIMT) aortic disease (other) anti-hypertensive therapy computed tomographic angiography (CTA) aortic dissection anti-platelet therapy duplex ultrasound aortitis anti-thrombotic therapy echocardiography arterial aneurysm (not aortic) biological therapies flow mediated vasodilation arterial compression syndromes bypass functional assessment arterial dissection (not aortic) compression therapy intravascular ultrasound arterial thrombosis endarterectomy magnetic resonance angiography (MRA) autoimmune disease endovascular therapy magnetic resonance imaging (MRI) behcet syndrome exercise therapy point-of-care devices carotid artery disease interventional radiology positron emission tomography (PET) cerebrovascular disease, other other pharmacotherapy toe-brachial index (TBI) chronic kidney disease (CKD) radiation safety transcutaneous oximetry (Tcpo2) chronic venous disease revascularization vascular imaging claudication sclerotherapy vascular physiological testing coronary artery disease smoking cessation critical limb ischemia (CLI) statins Basic/Translational/Mechanistic Terms deep vein thrombosis (DVT) stem cell therapy aldosterone diabetes mellitus stent angiogenesis embolism
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Core Keyword List
Vascular Medicine Core Keywords Disease States/Risk Factor Terms Therapeutic Terms Imaging/Diagnostic Terms abdominal aortic aneurysm (AAA) ablation angiography acute aortic syndrome amputation ankle-brachial index (ABI) acute limb ischemia (ALI) angioplasty brachial artery reactivity aneurysm anticoagulation carotid intima medial thickness (CIMT) antiphospholipid antibody syndrome (APLA) anti-hypertensive therapy computed tomography (CT) aortic disease anti-platelet therapy CT angiography (CTA) aortic dissection anti-thrombotic therapy duplex ultrasound aortitis biological therapies echocardiography arterial aneurysm bypass flow mediated vasodilation arterial compression syndromes compression therapy functional assessment arterial dissection endarterectomy intravascular ultrasound arterial thrombosis endovascular therapy magnetic resonance angiography (MRA) autoimmune disease exercise therapy magnetic resonance imaging (MRI) carotid artery disease interventional radiology point-of-care devices cardiovascular disease pharmacotherapy positron emission tomography (PET) cerebrovascular disease radiation safety toe-brachial index (TBI) chronic kidney disease (CKD) revascularization transcutaneous oximetry (Tcpo2) chronic venous disease sclerotherapy vascular imaging/diagnostics claudication smoking cessation vascular physiological testing coronary artery disease statins critical limb ischemia (CLI) stem cell therapy Basic/Translational/Mechanistic Terms deep vein thrombosis (DVT) stent aldosterone diabetes mellitus thrombectomy angiogenesis
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Acute Aortic Syndrome
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Acute Vascular Syndromes
7 CHAPTER 7 ACUTE VASCULAR SYNDROMES 7.1 ACUTE AORTIC SYNDROMES ______________________________________________ p.92 A. Evangelista 7.2 ACUTE PULMONARY EMBOLISM __________________________________________ p.102 A. Torbicki ACUTE AORTIC SYNDROMES: Concept and classification (1) Types of presentation 7.1 P.92 Classic aortic dissection Separation of the aorta media with presence of extraluminal blood within the layers of the aortic wall. The intimal flap divides the aorta into two lumina, the true and the false Intramural hematoma (IMH) Aortic wall hematoma with no entry tear and no two-lumen flow Penetrating aortic ulcer (PAU) Atherosclerotic lesion penetrates the internal elastic lamina of the aorta wall Aortic aneurysm rupture (contained or not contained) ACUTE AORTIC SYNDROMES: Concept and classification (2) Anatomic classification and time course 7.1 P.93 DeBakey’s Classification • Type I and Type II dissections both originate in the ascending aorta In type I, the dissection extends distally to the descending aorta In type II, it is confined to the ascending aorta • Type III dissections originate in the descending aorta Stanford Classification De Bakey Type I Type II Type III • Type A includes all dissections involving the ascending aorta regardless of entry site location • Type B dissections include all those distal to the brachiocephalic trunk, sparing the ascending aorta Time course • Acute: <14 days • Subacute: 15-90 days • Chronic: >90 days Stanford Type A Type A Type B Adapted with permission from Nienaber CA, Eagle KA, Circulation 2003;108(6):772-778. All rights reserved. Copyright: Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management: Part II: therapeutic management and follow-up.
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Acute Aortic Syndrome
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