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Acute Aortic Syndrome

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Acute Aortic Syndrome ACUTE AORTIC SYNDROME AAMIR SUHAIL MD DALHOUSIE UNIVERSITY ACUTE AORTIC SYNDROME • Heterogeneous group of patients with a similar clinical profile . • Non-traumatic life threatening injuries of the thoracic aorta. • Aortic Dissection • Intramural Hematoma (IMH) • Penetrating Atherosclerotic Ulcer (PAU) • Overall incidence is 2.6 – 3.5 cases / 100,000 person years. • Approx 65% of patients are men • Average at of presentation is 65 Abbas, A., I. Brown W., C. Peebles R., S. Harden P., and J. Shambrook S. "The Role of Multidetector-row CT in the Diagnosis, Classification and Management of Acute Aortic Syndrome." The British Journal of Radiology BJR 87.1042 (2014): 20140354. Web. RISK FACTORS • Hypertension (~72%) • Genetic • Marfan’s Sx (70%), Loeys-Dietz sx (32%), Ehlers-Danlos sx, Turner • Bicuspid Aortic Valve (2-9% of Type A, 3% of Type b) • HAS. • Mutations that affect structural proteins at the interface between ECM and smooth muscle cells • Influence aortic response to mechanical stimuli • Inflammatory Vascular Disease • Syphillis, Behcet’s, Takayasu arteritis, GCA • Iatrogenic • Aortic catheterization, Cardiac valve or Aortic Surgery Abbas, A., I. Brown W., C. Peebles R., S. Harden P., and J. Shambrook S. "The Role of Multidetector-row CT in the Diagnosis, Classification and Management of Acute Aortic Syndrome." The British Journal of Radiology BJR 87.1042 (2014): 20140354. Web. CLINICAL PRESENTATION • Severe tearing chest pain • 84-90% of cases • Maximal intensity at the time of onset • Acute Coronary Syndrome (ACS) – gradual increase in intensity. • Radiating to the neck, jaw or throat • Involvement of ascending aorta • Referred pain to the back or abdomen • Descending aorta • Other • Pulse deficits, regurgitant aortic murmur • Syncope • Heralds rupture or cerebrovascular occlusion Abbas, A., I. Brown W., C. Peebles R., S. Harden P., and J. Shambrook S. "The Role of Multidetector-row CT in the Diagnosis, Classification and Management of Acute Aortic Syndrome." The British Journal of Radiology BJR 87.1042 (2014): 20140354. Web. AORTIC ANATOMY • Aortic Root: aortic annulus to sinotubular junction. • Sinuses of valsalva • Tubular ascending: STJ to Brachiocephalic trunk • ~3cm of aA is within pericardium • Coronary arteries Mokrane, F.z., P. Revel-Mouroz, B. Lebes Saint, and H. Rousseau. "Traumatic Injuries of the Thoracic Aorta: The Role of Imaging in Diagnosis and Treatment." Diagnostic and Interventional Imaging 96.7-8 (2015): 693-706. Web. AORTIC ARCH • BCT to Lt Subclav. • Aortic Isthmus: • Lt. Subclav to Lig. Arteriosum. Mokrane, F.z., P. Revel-Mouroz, B. Lebes Saint, and H. Rousseau. "Traumatic Injuries of the Thoracic Aorta: The Role of Imaging in Diagnosis and Treatment." Diagnostic and Interventional Imaging 96.7-8 (2015): 693-706. Web. DESCENDING AORTA • Multiple branches • Bronchial • Intercostal • Spinal • Sup phrenic • Small mediastinal branches Mokrane, F.z., P. Revel-Mouroz, B. Lebes Saint, and H. Rousseau. "Traumatic Injuries of the Thoracic Aorta: The Role of Imaging in Diagnosis and Treatment." Diagnostic and Interventional Imaging 96.7-8 (2015): 693-706. Web. AORTIC WALL Mokrane, F.z., P. Revel-Mouroz, B. Lebes Saint, and H. Rousseau. "Traumatic Injuries of the Thoracic Aorta: The Role of Imaging in Diagnosis and Treatment." Diagnostic and Interventional Imaging 96.7-8 (2015): 693-706. Web. ANATOMIC VARIATION Mokrane, F.z., P. Revel-Mouroz, B. Lebes Saint, and H. Rousseau. "Traumatic Injuries of the Thoracic Aorta: The Role of Imaging in Diagnosis and Treatment." Diagnostic and Interventional Imaging 96.7-8 (2015): 693-706. Web. ANATOMIC VARIANTS • Ductus diverticulum • Focal bulge along the inner aspect of the isthmus • Remnant of ductus arteriousus. • Challenging to distinguish from traumatic aortic dissection. • Smooth margins with with obtuse angles relative to adjacent aorta. • Transection: irregular margins with acute angles. • Pseudocoarctation • Normal variant secondary to incomplete fusion of the third to seventh embryonic dorsal segments. • High proximal arch and “pseudokinking” of redundant aorta at the site of tethering to lig. Arteriosum. • No hemodynamically significant luminal narrowing. Mokrane, F.z., P. Revel-Mouroz, B. Lebes Saint, and H. Rousseau. "Traumatic Injuries of the Thoracic Aorta: The Role of Imaging in Diagnosis and Treatment." Diagnostic and Interventional Imaging 96.7-8 (2015): 693-706. Web. ANATOMIC VARIANTS ECHOCARDIOGRAPHY • Readily available, can be performed quickly and allows bedside imaging and interpretation. • Transthoracic (TTE) and Transesophageal (TEE) • TTE • Aortic valve dysfunction • Pericardial tamponade • Wall motion abnormalities. • Allows screening of proximal 4 – 8 mm of the ascending aorta to just above the sinotubular junction. • Short segment of descending aorta. • Distal ascending and arch NOT well-visualized. Baliga, Ragavendra R., Christoph Nienaber A., Eduardo Bossone, Jae Oh K., Eric Isselbacher M., Udo Sechtem, Rossella Fattori, Subha Raman V., and Kim Eagle A. "The Role of Imaging in Aortic Dissection and Related Syndromes." JACC: Cardiovascular Imaging 7.4 (2014): 406-24. Web. ECHOCARDIOGRAPHY • Overall SN only 59 – 83% , SP 63 – 93% • Type A dissection: SN 78-100% • Type B dissection: SN 31-55% • TEE • Highly accurate as a result of close proximity of the esophagus to thoracic aorta. • Can visualize both ascending and descending aorta and parts of the arch with high spatial resolution in real time. • ~7.5 MHz transducer mounted to the end of a gastroscopic probe. • TEE can reach SN 99% , SP 89% • 100% SN in detecting aortic regurgitation the complicates dissection. Baliga, Ragavendra R., Christoph Nienaber A., Eduardo Bossone, Jae Oh K., Eric Isselbacher M., Udo Sechtem, Rossella Fattori, Subha Raman V., and Kim Eagle A. "The Role of Imaging in Aortic Dissection and Related Syndromes." JACC: Cardiovascular Imaging 7.4 (2014): 406-24. Web. ECHOCARDIOGRAPHY • Requires esophageal intubation, but bedside evaluation w/in 15 min. • Limitations • Requires esophageal intubation, conscious sedation. • Limited visualization of the distal ascending aorta and proximal arch because of interposition of air-filled trachea and main bronchus. • Reverberation artefacts may mimic dissection flap. Baliga, Ragavendra R., Christoph Nienaber A., Eduardo Bossone, Jae Oh K., Eric Isselbacher M., Udo Sechtem, Rossella Fattori, Subha Raman V., and Kim Eagle A. "The Role of Imaging in Aortic Dissection and Related Syndromes." JACC: Cardiovascular Imaging 7.4 (2014): 406-24. Web. MDCT • Modality of choice • SN 100%, SP 98-99% • Rapid acquisition, universal emergency access. • >64 detector row MDCT can provide isovolumetric imaging with image reconstruction in any desired plane. • Cross-sectional reconstructions perpendicular to long axis of aortic lumen. • Can assess branch vessel involvement. • Provides detailed map of entire aorta and its branches • Serial measurements, easily identifiable landmarks Husainy, Mohammad Ali, Farhina Sayyed, and Sapna Puppala. "Acute Aortic Syndrome—pitfalls on Gated and Non-gated CT Scan." Emerg Radiol Emergency Radiology 23.4 (2016): 397-403. Web. MDCT • Significantly reduces cardiac motion artefacts that can often mimic AD. • Aortic root, Ascending aorta. • Enables more accurate assessment of the proximal coronary arteries. • Not routinely performed at all institutions. • Can lead to inappropriate transfer of patients to tertiary care centers (or negative open surgery) for patients with atypical cardiac motion artefact mimicking acute dissection flaps on non-gated MDCT. • ECG-gated pre-contrast imaging is critical • Pre-medication with B-Blockers and Nitroglycerin is not required and should be avoided. Husainy, Mohammad Ali, Farhina Sayyed, and Sapna Puppala. "Acute Aortic Syndrome—pitfalls on Gated and Non-gated CT Scan." Emerg Radiol Emergency Radiology 23.4 (2016): 397-403. Web. MDCT • Pre-contrast imaging is critical • Allows evaluation for presence of Intramural Hematoma • Localized rupture into the pleura or pericardium. • Followed by CTA • Bolus-tracked using 120 ml of [370 mgl/ml] iodinated contrast delivered at a rate of 4-5 cc/s via power injector • Target opacification of aorta of >250 HU • Contrast volume should be reduced to 80-100 ml in elderly patients (reduced cardiac output). • Ensure right arm IV access • Avoids streak artefact from contrast in the left brachiocephalic vein. • Further artefact minimization in IVC • 20 ml saline flush should immediately follow contrast medium injection Husainy, Mohammad Ali, Farhina Sayyed, and Sapna Puppala. "Acute Aortic Syndrome—pitfalls on Gated and Non-gated CT Scan." Emerg Radiol Emergency Radiology 23.4 (2016): 397-403. Web. INSTITUTIONAL PROTOCOL • DISSECTION PROTOCOL • Unenhanced phase followed by CE arterial acquisition. • FLASH scanner (256 MDCT) • ECG-triggered. • Acquisition in mid-diastole. • Low kvp • Pitch 3.4 • 100 mg Isovue 370 @ 4cc/sec via dual head injector using a 40 cc saline chaser over 35 seconds (25+10) • Bolus-tracking method triggers off ascending aorta at HU attenuation of 120 • Scan range from thoracic inlet to femoral head • Allows evaluation of supraaortic branches and iliac vessels MRI • Role in acute evaluation is limited given a relatively long examination (20-30 min) • Not readily compatible with life support and monitoring equipment required for critically ill patients. • Mainly used for serial follow-up of chronic Aortic Dissection. • Avoids radiation exposure and the use of contrast material. • IV gadolinium-enhanced imaging of the Aorta •
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