Aortic Aneurysm & Dissection

Presented by : Feryal AlKhateeb

Samah AlKhateeb

Anatomy

Histoloogy

Thoracic Aortic Aneurysm

Aortic aneurysm is defined as a permanent, localized dilatation

of the aorta to a diameter that is at least 50% greater
than is normal at that anatomic level.
The annual incidence of thoracic aortic aneurysms is
estimated to be 5.9 per 100,000 persons.
Aneurysms can be localized to a single aortic segment, or
they can involve multiple segments. In the most extreme
cases, the entire aorta is aneurysmal; this condition is
often called mega-aorta.

Aortic aneurysms can be either true or false.

True aneurysms can take two forms: fusiform and
saccular.
1. Fusiform aneurysms are more common and can be
described as symmetrical dilatations of the aorta.
2. Saccular aneurysms are localized outpouchings of the
aorta.
False aneurysms, also called pseudoaneurysms, are leaks in
the aortic wall that are contained by the outer layer of
the aorta and/or the periaortic tissue; they are caused by
disruption of the aortic wall and lead blood to collect in
pouches of fibrotic tissue.

Causes and Pathogenesis

Nonspecific medial degeneration
Aortic dissection
Genetic disorders
1. Marfan syndrome
2. Loeys-Dietz syndrome
3. Ehlers-Danlos syndrome
4. Familial aortic aneurysms
5. Aneurysms-Osteoarthritis syndrome
6. Congenital bicuspid aortic valve
7. Bovine aortic arch
Poststenotic dilatation
Infection
Aortitis
Takayasu arteritis
Giant cell arteritis
Rheumatoid aortitis
Trauma

Clinical Manifestation

1.

2.

3.

4.

In many patients with thoracic aortic aneurysms, the aneurysm is discovered

incidentally when imaging studies are performed for unrelated reasons. And they are
asymptomatic at time of diagnosis.
Local compression and erosion.
- anterior chest discomfort.
- left vocal cord paralysis and hoarsness.
- interscapular back pain.
- middle back and epigastric pain.
Aortic valve regurgetation.
- progressive heart failure.
- widened pulse pressure.
- diastolic murmer.
Distal embolization.
- occlusion and thrombosis of the visceral, renal, or lower extremity branches.
Rupture.
- sudden, severe pain in the anterior chest (ascending aorta), upper back or left
chest (descending thoracic aorta), or left flank or abdomen (thoracoabdominal
aorta).
- acute cardiac tamponade and death.
- severe hemorrhagic shock.

Diagnostic Evaluation

Plain radiography.
- (CXRs) may appear normal in patients with thoracic
aortic disease and, thus, cannot exclude the diagnosis of
aortic aneurysm.
1- convexity in the right superior mediastinum
2- loss of the retrosternal space (on lateral view)
3- widening of the descending thoracic aortic shadow
4- a rim of calcification outlining the dilated aneurysmal
aortic wall.
- Once a thoracic aortic aneurysm is detected on plain
radiographs, additional studies are required to define the
extent of aortic involvement.

Echocardiography and Abdominal Ultrasonography.

Computed Tomography.
- CT is the most commonand arguably the most
usefulimaging modality for evaluating thoracic aortic
aneurysms.
- provides information about an aneurysms location,
extent, anatomic anomalies, and relationship to major
branch vessels.

Magnetic Resonance Angiography.

- It is the best method of diagnosing aneurysms, but have
more limitations than CT.
- MRA environment is not appropriate for many critically
ill patients.
- MRA imaging is suboptimal in patients with extensive
aortic calcification.

Invasive Aortography and Cardiac Catheterization.

- the use of invasive aortography in patients with thoracic
aortic disease is generally limited to those undergoing
endovascular therapies or when other types of studies are
contraindicated or have not provided satisfactory results.
- A key limitation of aortography is that it :
images only the lumen and may therefore underrepresent the
size of large aneurysms that contain laminated thrombus.
Manipulation of intraluminal catheters can result in
embolization of laminated thrombus or atheromatous debris.

Treatment

1.

2.
3.
4.

Once a thoracic Aortic aneurysm is detected, management

begins with patient education, particularly if the patient is
asymptomatic.
- strict control of hypertension.
- cessation of smoking.
Indecations for operation :
Elective operation in asymptomatic patients when the
diameter of an ascending aortic aneurysm is >5.5 cm, or
diameter of a descending thoracic aortic aneurysm is >6.0
cm.
The rate of dilatation is >0.5 cm/y.
Emergent intervention for patients who present with
aneurysm rupture or superimposed acute dissection.
patients who present with symptoms may need urgent
operation

Traditional open operations to repair proximal aortic

aneurysms performed through a midsternal incision and
require cardiopulmonary bypass.
The spectrum of operations ranges from simple graft
replacement of the tubular portion of the ascending aorta
to graft replacement of the entire proximal aorta,
including the aortic root, and reattachment of the
coronary arteries and brachiocephalic branches.

Open repair vs. endovascular repair.

Stent graft repair of descending thoracic aortic aneurysms
has become the accepted treatment option

Operative Complications

Bleeding is a potential complication for all aneurysm repairs.

Stroke is a major cause of morbidity and mortality and
typically results from embolization of atherosclerotic debris or
clot.
Myocardial infarction may occur with technical problems with
coronary ostia implantation during root replacement for
ascending aortic aneurysms and may require reoperation.
Pulmonary dysfunction.
Renal dysfunction.
Paraparesis and paraplegia, either acute or delayed, are the
most devastating complications.
Complications specific to endovascular stenting include
endoleaks, stent fractures, stent graft migration or thrombosis,
iliac artery rupture, retrograde dissection, microembolization,
aortoesophageal fistula.

Long Term Monitoring

serial evaluations (ie, CT or MRI for ascending, arch, or

descending aneurysms; echocardiography for ascending
aneurysms) may be performed every 3-6 months during
the first postoperative year and every 6 months
thereafter.

Aortic Dissection
By Samah AlKhateeb

Pathology and Classification

Aortic dissection, the most common catastrophic event

involving the aorta, is a progressive separation of the
aortic wall layers that usually occurs after a tear forms in
the intima and inner media, resulting in blood tracking into the
aortic tissues splitting the medial layer and creating a false
lumen.

Figure 22-17. Illustration of longitudinal sections of the aortic wall and lumen. Blood
flows freely downstream in normal aortic tissue. In classic aortic dissection, blood entering
the media through a tear creates a false channel in the wall. Intramural hematomas arise
when hemorrhage from the vasa vasorum causes blood to collect within the media; the
intima is intact. Penetrating aortic ulcers are deep atherosclerotic lesions that burrow into
the aortic wall and allow blood to enter the media. In each of these conditions, the outer
aortic wall is severely weakened and prone to rupture.

The extensive disruption of the aortic wall has severe

anatomic consequences. First, the outer wall of the false
lumen is extremely thin, inflamed, and fragile, which makes
it prone to expansion or rupture in the face of ongoing
hemodynamic stress. Second, the expanding false
lumen can compress the true lumen and cause
malperfusion syndrome by interfering with blood flow
in the aorta or any of its branch vessels, including the
coronary, carotid, intercostal, visceral, renal, and iliac
arteries. Finally, when the separation of layers occurs
within the aortic root, the aortic valve commissures can
become unhinged, which results in acute valvular
regurgitation.

Dissection vs. Aneurysm.

Dissection and aneurysm are separate entities, although

they often coexist and are mutual risk factors. In most cases,
dissection occurs in patients without aneurysms. The
subsequent progressive dilatation of the weakened outer
aortic wall results in an aneurysm. On the other hand, in
patients with degenerative aneurysms, the ongoing
deterioration of the aortic wall can lead to a superimposed
dissection. The overused term dissecting aneurysm should be
reserved for this specific situation.

Classification.

For management purposes, aortic dissections are classified

according to their location and chronicity.
Location. To guide treatment, dissections are categorized
according to their anatomic location and extent.
Chronicity. Dissection is considered acute within the first 14
days after the initial tear; after 14 days, the dissection is
considered chronic.

Figure 22-19. Illustration of the classification

schemes for aortic dissection based on which portions of the aorta are
involved. Dissection can be confined to the ascending aorta (left) or
descending aorta (middle), or it can involve the entire aorta (right).

Causes and Clinical History

Aortic dissection is a lethal condition. Without appropriate

modern medical or surgical treatment, most patients
(approximately 90%) die within 3 months of dissection, mostly
from rupture.

the specific causes remain unknown. Ultimately, any condition

that weakens the aortic wall increases the risk of aortic
dissection.

Risk Factors:

Common general cardiovascular risk factors;

Smoking
Hypertension
Atherosclerosis
Hypercholesterolemia

Connective tissue disorders.

Bicuspid aortic valve.
Preexisting medial degenerative disease.
Iatrogenic dissection; aortic injury during cardiac
catheterization, surgery, or endovascular aortic repair.
Cocaine and amphetamine abuse.
Severe emotional stress or extreme physical exertion such as
during weightlifting.

Clinical Manifestations

The onset of dissection often is associated with sudden severe

chest or back pain, classically described as tearing, that
migrates distally as the dissection progresses along the length
of the aorta.

The location of the pain often indicates which aortic segments

are involved.

Clinical Manifestations

The dissection may track proximally to involve:

the head and neck vessels (symptoms and signs of a stroke or
transient ischemic attack).
the coronary vessels (myocardial infarction).
the aortic root (aortic regurgitation).
The dissection can extend distally down the aorta to
involve:
the renal arteries (renal failure).
the mesenteric arteries (abdominal pain and bowel ischemia).
the spinal arteries (paraplegia, incontinance).
the iliac arteries (leg pain, pallor, loss or reduced pulses and limb
ischemia).

Investigations

Diagnosis is confirmed by:

Chest X- ray shows widening of the mediastinum in two-thirds

of patients and a small left pleural effusion.
Contrast CT shows a flap across the aortic lumen with distal
aneurysmal change. (it is probably the investigation of choice)
Echocardiography may also demonstrate a flap and aortic
regurgitation. Transoesophageal echocardiography (TOE)

Figure 1. Chest X-ray (postero-anterior projection) showing that

the descending thoracic aorta is extremely dilated and tortuous.

Figure 22-21. Computed tomographic scans showing that the aorta has been separated
into two channelsthe true (T) and false (F) lumens in two patients with different phases
of aortic dissection. A. An acute DeBakey type I aortic dissection. The dissecting membrane
appears wavy (arrows) in the early phase of dissection. Here, the true lumen of the proximal
aorta can be seen to be extensively compressed. This may lead to malperfusion of the heart.
B. A chronic DeBakey type III aortic dissection. In the chronic phase, the membrane
appears straighter and less mobile (arrow) because it has stabilized over time.

Figure 2. Sagittal computed tomography images demonstrating the

thoracic (A) and abdominal (B) portions of the involved dissecting aorta
with arrows indicating the dissecting intimal flap.

Treatment

Once the diagnosis is made, treatment depends largely upon

the type of dissection.

In the emergency situation, before further imaging, blood

pressure (which is usually high at presentation) should be
brought under control to prevent extension of the dissection.

Surgical options

Type A (or type I and II)

Should be managed surgically because of the risk that the
dissection may extend back across the aortic root resulting in
tamponade, and to correct aortic incompetence.
The surgery aims to interpose a prosthetic tube graft at the
aortic root to prevent further dissection.

Illustration of proximal aortic repair for acute ascending aortic dissection

Illustration of distal aortic repair of a chronic dissection.

(Continued)

Type B (or type III)

Usually treated conservatively.
Hypertensive drugs are used, reducing systolic pressure to 100
120 mmHg to prevent further extension of the dissection.
Any organ, limb or mesenteric ischemia resulting from the
dissection is treated by revascularization.
An aneurysm resulting from a chronic dissection may require
treatment if it enlarges or produces pressure symptoms.
In cases where there is evidence of impending aortic rupture
or non-perfusion of a visceral artery, endovascular placement
of a covered stent (a stent graft) is appropriate.
The stent is placed to cover the proximal entry into the false
lumen, and to re-establish blood flow through the collapsed
true lumen.

The End
Thank You!

Resource : schwartzs principles of surgery , 10th edition.