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R9 > Chapter 81 - Aortic dissection > Flashcards

Chapter 81 - Aortic dissection Flashcards

1
Q

Mortality of Type A+B dissection without treatment

A

6hr: 22.7%
24hr: 50%
1wk: 68%

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2
Q

Definition of acute dissection and % of mortality that happen in this time frame

A

2 weeks

74% of all deaths occur in 2 weeks

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3
Q

Subacute dissection definition

A

2 weeks to 90 days

flap is still pliable

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4
Q

Chronic dissection definition

A

> 90 days

septum stiff

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5
Q

Debakey 1965 classification of dissection

A

Type 1: originate in ascending, extend into descending and abdomen

Type 2: originate and confined in ascending

Type 3a: originate in descending and limited

Type 3b: originate in descending and extend to abdomen

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6
Q

Stanford 1970 classification of dissection

A

A: ascending tear
B: descending tear

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7
Q

Incidence of aortic dissection

A

2.9-3.5/100000 person years

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8
Q

Risk factors for aortic dissection

A

1) Age
2) HTN
3) structural abnormality

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9
Q

IRAD study - stands for

A

International registry of acute aortic dissection

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10
Q

INSTEAD study - stands for

A

Investigation of stent grafts in aortic dissection

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11
Q

IRAD distribution of Type A and B and age group

A

Type A: 60%, peak age 50-60
Type B: 40%, peak age 60-70

Male 70%
HTN 70%

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12
Q

Dissection occurs more commonly in these times and other associated conditions

A

1) Between 6am - 12pm
2) Winter 28% > Summer 20%
3) No difference on actual climate
4) Bicuspid valve (7-14% of all dissections have this)

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13
Q

Marfan accounts for this % of dissections in < 40 yr old

A

50%

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14
Q

Aortic disease associated with dissection

A

1) Bicuspid valve
2) coarctation
3) annuloaortic ectasia
4) chromosome (Turner, Noonan)
5) Aortic arch hypoplasia
6) Hereditary (Marfan, Ehler-Danlos)

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15
Q

Pregnancy risk for dissection and rupture

A
  1. 4x

5. 5 / million

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16
Q

Dilation of aortic root above this is predictor for dissection in pregnant Marfan

A

4 cm

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17
Q

Most common site of dissection in < 40 year old

A

Sinus of valsalva or sinotubular junction

older people dissect in distal ascending

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18
Q

Contribution of cocaine to dissection

A

37% in urban setting as cause
1.7% in IRAD

type A and B equal distribution

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19
Q

Cocaine MOA for dissection

A

1) hypertension
2) vasoconstrictuion
3) increase cardiac output

all increase shear force dP/dt

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20
Q

intimal flap location distribution

A

Ascending 65%
Descending 25%
Arch + abd 10%

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21
Q

Most common site of tear in aorta

A

Left posterior-lateral aspect 80%

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22
Q

Cystic medial necrosis definition

A

degeneration of media in connective tissue disease

Decrease collagen and elastin

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23
Q

% of dissections associated with connective tissue disease

A

10-15%

24
Q

Arch vessel compromise in dissection

A

31% of cases

25
Q

Key points in looking at CTA after dissection

A

1) % of circumference dissection
2) distal reentry point
3) branch ostia to TL or FL

26
Q

William et al description in vessel branch compromise

A

Dynamic obstruction 80%

1) compressed TL not enough flow
2) dissection flap prolapse into ostium

Static obstruction 20%

1) dissect into the branch itself
2) thrombosis of the branch

27
Q

Symptoms of dissection

A

Pain 93%

Abrupt onset 85%

28
Q

Location of pain in Type A or B

A

Type A:
Front chest 78%
Abdomen 21%

Type B:
Back 64%
abdomen 43%

29
Q

Blood pressure in patients after dissection

A

HTN
Type A: 25-35%
Type B: 70% (most refractory)

HypoTN
Type A: 25%
Type B: < 5%

30
Q

Other symptoms after dissection

A

1) Syncope 5-10%
2) Spinal ischemia 2-10% (parasthesia lumbar plexus, hoarseness recurrent laryngeal, horner sympathetic)
3) Peripheral vascular 30-50%

31
Q

Rate of pulse deficit after dissection and associated mortality

A

Brachiocephalic 14%
Left CCA 21%
LSCA 14%
iliofemoral 35%

1) no deficit 9.4% mortality 24 hr
2) 1+2 deficit 15.8%
3) 3 deficit 35.3%

32
Q

CTA sen and spe in dissection

A

Sensitivity 83-95%
Specificity 87-100%

Ascending sensitivity < 80

33
Q

Rate where FL greater than TL

A

90%

34
Q

Shape of the intimal flap

A

Curved 63% acutely

Flat 75% chronically

35
Q

TTE sen and spe in dissection

A

Sensitivity 35-80%

Specificity 40-95%

36
Q

Blindspot of TTE in dissections

A

1) Distal ascending
2) arch
3) beyond diaphragm

due to trachea and left main bronchus

37
Q

TEE sen and spe in dissection

A

Sensitivity 98%

Specificity 63-96%

38
Q

MRI sen and spe in dissection

A

95-100% for both

39
Q

Problem with using sodium nitroprusside in dissection

A

Reflex sympathetic stimulation –> catecholamine release –> increase dP/dt

40
Q

BP target in dissection

A

SBP 100-120

MAP 60-70

41
Q

Type B dissection rate of complication and mortality in 15 days

A

12% complicated

5% mortality

42
Q

Imaging follow up for TBAD medical management

A

1) before discharge
2) 6 months
3) after 2 stable exams then annual

43
Q

30 day mortality of TBAD

A

10% medical management

30% open repair (spinal cord ischemia 32%)

44
Q

False lumen enlargement rate

A

3.3 mm/yr

45
Q

Mortality in relationship with false lumen patency

A

Patent FL 13.7%
Partial thrombosis 31.6%
complete thrombosis 22.6%

46
Q

IRAD TEVAR mortality in hospital

A

10%

47
Q

Gore TAG 08-01 study key points

A

1) 50 patients
2) acute complex TBAD treated with TEVAR
3) 30d mortality 8%
4) stroke 18%

48
Q

STABLE study key points

A

1) 40 patients
2) 30d mortality 5%
3) stroke 7.5%
4) paraplegia 2.5%

49
Q

SVS study key points

A

1) 85 patients
2) 30d mortality 10.6%
3) stroke 9.4%
4) paraplegia 9.4%

50
Q

Positive remodelling rate

A

90% at 1 year
74% at 2 year (different study)
84% at 5 year

51
Q

Malperfusion rate in TBAD

A

25-40%

52
Q

Natural fenestration location typically

A

Left renal artery or other branch vessels

53
Q

Open fenestration in dissection technique

A

1) Aortotomy
2) fenestrate or cut out flap
3) tack down branch ostia
4) close aorta with felt strips

54
Q

TBAD risk of aneurysm and rupture

A

Aneurysm 25-50%

Rupture 10-20%

55
Q

Risk factors of aneurysmal degeneration after dissection

A

1) HTN
2) aorta > 4cm in acute phase
3) entry tear > 10 mm
4) patency of false lumen
5) partially thrombosed distal false lumen

56
Q

INSTEAD trial key points

A

1) Europe
2) medical vs stent in subacute/chronic TBAD
3) 140 patients randomized
4) no difference at 2 years
5) 5 year better survival in TEVAR

Supported by IRAD and Durham et al study

57
Q

Long term HTN control treatment target

A

BP < 125/80

if Marfan then SBP < 120

R9 (200 decks)

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